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41,034
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Discharge summary
|
report+addendum
|
Admission Date: [**2128-11-26**] Discharge Date: [**2128-12-27**]
Date of Birth: [**2100-8-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
[**11-26**] a.m. Ventriculostomy placemtent
[**11-26**] A-Comm Aneurysm coiling
[**11-26**] Ventriculostomy placement
[**12-2**] Cerebral angiogram
[**12-8**] IVC filter
[**12-8**] Tracheostomy
[**12-8**] Peg
History of Present Illness:
28y/o male who reportidly had a sudden onset [**10-29**] occipital
headache after intercourse. Question of a seizure prior to
arrival at outside facility. Patient alert prior to head CT, and
then rapidly declined requiring sedation and intubation. CT
revealed diffuse SAH with early HCP. Pt. Transferred to [**Hospital1 18**]
and arrived at approx. 12:30 am, heavily medicated, proceeded to
CT
for a CT and CTA which revealed a L MCA aneursym.
Past Medical History:
Non contributory
Social History:
Per mother: no Tobacco
[**Name (NI) 80077**] use
Family History:
Non contributory
Physical Exam:
VSS. Afebrile.
Eyes open throughout 90% of evaluation with increased verbal and
tactile stimulation to maintain eyes open when in supine
position. Eyes track to voice, cross midline. PERRL 4mm to 2mm
bilaterally. +Corneal,+Cough. Following approximately 20% of
commands with Bilateral upper extremities. Has not been moving
the lower extremities to this point. MRI imaging of the spine
has not demonstrated pathology to account for this. No seizure
activity, pt to continue on Keppra upon discharge.
CV: Pt continues to remain hemodynamically stable. Recieving
B-blockade to control his episodic tachycardia. Pt remains on
coumadin for treatment of his DVT. Coumadin was begun on
[**2128-12-19**].
Resp: Pt with Cuffed 8.0mm [**Last Name (un) 295**] tracheostomy. Course breath
sounds throughout with copious amouts of thick white secretions.
RR 16-40. O2 sat 100%
GI/GU: PEG functioning as expected. Estimated nutritional needs
based on adjusted weight is 1710-2137 calories (20-25cal/kg) and
103-128 (1.2-1.5G/kG) of protien.
Foley draining clear yellow urine. Essentially Euvolemic. No
evidence of DI.
Code Status: Full
Pertinent Results:
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2128-11-26**] 12:30 AM
Final Report CTA OF THE BRAIN/CIRCLE OF [**Location (un) **]
FINDINGS:
There is diffuse subarachnoid hemorrhage as well as a small
amount of
intraventricular hemorrhage in the occipital horns. There is
enlargement of ventricles. There is effacement of the basilar
cisterns compatible with edema. There is a small amount of mls
to the left. There is a 2.5-mm aneurysm at the junction of the
AComm and the right A1-A2 junction. No other aneurysms are seen.
There is no evidence for vasospasm. There is a hypoplastic left
A1 segment. There is a tiny fenestration at the origin of the
basilar artery.
IMPRESSION:
2.5-mm aneurysm at the junction of the right A1, A2 and ACom
segments.
The study and the report were reviewed by the staff radiologist.
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND
FINDINGS: Grayscale and color Doppler images of the left and
right common
femoral, superficial femoral, and popliteal veins were obtained.
There is
non-compressibility and absence of wall-to-wall flow in the
proximal
superficial left femoral vein, consistent with a non-occlusive
deep venous
thrombosis. The remainder of the interrogated vessels
demonstrate normal
flow, compressibility, and augmentation.
IMPRESSION: Non-occlusive deep venous thrombosis of the left
proximal
superficial femoral vein. The findings were conveyed directly to
the ICU
nurse caring for the patient at the conclusion of the study.
[**2128-10-28**]: CT perfusion
IMPRESSION:
1. Status post extensive right frontal craniectomy with
placement of paired ventricular drains, with persistent
herniation of a significant portion of the right frontal lobe
through the craniectomy defect.
2. Hemorrhage and edema involving the paramedian frontal lobes,
bilaterally, which may represent evolving hemorrhagic
transformation of acute infarcts, or, less likely, contusions.
3. Continued blood in the interhemispheric fissure as well as
within the
ventricular chain, with a very small amount of residual
subarachnoid
hemorrhage.
4. Perfusion abnormality corresponding to the abnormal portion
of both frontal
lobes, but, elsewhere, perfusion is normal, and the CTA
demonstrates no
evidence of vasospasm or flow-limiting stenosis.
5. Chronic inflammatory changes involving the left sphenoidal
air cells and
bilateral maxillary antra.
see attached. Results pending at this time
Brief Hospital Course:
On [**11-26**] pt was brought to angio to have 5 coils placed into
A-comm aneurysm. Later in the day he was emergently brought to
the OR for emergent R craniectomy and bilat. EVD's placed. His
mental status remained poor and elevated ICP's. Pt was
chemically paralyzed, sedated and on Pentobarb in order to
decrease ICPs along with HHH therapy for vasospasm. On [**11-28**] the
R EVD was not-functioning and CT head showed increasing edema.
The pentobarb was weaned and paralytic d/c'd. He also had an
angio on [**11-29**] which did not show any vasospasm. Pentobarb was
then d/c'd on [**12-2**] and angio on that day showed mild vasospasm.
During this time pt was febrile and CSF was sent for culture
however pt was found to have LLL PNA which was treated and ID
was involved due to gram + cocci in CSF. On [**12-6**] the R EVD was
clamped and then removed on [**12-9**]. On [**12-9**] His exam remained
poor with only external rotation of BUE and triple flexion of
BLE with noxious. He was then found to have a L common fem DVT
and an IVC filter was placed. He also had elevated LFTs and
abdominal US was negative however an Abd CT was done to confirm
these findings. A CTA of the head was done as well to look for
vasospasm On [**12-10**], which was positive. he was Trached and
Peg'd. On [**12-11**] Patients exam has slowly improved, he is
opening his eyes and tracking the examiner and following simple
commands with his upper extremities, with minimal to no movement
of his lower extremities. During his ICU stay the patient has
been bronched multiple times for theraputic lavage and to obtain
a BAL. His sputum is positive for Coag negative staph. He is at
this time recieving Nafcillin per recommendations made by ID.
[**12-13**] Left EVD d/c'ed. [**12-14**] slight development of
hydrocephalus.
Medications on Admission:
None
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Acetaminophen 650 mg Suppository Sig: [**1-21**] Suppositorys Rectal
Q6H (every 6 hours) as needed.
6. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for fever >101.5.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Monitor INR weekly once theraputic .
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Per sliding Scale AC and hs.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q6H
(every 6 hours).
13. 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.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Vancomycin 1000 mg IV Q 8H
16. Piperacillin-Tazobactam Na 4.5 g IV Q8H
17. Med end dates
Vancomycin and Zosyn dosing will end [**2128-12-28**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aneursymal Subarachnoid Hemorrhage
Anterior communicating artery aneurysm
Atrial fibrillation
L common fem DVT
Respiratory failure
Cerebral Vasospasm
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Follow-Up Appointment Instructions
?????? Please return to the office in [**7-29**] days for removal of your
staples or sutures.
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 2 weeks.
?????? You will / will not need a CT scan of the brain with / without
contrast.
?????? You will / will not need an MRI of the brain with/ or without
gadolinium contrast.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? If you brain imaging for this appointment it can be arranged
by the office.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks please call [**Telephone/Fax (1) 1669**]
Completed by:[**2128-12-24**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12864**]
Admission Date: [**2128-11-26**] Discharge Date: [**2128-12-27**]
Date of Birth: [**2100-8-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 40**]
Addendum:
Addendum covering dates [**0-0-**]. Pt following simple
commands. Showing one and two fingers respectively. Hand grasps
equal and strong. Eyes open to voice. PERRLA Left 3mm, Right
4mm. Continued no movement in the LE's. + quad extraction to
noxious stimuli. Hemodynamically stable. [**First Name8 (NamePattern2) 12865**] [**Last Name (NamePattern1) 12866**], NP
Major Surgical or Invasive Procedure:
[**11-26**] a.m. Ventriculostomy placemtent
[**11-26**] A-Comm Aneurysm coiling
[**11-26**] Ventriculostomy placement
[**12-2**] Cerebral angiogram
[**12-8**] IVC filter
[**12-8**] Tracheostomy
[**12-8**] Peg
History of Present Illness:
See prior dictation
Past Medical History:
Non contributory
Social History:
Per mother: no Tobacco
[**Name (NI) 12867**] use
Family History:
Non contributory
Physical Exam:
As stated previously
Brief Hospital Course:
Stable. [**Hospital 11319**] transfer to [**Hospital3 **] when bed available.
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Acetaminophen 650 mg Suppository Sig: [**1-21**] Suppositorys Rectal
Q6H (every 6 hours) as needed.
6. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for fever >101.5.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Per sliding Scale AC and hs.
11. 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.
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
13. Vancomycin 1000 mg IV Q 8H
14. Piperacillin-Tazobactam Na 4.5 g IV Q8H
15. Med end dates
Vancomycin and Zosyn dosing will end [**2128-12-28**]
16. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
17. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Monitor 2x per week until Therapeutic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
Aneursymal Subarachnoid Hemorrhage
Anterior communicating artery aneurysm
Atrial fibrillation
L common fem DVT
Respiratory failure/Pneumonia
Cerebral Vasospasm
dysphagia / peg placed
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 1702**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? If you brain imaging for this appointment it can be arranged
by the office.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks please call [**Telephone/Fax (1) 8659**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2128-12-27**]
|
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59,731
| 144,388
|
4959
|
Discharge summary
|
report
|
Admission Date: [**2104-4-2**] Discharge Date: [**2104-4-18**]
Date of Birth: [**2052-11-30**] Sex: M
Service: MEDICINE
Allergies:
Thorazine / Haldol
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Fever, altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
(Pt obtunded; history obtained through OMR, group home and ED)
51 year-old man with schizophrenia and HTN who was last seen
leaving group home this morning. Approximately 2-3pm he was
found in field near group home by some kids playing baseball.
EMS was called and brought him to the ED. Per EMS patient was
somnolent, tremulous and with non-sensical speech. Per group
home the patient had reported general malaise for 3 days PTA and
had been running low grade temperatures. He was felt to have a
normal mental status the evening prior to admission. This
morning he awoke, took his medications and went out for some
time as is his usual habit; he generally returns to the group
home in time to take his evening medications. He recently had
some teeth extractions, but no other instrumentations or
surgeries. At baseline, he is alert, gets assistance with meds
but otherwise fairly functional and generally very polite and
hyper-religious as a part of his schizophrenia.
In the ED, initial vs were: T 102.7 HR 129 BP 128/110 RR 22
O2Sat 100 FS 129. On arrival to the ED, the patient had a
generalized tonic-clonic generalized seizure that lasted
approximately 30 seconds and was self-terminating. It was
witnessed by the ED staff. He was alert, oriented to person
only and with non-sensical speech per ED staff. Head CT and
neck CT scan were negative. His rectal temp was noted to be
105.1 so Toxicology consulted for extremely high fever due to
concern re: possible NMS given his psychiatric regimen. They
felt his symtpoms were more consistent with an infectious
eitology. Patient was given CeftriaXONE 2g IVx1, Vancomycin 1g,
Acyclovir 800 mg IV, Ampicillin Sodium 2 g IV, and tylenol 1gm
PR. He was given ativan total of 4mg IV, 2mg for sedation in
order to perform the LP and 2mg for tremors. LP performed and
opening pressure was 27.5. CSF was yellow-tinged but clear
consistent with bacterial infection. VS prior to transfer are T
102 HR 100-110 BP 140/70s O2sat 99% 3L.
Unable to obtain ROS [**12-25**] pt obtunded.
Past Medical History:
- Paranoid schizophrenia, severe - diagnosed at age 18,
committed to grp home, mandatory med compliance, has outside
psychiatrist, no recent HI/SI
- Prostate cancer s/p Brachytherapy [**2-28**]
- HTN
- Poor dentition - s/p multiple dental extractions at [**Hospital1 2177**]
recently
- Constipation, chronic -has been on several combinations of
stool softeners and often uses lactulose
- History of EtOH abuse
- Possible history of pericardial effusion & window in late 90s.
- No known seizure history
Social History:
Lives in group home which dispenses medications and meals. Has
one brother (very strained relationship). Victim of
physical/sexual abuse.
Tob: history of tobacco use, likely current smoker per brother.
EtOH: H/o of alcoholism, but no use recently.
IVDU: Denies
The patient has a conservator named [**Name (NI) **] [**Name (NI) **].
His brother's name is [**Name (NI) **] [**Name (NI) **].
Family History:
Mother died of MS
Father with alcoholism
Physical Exam:
ADMISSION EXAM:
General: obtunded, unlabored breathing, warm, diaphoretic
HEENT: NCAT, PERRL, Sclera anicteric, MMM, oropharynx with dry
MM and clear
Neck: supple, JVP 5, no LAD, EJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: rapid rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ radial, DP & PT pulses, no
clubbing, cyanosis or edema
Neuro: obtunded. A&Ox0, pupils 2mm and minimally reactive bilat,
intermittently responds to voice with garbled speech or one-two
word phrases, withdraws in all 4 extremities to pain,
intermittently follows commands, babinski mute bilat, neck
stiffness, extremeties with normal muscle tone.
EXAM UPON TRANSFER FROM ICU [**2104-4-5**]:
VS: 98.7, 124/88, 83, 22, 95% on 4L
GEN: NAD, unlabored breathing, interactive
HEENT: PERRL, EOMI, MMM, no oral lesions
NECK: Very mild stiffness, but no pain with movement
CV: RRR, normal s1 and s2, no murmurs
CHEST: CTAB
ABD: Soft, nontender, nondistended, bowel sounds present
SKIN: Face mildly plethoric
EXT: Trace edema BLE
NEURO: Awake, alert, oriented x3, CN 2-12 intact, strength 5/5
RUE and BLE, LUE has only [**1-25**] proximal muscle strength and [**2-25**]
wrist and handgrip strength, +dysmetria of LUE and exertional
tremor, sensory normal throughout, fluent speech
PSYCH: Very polite, calm, appropriate
EXAM ON DISCHARGE DAY [**2104-4-18**]:
VS: 98.1, 125/82, 87, 18, 97% on room air
GEN: NAD, unlabored breathing, interactive
HEENT: PERRL, EOMI, MMM, no oral lesions
NECK: Supple
CV: RRR, normal s1 and s2, no murmurs
CHEST: CTAB
ABD: Soft, nontender, nondistended, bowel sounds present
SKIN: Normal
EXT: Trace edema BLE
NEURO: Awake, alert, oriented x3, CN 2-12 intact, strength 5/5
RUE and BLE, LUE has only [**2-25**] proximal muscle strength and [**3-26**]
wrist and handgrip strength, Dysmetria of LUE has greatly
improved, sensory normal throughout, fluent speech
PSYCH: Very polite, calm, appropriate
Pertinent Results:
LABS/STUDIES:
[**2104-4-2**] 03:30PM
WBC-13.1*# RBC-4.31* HGB-13.5* HCT-39.6* MCV-92 MCH-31.2
MCHC-34.0 RDW-14.6
NEUTS-90.3* LYMPHS-5.0* MONOS-4.5 EOS-0 BASOS-0.2
PLT COUNT-202
PT-11.4 PTT-30.1 INR(PT)-0.9
LITHIUM-NEGATIVE VALPROATE-90
GLUCOSE-113* UREA N-7 CREAT-0.9 SODIUM-131* POTASSIUM-3.1*
CHLORIDE-87* CO2-28
ALT(SGPT)-19 AST(SGOT)-33 CK(CPK)-319 ALK PHOS-73 TOT BILI-0.4
LIPASE-18
[**2104-4-5**]:
NA 132, K 4.3, CL 98, CO2 27, BUN 13, CR 0.7, GLU 131
Ca: 8.4 Mg: 2.2 P: 2.1
ALT: 49 AP: 60 Tbili: 0.2 AST: 64 LDH: 200
WBC 13.9, HCT 33.2, PLT 222, MCV 94
PT: 11.5 INR: 1.0
URINE [**2104-4-2**]: COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 BLOOD-LG
NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-50 BILIRUBIN-SM
UROBILNGN-8* PH-6.5 LEUK-NEG
bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG
mthdone-POS
CSF [**2104-4-2**]: PROTEIN-222* GLUCOSE-7 WBC-704 RBC-95* POLYS-93
LYMPHS-4 MONOS-3 WBC-483 RBC-141* POLYS-95 LYMPHS-5 MONOS-0
MICRO:
[**2104-4-2**] BLOOD CULTURE {STREPTOCOCCUS PNEUMONIAE}
[**2104-4-2**] BLOOD CULTURE {STREPTOCOCCUS PNEUMONIAE}
[**2104-4-2**] CSF;SPINAL FLUID FLUID CULTURE-FINAL
{STREPTOCOCCUS PNEUMONIAE}
STREPTOCOCCUS PNEUMONIAE:
CEFTRIAXONE-----------<=0.06 S
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- 1 S
MEROPENEM------------- S
PENICILLIN G----------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
BLOOD CULTURES: [**Date range (1) 13508**] NGTD.
IMAGING:
CXR [**2104-4-2**]: IMPRESSION: Elevated left hemidiaphragm with left
basilar atelectasis versus pneumonia. Consider lateral view to
aid in evaluation.
CT HEAD [**2104-4-2**]: -IMPRESSION:
1. No acute intracranial process.
2. Chronic sinusitis of the right maxillary sinus.
CT C-SPINE [**2104-4-2**]: -IMPRESSION:
No acute fracture or traumatic malalignment. If there is a
clinical concern for spinal cord injury, an MRI can be performed
for further assessment.
EEG [**2104-4-3**]:
IMPRESSION: Abnormal EEG in the waking and drowsy states due to
the
bilateral independent areas of mixed frequency slowing and due
to the
lower voltage background and loss of normal frequencies broadly
on the
right. The slowing suggests bilateral areas of subcortical
dysfunction
but cannot specify the etiology. Vascular disease is one
possibility.
The widespread lower voltage and loss of background frequencies
on the
right suggest a widespread cortical dysfunction. This could come
from
cortical loss itself (e.g. with vascular lesions) or, less
frequently,
from material interposed between the brain and recording
electrodes,
such as subdural fluid. Nonetheless, there were no areas of
prominent
delta slowing, and there were no epileptiform features.
MRI HEAD [**2104-4-3**]: -IMPRESSION:
1. Diffuse leptomeningeal FLAIR hyperintensity, with debris
layering in the posterior horns of the lateral ventricles. The
findings are highly suspicious for a meningitis and
ventriculitis. There is no definite evidence of an empyema given
that the decreased diffusion associated with debris layering in
the occipital horns do not demonstrate any abnormal enhancement
in that region.
2. A few non-specific foci of white matter signal abnormality
are noted in
the white matter, which may represent the sequela of chronic
microangiopathy given the patient's age. There is mild
parenchymal volume loss as well.
3. Diffuse hyperostosis of the calvarium and visualized facial
bones, of
unclear significance.
ECHOCARDIOGRAM [**2104-4-4**]: Conclusions
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. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior report (images unavailable for review)
of [**2099-8-6**], the findings are similar.
CXR [**2104-4-4**]:
1. Findings concerning for right lower lobe pneumonia.
2. Mild central pulmonary vascular congestion without frank
pulmonary edema.
3. Apparent chronic left hemidiaphragmatic elevation.
CXR [**2104-4-5**]:
IMPRESSION: Concern for newly developing airspace disease in the
right upper lobe; followup recommended.
COMPLETE BLOOD CT WBC RBC Hgb Hct MCV Plt
[**2104-4-17**] 05:09 8.4 3.03* 9.5* 28.9* 95 427
RENAL & GLUCOSE Glu BUN Cr Na K Cl HCO3 AG
[**2104-4-17**] 05:09 741 8 0.6 132* 4.3 94* 33* 9
Brief Hospital Course:
51 yo male with schizophrenia was brought in by ambulance after
being found down, subsequently febrile and had a seizure in ED
admitted to the ICU with pneumococcal meningitis and bacteremia
with the subsequent development of RLL/RUL PNA. It is possible
that the PNA was the source of the infection vs a complication
of aspiration from being obtunded. The patient rapidly improved
and was subsequently transferred to the medicine floor.
On the floor, he had a notable left upper extremity weakness and
dysmetria upon transfer from the ICU. These are likely sequelae
from the meningitis and actually showed improvement daily as his
meningitis resolved. The patient was medically ready to be
transitioned to rehabilitation facility but guardianship posed
logistical difficulties. The patient has a guardian, but the
court to [**Doctor First Name 8266**] him power to consent to rehab. Patient was fully
treated with 2 weeks of IV antibiotics in hospital given time
course for court appointments, and he did well so is being sent
back to his group home.
The patient was also found to have primary polydipsia (urine osm
150, serum osm normal). If left to his own desires, he can
easily drink more than 10 liters of fluid a day. Fluid
restriction was placed because of developing hyponatremia in
setting of persistent fluid requests by the patient.
# Pneumococcal meningitis and bacteremia: The patient was
initially treated with broad spectrum antibiotics and
dexamethasone for bacterial meningitis. His CSF and 2 sets of
blood cutlures eventually grew Pneumococcus which was
pan-sensitive. His antibiotics were narrowed to ceftriaxone and
he completed 14 days in hospital via PICC line. Initial
obtundation was [**12-25**] meningitis. Mental status returned to
baseline within 48 hours after starting treatment.
# RLL/RUL PNA: Primary vs aspiration from being obtunded.
Swallow evaluation found no evidence of aspiration. The
antibiotics covered infectious etioloigies, and clinically he
improved. A follow-up CXR is recommended as outpatient in [**2-26**]
weeks to ensure that it has cleared.
# Seizure: The patient has no known history of seizure
disorder. He had one witnessed generalized tonic clonic seizure
in the ED. EEG was negative for seizure activity, but
concerning for possible abscess in the brain. MRI was performed
and showed only leptomeningeal enhancement. Neurology evaluated
the patient felt that antiepileptic medications were not
indicated at this time.
# Hyponatremia: Patient was initially volume depleted and
hypernatremic. It improved with fluid resuscitation. The
patient also has psychogenic polydipsia. Fluid restriction was
placed to prevent patient from developing hyponatremia from
polydipsia. He does well with 2.5 liters fluid/day.
# Schizophrenia: Per group home has been well controlled on
current medications. Psychiatry was consulted to assist with
medication management in the setting of patient's altered mental
status. All of his medications were held initially except for
the Depakote. He is currently on all of his medications for
schizophrenia except for Naltrexone (non-formulary) which should
be restarted at discharge. Periodic CBC should be checked (per
Psychiatry) to monitor for Clozapine-associated agranulocytosis.
# Constipation, chronic: He was treated with aggressive bowel
regimen with colace, senna, bisacodyl and lactulose.
# Hypertension: Amlodipine continued.
# DVT Prophylaxis: Heparin Subcutaneous
# Code status: Full code (confirmed with brother and group
home)
# Communication:
Patient's Legal Guardian: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 20579**], (c)
[**Telephone/Fax (1) 20580**]. Would make all health decisions for him. Patient
does not have the ability to change code status or consent for
major surgery.
Brother: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 20581**]
Medications on Admission:
# Metamucil 0.52 g Cap 1 Capsule(s) by mouth once a day
# Multivitamin Tab 1 Tablet(s) by mouth once a day
# Acetaminophen 325 mg [**11-24**] Tablet(s) by mouth every 6 hours as
needed for pain; never exceed 3,000mg in one day
# Cogentin 1 mg by mouth qhs **uncertain if PO or IM**
# Guaifenesin 100 mg/5 mL Oral Liquid [**3-31**] ml(s) by mouth up to
four times a day
# Colace 100 mg Cap one Capsule(s) by mouth twice daily
# Naltrexone 50 mg Tab one Tablet(s) by mouth q am
# Amlodipine 5 mg Tab 1 Tablet(s) by mouth Daily
# Depakote 250 mg in am and 750 mg in pm
# Clozaril 100 mg PO in am, 400 mg in pm and 25mg PO QHS.
# Perphenazine 8 mg Tab 1 Tablet(s) by mouth twice a day
# Perphenazine 8 mg PO daily PRN agitation.
Discharge Medications:
1. Naltrexone 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablets* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QPM (once a day (in the
evening)).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Clozapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
6. Clozapine 100 mg Tablet Sig: Four (4) Tablet PO QPM (once a
day (in the evening)).
Disp:*120 Tablet(s)* Refills:*0*
7. Perphenazine 8 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-24**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
Constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Metamucil 0.52 g Capsule Sig: One (1) Capsule PO once a day
as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
12. Benztropine 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for Stiffness from Extrapyramidal Signs.
Disp:*15 Tablet(s)* Refills:*0*
13. Guaifenesin 100 mg/5 mL Liquid Sig: [**3-31**] ml PO every [**2-26**]
hours as needed for cough.
Disp:*1 bottle* Refills:*0*
14. Perphenazine 8 mg Tablet Sig: One (1) Tablet PO once a day
as needed for Agitation.
Disp:*15 Tablet(s)* Refills:*0*
15. Miralax 17 gram Powder in Packet Sig: One (1) Packet PO once
a day as needed for constipation.
Disp:*30 Packets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Pneumococcal meningitis and bacteremia
- Pneumonia, aspiration versus primary
- Psychogenic polydipsia
SECONDARY DIAGNOSES:
- Paranoid schizophrenia, severe
- Prostate cancer
- Hypertension
- Poor dentition - s/p multiple dental extractions at [**Hospital1 2177**]
recently
- Constipation, chronic
- History of alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were found unresponsive outside of your group home and
brought to the Emergency Department where you also had a
seizure. Exam and laboratory studies revealed that you
developed meningitis (Brain infection) and bacteremia (infection
in your blood) from a bacteria called Pneumococcus (Strep
pneumoniae). When unresponsive, you likely also developed
pneumonia. Antibiotics were administered for 14 days to treat
these infections and you have done well. You need a repeat
chest xray in THREE WEEKS.
You are maintained on 2 to 3 liters of fluid restriction because
you drink too much fluid, which causes potentially dangerous
electrolyte disturbances which can harm your health. Please do
not exceed this fluid restriction limit.
MEDICATION CHANGES:
1. Depakote was increased to the following dosing schedule:
250mg PO QAM and 1000mg PO QPM. Psychiatry should follow liver
tests and Depakote level.
2. Constipation meds are Docusate, Senna, Bisacodyl, Metamucil,
and Miralax as needed
3. No other changes were made to the medication regimen
***Mr. [**Known lastname **] should take 3 days off to re-acclimate to his home
environment before resuming his chores. He may resume all
chores beginning [**2104-4-22**].
Followup Instructions:
APPOINTMENT #1
Department: PSYCHIATRY
When: [**2104-4-24**] at 09:00AM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
Building: [**Hospital **] [**Hospital 4189**] Health Center
[**Hospital1 **]. [**Location (un) 538**] - [**Location (un) 86**], MA
Tel: [**Telephone/Fax (1) 20582**]
Fax: [**Telephone/Fax (1) 20583**]
APPOINTMENT #2
Department: [**Hospital3 249**]
When: MONDAY [**2104-4-28**] at 10:50 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
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icd9pcs
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]
] |
17111, 17117
|
10411, 14317
|
308, 325
|
17508, 17508
|
5531, 10388
|
18906, 19576
|
3345, 3387
|
15092, 17088
|
17138, 17263
|
14343, 15069
|
17659, 18396
|
3402, 5512
|
17284, 17487
|
18416, 18883
|
240, 270
|
353, 2397
|
17523, 17635
|
2419, 2922
|
2938, 3329
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,307
| 152,397
|
9074
|
Discharge summary
|
report
|
Admission Date: [**2104-5-29**] Discharge Date: [**2104-6-2**]
Date of Birth: [**2081-3-17**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 21007**]
Chief Complaint:
Vulvar abscess
Tachycardia
Major Surgical or Invasive Procedure:
Incision and Drainage
History of Present Illness:
23 year old female 4 months postpartum presenting with recurrent
left labial abscess. The patient was first treated for a labial
abscess in [**3-20**] with I/D and oral antibiotics. She did not
complete the course of bactrim. Three days prior to admission
she noted the onset of swelling and pain over the left labia
majora. She had pain with walking and sitting. No fever, chills
or other systemic symptoms. She presented today for evaluation.
.
In the ED, vitals were 98 113/66 93 16 99% RA. She underwent I/D
of the labial cyst and developed chills/rigors following the
procedure. Her BP dropped to 86/63 and heart rate increased to
130s. She was given 4L of fluid, but remained tachycardic and
was admitted to the ICU for further management. Tmax 99.9. She
was treated with vancomycin and ceftriaxone. She had a reaction
to the morphine with lightheadedness and rash, treated with
Benadryl. Blood and wound cultures taken after administration of
antibiotics. GYN was consulted.
.
At arrival to the floor, she is feeling tired and but without
acute complaint. She has some mild tightness across her chest
with deep inspiration but denies chest pain or specific
shortness of breath or wheezing. She denies scratchy or swollen
throat or tongue, but does note some hoarseness to her voice.
Not sexually active currently, no new partners or HIV risk
factors since her delivery. No leg swelling or redness. She is
not breast feeding.
Past Medical History:
PMH: none
PSH: Drainage of vulvar abscess x 2 at bedside
Ob: SVD x 1 [**2104-2-9**]
GynHx: Reports nl Pap, denies hx of STI.
Social History:
single, father of baby taking care of child. No
tobacco/alcohol/drugs and works part time
Family History:
Hypertension, no history of blood clots.
Physical Exam:
98.2 102/58 125 98% RA
Gen: well appearing, facial plethora, no distress, speaking
fluently
HEENT: periorbital edema, PERRL, OP clear, MMM, no MM swelling
Neck: no LAD
Car: Tachycardic, hyperdynamic precordium
Resp: CTAB--no wheeze, crackles
Abd: s/nt/nd/nabs No HSM
Ext: no LE edema
GYN: left labia majora site of I/D c/d/i with wick in-place-not
indurated. Tender to touch, tender also along inner aspect of
left leg without discrete abscess. No cellulitis.
Pertinent Results:
ADMISSION LABS:
===============
[**2104-5-29**] 08:30PM WBC-2.0*# RBC-4.45 HGB-13.0 HCT-37.1 MCV-83
MCH-29.1 MCHC-34.9 RDW-15.0
[**2104-5-29**] 08:30PM NEUTS-57 BANDS-1 LYMPHS-42 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2104-5-29**] 08:30PM PLT COUNT-295
[**2104-5-29**] 08:30PM GLUCOSE-65* UREA N-10 CREAT-0.8 SODIUM-140
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
[**2104-5-29**] 08:43PM LACTATE-4.0*
[**2104-5-29**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-5-29**] 10:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2104-5-29**] 10:32PM LACTATE-2.0
[**2104-5-29**] 6:50 pm ABSCESS
GRAM STAIN (Final [**2104-5-29**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2104-6-2**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2104-6-2**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
[**5-29**] Blood Cultures x 2: pending
[**5-29**] Urine Culture: negative
Brief Hospital Course:
MICU COURSE:
The patient was admitted for hypotension and tachycardia s/p
labial I&D. This was likely both a manifestation of bacteremia
following I&D as well as allergic reaction. Her hypotension
resolved with IVF boluses. She had some mild facial swelling
and hoarse voice following antibiotic administration. She was
started on vancomycin and unasyn, but was noted that during
vancomycin administration, she again had some allergic reactions
with hypotension, tachycardia, and periorbital edema.
Vancomycin was held and instead, she was started on bactrim for
MRSA coverage. Epipen remained at bedside and did not need to
be used. She was also started on famotidine and benadryl
standing doses for probable allergic reaction.
GYN COURSE:
The patient was transferred to 12R on HD#2/POD#1. She was
treated with Unasyn and Bactrim throughout the remainder of her
hospitalization. She had no further signs or symptoms
suggestive of an allergic reaction.
Additionally, she has daily left labial packing changes for
which she was pre-medicated wit Percocet.
She was afebrile, with a WBC count of 4.6 on her day of
discharge.
She was discharged home on HD#5/POD#4 in stable condition. VNA
was arranged for daily labial packing changes. She will remain
on Augmentin and Bactrim for ten days.
Medications on Admission:
Prenatal vitamins
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain and packing change for 7
days.
Disp:*20 Tablet(s)* Refills:*0*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. 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*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
vulvar abscess
adverse reaction to vancomycin
Discharge Condition:
good
Discharge Instructions:
Call for fever, increasing pain, swelling, or discharge at
wound, nausea and vomiting, or any other questions or concerns.
Take all of your antibiotics.
Do not drive while taking narcotics.
Follow up with Dr. [**Last Name (STitle) **] at the end of this week, [**Last Name (STitle) 2974**], [**6-6**] Clinic.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] at [**Hospital **] [**Hospital **] clinic on [**Last Name (LF) 2974**], [**6-6**].
[**First Name8 (NamePattern2) 3130**] [**Last Name (NamePattern1) 3131**] MD, [**MD Number(3) 21009**]
|
[
"E930.8",
"784.2",
"616.4",
"288.00",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"71.09"
] |
icd9pcs
|
[
[
[]
]
] |
6027, 6084
|
3960, 5262
|
311, 334
|
6174, 6181
|
2607, 2607
|
6538, 6801
|
2069, 2111
|
5330, 6004
|
6105, 6153
|
5288, 5307
|
6205, 6515
|
2126, 2588
|
245, 273
|
362, 1797
|
2623, 3937
|
1819, 1946
|
1962, 2053
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,906
| 102,876
|
48022
|
Discharge summary
|
report
|
Admission Date: [**2165-3-18**] Discharge Date: [**2165-3-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
R IJ placement
History of Present Illness:
Mr. [**Known lastname **] is a 89 year-old man with a history of CAD s/p CABG,
CHF (EF 25%) and PAF who initially p/w respiratory distress,
transferred to the ICU on day of admission for continued
borderline hypoxia and tachypnea, DNR/I, briefly on Dopa gtt for
hypotension, then called out to floor on [**3-20**] at night, now
re-transferred to MICU for recurrent SOB.
.
Of note, two recent admission: First admission ([**2-18**] - [**2-20**]) was
for an enterococcal UTI; he was treated with ampicillin and
discharged to home. Second admission ([**3-1**] to [**3-8**]) was for CHF
in the setting of afib with RVR; he was treated with rate
controlling agents (amiodarone was added to metoprolol);
valsartan was also added to his regimen. At rehab the day before
admission, he developed labored breathing and inability to
urinate.
.
In the ED, initial vitals were HR 124 BP 80s-90s/30s-40s
RR:20-30 O2Sat 97% on 2L NC. BNP [**Numeric Identifier 101296**], down from [**Numeric Identifier 101294**] on last
admission [**2165-3-1**]. A CXR showed bilateral effusions,
atelectasis, and appearance concerning for left lower lobe
pneumonia. He was given 500 mg levofloxacin given and 2 liters
of NS. Also recieved nebs given.
.
On the floor, his labored breathing -> IV lasix, foley placed ->
350cc of cola-colored urine. ABG 7.40/38/64. On arrival to the
MICU, pt with SBPs in 80's then drifting into ?60's-70's. He was
transiently on Dopa gtt, weaned off and started on empiric Vanc
and Zosyn for possible PNA although afebrile and normal WBC but
productive cough. Lactate was initially 3.0, then trended down
to 1.4. Pt had reportedly his flu shot. Legionella Ag was
negative. A repeat Echo did not show worsening EF or tamponade
but worsened MR. Elevated cardiac enzymes were felt to be due to
past event or demand ischemia. Also in acute on chronic renal
failure with Cr of 3.3. INR supratherapeutic, thus coumadin was
held. Once off the dopa, he was called out to the floor in AM on
[**3-20**]. However, developed AF/RVR and was kept in the ICU until
9PM. He received 5mg IV lopressor with rate control. He also
received 40 IV lasix since it was felt that he was now fluid
overloaded. Once stable, he came to the floor on 9PM on [**3-20**].
.
On the floor, he triggered overnight for tachypnea and AF/RVR.
He received 10 IV dilt with rate control. He also received
2x250cc IVF boluses for SBP in 90s. A foley was placed and 1L
dark urine came back. UA without infection. In the morning, he
was restarted on abx (Vanc/CTX this time). He was found to be
tachypneic again. ABG was 7.38/41/77. CXR was ordered. He was
given 40 IV lasix, O2 was uptitrated on NC, then switched to FM.
Nebs were given. It was felt that he was tiring out and would
benefit from retransfer to MICU, also for possible lasix gtt
since BP dropped to low 90s after IV lasix bolus.
.
On arrival to the ICU on [**3-21**], he was less tachypneic, satting
100% on 3L NC but still using accessory muscles. He denied any
CP, palpitations, but has productive cough (whitish sputum x2
weeks). No F/C/N.
.
ROS: negative for abdominal pain, N/V/D, urinary sxs. Last BM
few days ago.
Past Medical History:
1. Systolic Congestive Heart Failure: Infarct-related. EF ~20%
on echocardiogram [**4-/2164**]
2. Coronary Artery Disease: S/P CABG w/ LIMA-LAD, SVG-OM1-OM2,
SVG-RCA-PL. Last P-MIBI [**2-14**] w/ large fixed defect involving the
entire inferior wall and the basal inferoseptum and the basal
inferolateral (PDA region). History of small nonQ wave infarct.
3. Paroxysmal Atrial Fibrillation - on coumadin
4. Type II Diabetes (non-insulin dependent) controlled
5. Peripheral Vascular Disease w/ AAA and common iliac aneurysm
6. CVA in [**2153**]
7. GERD
8. LBBB on EKG
9. NSVT - has declined ICD in the past
10. Hypertension
11. Hyperlipidemia
Social History:
Wife currently has cancer, lives with her in [**Hospital3 **]
apartment. He denies ever smoking, etoh or other illicits.
Family History:
Family history of hypertension and coronary artery disease
Physical Exam:
Vitals: T 96.7, BP 107/34, HR 76 SR, RR 22, 100% on 3L, CVP 10
GEN - Elderly male in mild respiratory distress. Able to
complete full sentences but uses accessory muscles to breathe.
SKIN - bruises over L arm and back, no rash
HEENT - PERRL, EOMI, dry MM, JVP up to jaw (but with known
2+TR), no HJR, R IJ in place
CV - RR, nl S1, S2, no obvious murmur appreciated.
PULM - Dull at bases, crackles half-way up, diffuse wheezes.
ABD - Soft and non-tender. nondistended, sparse BS, no
hepatomegaly appreciately, no hepatic tenderness suggesting
congestion.
EXT - Warm. No peripheral edema. No clubbing or cyanosis.
NEURO - A&O x 3, responds appropriately to all questions. Moves
all extremities.
Pertinent Results:
[**2165-3-18**] 10:35AM WBC-9.9# RBC-3.45* HGB-10.3* HCT-30.2* MCV-88
MCH-29.7 MCHC-34.0 RDW-14.7
[**2165-3-18**] 10:35AM NEUTS-86.3* BANDS-0 LYMPHS-8.7* MONOS-4.7
EOS-0.1 BASOS-0.1
[**2165-3-18**] 10:35AM PLT SMR-NORMAL PLT COUNT-175
[**2165-3-18**] 10:35AM proBNP-[**Numeric Identifier 101296**]*
[**2165-3-18**] 10:35AM GLUCOSE-101 UREA N-93* CREAT-3.2* SODIUM-136
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-28 ANION GAP-18
[**2165-3-18**] 10:35AM ALT(SGPT)-17 AST(SGOT)-41* ALK PHOS-66 TOT
BILI-0.5
[**2165-3-18**] 08:07PM LACTATE-3.0*
.
ECG #1: NSR with LBBB.
ECG #2: Afib with RVR (rate 129)
ECG [**2165-3-21**]: LAD, LBBB, no acute ST changes
.
CXR [**3-21**] (read pending): prelim read by MICU with no significant
change to yesterday, retrocardiac opacity visible, b/l
effusions, minimal pulmonary edema.
.
CXR [**3-20**]:
As compared to the previous radiograph, there is no major
change. Extensive cardiomegaly with retrocardiac opacities.
Small bilateral pleural effusions. Unchanged position of the
central venous access right.
.
Echo [**2165-3-19**]:
Severe regional left ventricular systolic dysfunction with
akinesis of the inferior and inferolateral walls, hypokinesis of
the setpum, anterior and lateral walls. The basal to mid septum
contracts best. (LVEF= 20 %). (3+)MR, 2+ TR. moderate pulmonary
artery systolic hypertension. IMPRESSION: Moderately dilated
left ventricular cavity with severe regional dysfunction
consistent with multivessel coronary disease. Moderate to severe
mitral regurgitation. At least moderate pulmonary hypertension.
c/w [**2164-4-25**], the severity of mitral regurgitation has
increased. Estimated pulmonary pressures are higher.
.
CXR ([**2165-3-18**]): Bilateral effusions, atelectasis, and appearance
concerning for left lower lobe pneumonia.
.
PFTs ([**2165-3-8**]): Normal spirometry and lung volumes. The reduced
DLCO suggests a perfusion limitation. There are no prior studies
available for comparison.
.
TTE ([**2164-4-25**]): EF 20%, inferior/inferolateral
akinesis/dyskinesis and hypokinesis elsewhere. Mild to moderate
([**12-12**]+) mitral regurgitation is seen. Biatrial enlargement.
.
Micro data:
[**2165-3-21**] SPUTUM GRAM STAIN-good sample, 2+ GPC IN PAIRS AND
CLUSTERS. Cx-PENDING
[**2165-3-21**] Ucx-PENDING
[**2165-3-20**] Ucx-PENDING
[**2165-3-19**] URINE Legionella Urinary Antigen -negative
[**2165-3-18**] Ucx negative
[**2165-3-18**] Bcx pending x2
Brief Hospital Course:
89M w/ CAD s/p CABG, CHF (EF 25%), PAF p/w tachypnea, cough,
course c/b hypotension in MICU (briefly on dopa gtt), Vanc/Zosyn
for PNA, AF/RVR, A/CRF, on floor again tachypneic,
re-transferred to MICU for possible noninvasive ventilation,
instead pt remained stable on NC, was treated for 7 days with
Vanc/CTX for PNA, remained labile with regards to BP and UOP,
was initially started on NTG gtt and Lasix gtt, then switched to
Milrinone gtt and continue on Lasix gtt with moderate increase
in UOP. His Cr continued to increase and the patient stated that
he would not want hemodialysis if this became necessary.
Decision was made to transition to comfort care, and pt. was
d/c'd of all noncomfort medications. He was transferred to
floor and expired 5PM [**3-29**]. Autopsy declined.
.
Medications on Admission:
MEDICATIONS (rehab):
1. Aspirin 81 mg daily
2. Coumadin 2 mg PO QD
3. Lasix 40 mg PO once a day-recent increase to [**Hospital1 **], but says
was
not taking prior
4. Valsartan 80 mg [**Hospital1 **]
5. Amiodarone 200 mg QD
6. Isosorbide Mononitrate 30 mg
7. Metoprolol 50 mg Sustained Release PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Glipizide 5 mg daily
10. Calcitriol 0.25 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Ampicillin 500 mg PO twice a day for 14 days twice a day
starting [**2-21**].
13. RISS
- miconazole powder 85 gm topical TID
.
MEDICATIONS (on first transfer to MICU on [**3-18**]):
- levofloxacin 250 mg Q48 day 1
- zosyn 2.25g Q8H day 1
- vanco 1 g x1 today
- Isosorbide Mononitrate 30 mg daily
- Metoprolol 50 mg [**Hospital1 **]
- Calcitriol 0.25 mcg PO DAILY
- Aspirin 81 mg Tablet, PO DAILY
- Coumadin 2 mg PO QD
- Lasix 40 mg PO BID
- Amiodarone 400 mg QD
- RISS
- miconazole powder 85 gm topical TID
- Albuterol nebs Q3H; ipratropium neb Q4H
.
MEDICATIONS (on re-transfer to MICU on [**3-21**]):
- Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN
- Insulin SC (per Insulin Flowsheet)
- Ipratropium Bromide Neb 1 NEB IH Q4H
- Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN
- Metoprolol Tartrate 12.5 mg PO BID
- Acetylcysteine 20% 6-10 mL NEB Q6H:PRN congestion
- Miconazole Powder 2% 1 Appl TP TID
- Amiodarone 200 mg PO DAILY
- Senna 1 TAB PO BID:PRN
- Aspirin 325 mg PO DAILY
- Simvastatin 20 mg PO DAILY
- Bisacodyl 10 mg PO DAILY:PRN
- Calcitriol 0.25 mcg PO DAILY
- Cepacol (Menthol) 1 LOZ PO PRN
- CeftriaXONE 1 gm IV Q24H
- Valsartan 80 mg PO DAILY
- Docusate Sodium 100 mg PO BID
- Zolpidem Tartrate 5 mg PO HS:PRN
- Vancomycin 1000 mg IV ONCE
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
chronic CHF
Diabetes
Atrial fibrillation
Hypertension
Discharge Condition:
expired
Followup Instructions:
none
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"276.2",
"250.00",
"427.31",
"428.0",
"414.01",
"518.5",
"276.51",
"585.4",
"416.8",
"486",
"530.81",
"584.9",
"443.9",
"785.59",
"403.90",
"272.4",
"511.9",
"424.0",
"428.23",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10082, 10091
|
7534, 8324
|
271, 287
|
10188, 10197
|
5071, 7511
|
10220, 10321
|
4283, 4343
|
10053, 10059
|
10112, 10167
|
8350, 10030
|
4358, 5052
|
222, 233
|
315, 3462
|
3484, 4129
|
4145, 4267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,535
| 113,469
|
2249
|
Discharge summary
|
report
|
Admission Date: [**2133-5-26**] Discharge Date: [**2133-6-4**]
Date of Birth: [**2068-9-24**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 64 year old gentleman
who has a recent significant history for excision of
malignant melanoma in [**2133-3-19**], with bilateral groin lymph
node dissection with positive groin lymph nodes, had been
recovering well until one week prior to admission when he
developed increasing shortness of breath and decreased
exercise tolerance, positive orthopnea, paroxysmal nocturnal
dyspnea, and left sided chest discomfort with exertion. The
patient presented to outside radiation technologist to
receive radiation therapy to his groin, where upon discovery
of symptoms, the patient was referred to the Emergency
Department for further evaluation.
PAST MEDICAL HISTORY: Type 2 diabetes mellitus.
Hypertension.
Hypercholesterolemia.
History of malignant melanoma as previously described.
Status post ventral hernia repair.
MEDICATIONS ON ADMISSION:
1. Glucophage 500 mg p.o. twice a day.
2. Glipizide 1.25 mg p.o. once daily.
3. Hydrochlorothiazide 25 mg p.o. once daily.
4. Lisinopril 40 mg p.o. once daily.
5. Verapamil XR 240 mg p.o. once daily.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] where he was noted to have
congestive heart failure by chest x-ray, was started on
Heparin drip, Lasix for diuresis and he subsequently
improved. The patient was taken for cardiac catheterization
on [**2133-5-27**], which showed pulmonary artery pressure of 59/32
with a wedge of 32, 100 percent mid right coronary artery
lesion, 100 percent mid left anterior descending coronary
artery lesion, 90 percent first diagonal lesion, 100 percent
obtuse marginal lesion. During the cardiac catheterization,
the patient developed worsening pulmonary edema and
subsequent respiratory failure and required emergent
intubation for this. The patient had an intra-aortic balloon
pump placed in the cardiac catheterization laboratory and the
patient was taken to the operating room by Dr. [**Last Name (STitle) 70**]
emergently for a coronary artery bypass graft and a mitral
valve repair. The patient's ejection fraction had previously
been determined on echocardiogram to be 25 percent with three
plus mitral regurgitation.
In the operating room upon performing sternotomy, it was
noted the patient had a fair number of darkly colored nodules
as well as a dark rubbery spot on the heart. These tissues
were sent to the pathology department with the subsequent
frozen section coming back positive for melanoma. In the
operating room, the patient [**Last Name (STitle) 1834**] a coronary artery
bypass graft times two, saphenous vein graft to left anterior
descending coronary artery, saphenous vein graft to obtuse
marginal, as well as a mitral valve repair. Postoperatively,
the patient was transported to the Intensive Care Unit in
stable condition with an intra-aortic balloon pump which had
been placed in the cardiac catheterization laboratory on a
Milrinone infusion, Levophed infusion, Epinephrine infusion.
Please see operative note for full details.
The patient remained intubated on his first postoperative
night with good hemodynamics. The Milrinone was weaned down.
Intra-aortic balloon pump was removed on postoperative day
number one. The patient was weaned and extubated from
mechanical ventilation on postoperative day number two. On
postoperative day number two after the patient developed
atrial fibrillation, the patient was started on Amiodarone
and Lopressor after the pressors and inotropes had been
weaned off. The pulmonary artery catheter was removed as the
patient continued to have good hemodynamics in spite of the
atrial fibrillation. Chest tubes were removed without
incident. On postoperative day number three, the patient
began working with physical therapy. On postoperative day
number four, the patient was transferred from the Intensive
Care Unit to the regular part of the hospital. By that time,
he had converted into sinus rhythm. He had no further atrial
fibrillation. The patient's pacing wires were removed on
postoperative day number five.
At that time, he was noted to have a moderate amount of
serosanguinous drainage from his sternal incision. The
patient was started on Keflex. The amount of drainage
decreased over the next several days and had completely
disappeared by postoperative day number seven. By
postoperative day number six, the patient had completed a
level V with physical therapy and was able to ambulate 500
feet and climb one flight of stairs without difficulty and at
that time had been cleared for discharge to home by physical
therapy; however, due to the patient's drainage from his
sternal incision, the patient remained in the hospital until
postoperative day number eight at which time he was cleared
from a cardiac surgery standpoint.
CONDITION ON DISCHARGE: Temperature maximum 98.8, pulse 93,
sinus rhythm, blood pressure 123/79, respiratory rate 16,
oxygen saturation in room air 94 percent. Laboratory date
showed white blood cell count 12.9, hematocrit 31.4, platelet
count 337,000. Sodium 137, potassium 4.6, chloride 100,
bicarbonate 26, blood urea nitrogen 27, creatinine 1.0. The
patient's weight on [**2133-6-4**], is 126 kilograms. The patient
weighed 120 kilograms preoperatively. Neurologically, the
patient is awake, alert and oriented times three.
Examination is nonfocal. Heart is regular rate and rhythm
without rub or murmur. Respiratory - breath sounds are
decreased at bilateral bases. Gastrointestinal - The abdomen
is obese, positive bowel sounds, nontender, nondistended.
Sternal incision is clean and dry. There is a small amount,
less than one half centimeter, of erythema at the distal
portion of the incision. The sternum is stable. Bilateral
lower extremities have two to three plus pitting edema. The
left lower extremity vein harvest site has a small amount of
serous drainage, no erythema and no pain on palpation.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg p.o. twice a day times ten days.
2. Potassium Chloride 20 mEq p.o. twice a day times ten days.
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Enteric Coated Aspirin 325 mg p.o. once daily.
6. Plavix 75 mg p.o. once daily.
7. Lopressor 25 mg p.o. twice a day.
8. Keflex 500 mg p.o. once daily times seven days.
9. Glucophage 500 mg p.o. twice a day.
10. Glipizide 1.25 mg p.o. once daily.
DISCHARGE STATUS: The patient is to be discharged to home in
stable condition.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post emergent coronary artery bypass graft and mitral
valve repair.
Malignant melanoma.
Postoperative sternal drainage.
FOLLOW UP: The patient has an appointment with Dr. [**Last Name (STitle) 70**]
on [**2133-7-1**], at 1:15 p.m. and the patient has an appointment
with Dr. [**Last Name (STitle) 6530**], his oncologist, on [**2133-7-8**], at 9:15 a.m. The
patient is to follow-up with his primary care physician in
one to two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2133-6-5**] 18:57:06
T: [**2133-6-6**] 10:27:34
Job#: [**Job Number 11886**]
|
[
"410.71",
"785.51",
"198.89",
"424.0",
"414.01",
"428.0",
"V10.82",
"786.05",
"250.00",
"794.31",
"196.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.20",
"97.44",
"36.12",
"88.56",
"37.23",
"39.61",
"37.61",
"96.71",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
6597, 6753
|
6058, 6575
|
1021, 1223
|
1241, 4907
|
6765, 7341
|
164, 815
|
838, 995
|
4932, 6032
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,513
| 139,550
|
39409
|
Discharge summary
|
report
|
Admission Date: [**2135-10-30**] Discharge Date: [**2135-11-5**]
Date of Birth: [**2063-4-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Procaine / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue, Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2135-10-31**]:
redo sternotomy/Mitral Valve annuloplasty with 28 mm ring,
History of Present Illness:
72 yo male with prior cardiac history significant for an aortic
valve replacement in [**2123**] and device closure of a patent foramen
ovale in [**2127**] who was hospitalized in [**2135-7-7**] for acute
congestive heart failure. Echocardiogram at that time revealed
severe mitral regurgitation which was worse than his prior
echocardiogram. Of note, his hematocrit was found to be 25%
however workup was only notable for mild gastritis. Protonix was
subsequently started. Given the severity of his mitral
regurgitation and progression of his failure symptoms, Mr.
[**Known lastname 72001**] was referred for surgical evaluation.
Past Medical History:
Chronic A Fib
Transient ischemic attack due to PFO
***Right femoral /Iliac atherosclerosis
Amplatz device closure PFO [**2127**]
Sustained VT (ICD [**2133**])
*** heparin-induced thrombocytopenia (after AVR [**2123**])
CHF (acute, diastolic)
Severe MR
[**First Name (Titles) 49100**]
[**Last Name (Titles) **] deficiency anemia
Mild gastritis
BPH
Hematuria
Chronic low back pain (facet inject. [**7-16**])
Mild non-obstructive bladder neck contracture
Recurrent UTIs
Past Surgical History:
AVR [**2123**] (St. [**Male First Name (un) 923**] mechanical-[**Doctor Last Name **])
Bladder outlet/Prostate surgery and cystoscopy [**2131**]
AICD [**2133**]
Device PFO closure [**2127**]
Social History:
Lives with: Wife. [**Name (NI) 3597**], [**Name2 (NI) **]
Occupation:retired
Tobacco: 1ppd for 42 years. Quit 20 years ago.
ETOH: Former mod/heavy use.
Family History:
Father with MI at age 69. Mother with diabetes.
Physical Exam:
Pulse: 81 AF Resp: 18 O2 sat: 98%RA
B/P Right: Left: 109/64
Height: 5' 7 [**1-8**] " Weight: 171
General: WDWN in NAD
Skin: Dry, warm and intact. Well healed sternotomy. Left upper
chest AICD pocket well healed.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign,
Edentulous.
Neck: Supple [X] Full ROM [X] No JVD
Chest: CTAB
Heart: Irregular rhythm, rate 80. Nl S1 - Mechanical S2, II/VI
systolic murmur best heard at left mid sternal border.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: Early venous stasis changes
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 vs. bruit on left. Right without
bruit
Discharge Physical
VS: T 98.0 HR: 80 SR BP: 116/64 Sats: 97% RA
General: in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR no murmur good click
Resp: crackles 1/4 up bilateral no wheezes
GI: benign
Extr: warm 2+ edema bilateral
Incision: sternal clean dry intact, margins will approximated,
no erythema
Neuro: Awake, alert and oriented
Pertinent Results:
[**2135-11-5**] Hct-24.3*
[**2135-11-4**] Hct-27.5*
[**2135-11-2**] WBC-15.1* RBC-3.51* Hgb-9.9* Hct-29.2* MCV-83 MCH-28.2
MCHC-33.9 RDW-16.8* Plt Ct-142*
[**2135-11-5**] PT-25.0* PTT-37.6* INR(PT)-2.4*
[**2135-11-4**] PT-20.7* INR(PT)-1.9*
[**2135-11-4**] PT-19.5* INR(PT)-1.8*
[**2135-11-2**] PT-14.7* INR(PT)-1.3*
[**2135-11-5**] UreaN-28* Creat-1.2 Na-140 K-4.0 Cl-101
[**2135-11-2**] Glucose-126* UreaN-30* Creat-1.5* Na-137 K-5.0 Cl-104
HCO3-26
[**2135-10-30**] ALT-19 AST-27 LD(LDH)-236 AlkPhos-49 TotBili-0.4
[**2135-10-30**] %HbA1c-6.1* eAG-128*
The left atrium is moderately dilated. No mass/thrombus is seen
in the left atrium or left atrial appendage. A septal occluder
device is seen across the interatrial septum. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] with mild global free wall
hypokinesis. There are simple atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta. A mechanical
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. An eccentric,
posteriorly directed jet of Moderate to severe (3+) mitral
regurgitation is seen. There a dilated mitral annulus (4.4 cm)
and a restricted posterior leaflet, with malcoaptation seen most
prominently at P3 cusp.
Post Bypass: Patient is paced on epinepherine, milrinone and
phenylepherine infusions.
I certify that I was present for this procedure in compliance
with HCFA regulations.
CXR:
[**2135-11-1**]: FINDINGS: Endotracheal and nasogastric tubes and chest
tube have been removed. No evidence of pneumothorax. Bibasilar
atelectasis and effusion, more prominent on the left, persists.
Small amount of pericardial or mediastinal gas is again seen.
Brief Hospital Course:
Admitted [**10-30**] for IV heparin /PATs and underwent surgery with
Dr. [**Last Name (STitle) **] on [**10-31**]. Transferred to the CVICU in stable
condition on propofol, milrinone, insulin, and epinephrine
drips. Extubated and transferred to the floor on POD #1 to begin
increasing his activity level. Chest tubes and pacing wires
removed per protocol. Gently diuresed toward his preop weight.
Continued to make good progress and was cleared for discharge to
home with VNA on [**2135-11-5**]. All followup appts were advised.
Medications on Admission:
***Coumadin*** Usually takes 5mg daily
LD [**2135-10-25**]
lisinopril 5 mg daily
ASA 81 mg daily
lasix 20 mg daily
metoprolol 25 mg [**Hospital1 **]
protonix 40 mg [**Hospital1 **]
vytorin 10/40 mg daily
spironolactone 25 mg daily
colace [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
3. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
take 2 day for 7 days then once daily.
Disp:*30 Tablet(s)* Refills:*2*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: take with
lasix in morning.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-12**]
hours as needed for pain/temp.
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400 mg daily x 7 days
then 200 mg daily
.
Disp:*60 Tablet(s)* Refills:*2*
13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
14. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Health and Hospice
Discharge Diagnosis:
S/P redo sternotomy/Mitral Valve annuloplasty with 28 mm ring
Past Medical History: Chronic A Fib, TIA (PFO), Right femoral
/Iliac atherosclerosis, Amplatz device closure PFO [**2127**],
Sustained VT (ICD [**2133**]), HIT following AVR [**2123**], CHF, Severe MR,
[**Year (4 digits) 49100**], [**Year (4 digits) **] deficiency anemia, Mild gastritis, BPH,
Hematuria, Chronic low back pain (facet inject. [**7-16**]), Mild
non-obstructive bladder neck contracture, Recurrent UTIs
PSH: AVR [**2123**] (St. [**Male First Name (un) 923**] mechanical-[**Doctor Last Name **]), Bladder
outlet/Prostate surgery and cystoscopy [**2131**], AICD [**2133**], Device
PFO closure [**2127**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - 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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2135-11-24**] 1:15
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 87113**] [**12-16**] @ 11:00 AM
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 53353**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 53355**] in [**4-11**] 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**
Labs: PT/INR for Coumadin ?????? indication A Fib home dose 5mg 4
days, 2.5 mg 3 days
Goal INR 2.0-2.5
First draw Monday [**2135-11-7**] INR [**2135-11-5**] 2.4
Results to phone Dr[**Doctor Last Name 87114**] office
Completed by:[**2135-11-5**]
|
[
"600.00",
"V12.54",
"280.9",
"790.29",
"428.0",
"427.31",
"V45.89",
"272.4",
"V45.02",
"V43.3",
"458.29",
"424.0",
"724.2",
"428.32",
"535.50",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7740, 7794
|
5393, 5923
|
330, 410
|
8516, 8672
|
3293, 5370
|
9513, 10399
|
1962, 2012
|
6229, 7717
|
7815, 7877
|
5949, 6206
|
8696, 9490
|
1583, 1776
|
2027, 3274
|
261, 292
|
438, 1070
|
7899, 8495
|
1792, 1946
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,130
| 111,900
|
10111
|
Discharge summary
|
report
|
Admission Date: [**2117-7-11**] Discharge Date: [**2117-7-27**]
Date of Birth: [**2055-10-24**] Sex: M
Service: LIVER TRANSPLANT SURGERY SERVICE
CHIEF COMPLAINT: End stage liver disease secondary to
Laennec cirrhosis, ETOH.
HISTORY OF PRESENT ILLNESS: Patient was a 61 year-old male
with a history of alcohol related cirrhosis of the liver.
Patient with long standing history of alcohol consumption to
the point that where he would pass out presented for
transplantation. He quit drinking 6 years ago. Starting in
[**2106**] the patient had bleeding from esophageal varices for
which he was status post banding multiple times most recently
in [**2116-11-25**]. Patient also had a history of hepatic
encephalopathy with the first episode in [**2116-8-26**].
The patient has had 6 or so events during which he became
confused and near comatose was admitted to the hospital and
later discharged with complete resolution of symptoms.
Patient noted these episodes usually occurred after consuming
high protein intake. Patient was also status post
paracentesis x 3 in the past 6 months each one removing large
volumes of 3 to 5 liters respectively with last tap earlier
in the month. Patient denied recent hematemesis, variceal
bleed, no blood in his stools, no abdominal pain, no
shortness of breath, no chest pain, no nausea, vomiting,
fever, chills, headache or dizziness. No blood or difficulty
with urination. No history of bleeding problems or
coagulopathy. Patient started the transplant with process
back in [**2116-8-26**]. No history of hepatitis or IV drug
use. Never experienced withdraw symptoms.
PAST MEDICAL HISTORY: IDDM since [**2101**] status post cardiac
stent placement approximately 6 months ago.
PAST SURGICAL HISTORY: Cholecystectomy in [**2086**]. In the
spring of [**2115**] he had an LIH repair, status post cardiac
stent replacement.
MEDICATIONS AT HOME: Lasix, insulin, Aldactone, Prilosec and
Inderal.
ALLERGIES: No known drug allergies. No environmental
allergies noted. Patient became heparin induced antibodies.
The patient is now allergic to heparin.
SOCIAL HISTORY: Patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] that has 1
set of stairs for him to climb. No alcohol in 6 years. One
pack of cigarettes per week x 10 years. No IV drugs or
recreational drugs. He has a helpful significant other. She
was present postoperatively.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: On admission the patient was able to walk
several blocks with some shortness of breath. Vital signs
were 97.4, 63, 122/58, 16, 100% on room air. His weight was
77.4 kilos. He was a well developed, well nourished and in no
acute distress, resting comfortably. HEENT pupils equal,
round, reactive to light and accommodation. EOMs intact.
MCAT. Lungs clear to auscultation. No wheezes, rhonchi
appreciated. Cardiac regular rate and rhythm. Normal S1, S2.
No murmurs, regurg or gallop. No JVD appreciated. Abdomen was
soft, distended, tender to deep palpation right upper
quadrant. Bowel sounds positive. No spider angiomatas. No
caput medusae were noted on extremities. Pulses were 2+. No
cyanosis, clubbing or edema. Capillary refill was
approximately 2 seconds. No asterixis.
LABORATORIES ON ADMISSION: He had white count of 2.6, crit
of 28.4 and platelets of 30. Sodium 135, potassium 4.3,
chloride 100, bicarb 28, BUN 34, creatinine 2 and glucose of
213. AST 33, ALT 201, alkaline phosphatase 178 and T bili
3.6. Coags 15.3, 34.4 and 1.5. An EKG was normal. Hemoglobin
A1C was 5.5 back in [**2117-6-17**].
HOSPITAL COURSE: Patient was taken to the OR on [**2117-7-11**] for
piggy back liver transplant. Surgeons were Drs. [**Last Name (STitle) **] and
[**Name5 (PTitle) 816**]. Assistants Dr. [**Last Name (STitle) 33758**] and [**Doctor Last Name **]. Anesthesia was general
anesthesia. EBL was 4 liters. Fluids in were 10 liters of
crystalloid, 750 of albumin, 10 units of packed red blood
cells, 6 units of platelets, 4 units of FFP and 1 unit of
cryo. Urine output was 1450. There were no complications.
Patient was transferred to the CICU and intubated, sedated.
He had a JP, a Foley an NG tube. He was NPO.
Immunosuppression was started intraop with Solu-Medrol and
CellCept and he also had a Foley postoperatively. In the CICU
he did well. Vital signs were stable. Hematocrit was
initially 29.8. He did receive on postop day one 1 unit of
packed red blood cells, 2 units of FFP and 6 units of
platelets for platelets count of 68, white count of 5.2 and a
crit of 28.1. creatinine increased to 2.1 on hospital day 1.
JP medial put out 330 cc and lateral 1025 cc. LFTs trended
down on postop day 1 with an AST of 167, an ALT of 179 and
alk phos of 8.1 with a total bili of 1.2 down from 5.8. An
ultrasound was done on postop day 1. Ultrasound of the liver
on postop day 1 demonstrated abnormal weight form in the main
and right hepatic artery with no diastolic flow to inverted
diastolic flow. A single tracing of the left hepatic artery
demonstrated normal flow within that vessel. The portal vein
and branches as well as the hepatic veins demonstrated normal
flow. Flow was also seen within the conduit. A duplex was
again repeated on postop day 2 and again the conclusion was
that the hepatic and portal veins were patent. The arterial
assessment was suboptimal, but there was arterial flow in the
main hepatic artery towards the bifurcation. The transplanted
liver was normal in size. The left common, middle and right
hepatic veins were patent with normal directional flow and
spectral doppler wave form. Main portal vein right and left
portal veins were patent. The arterial assessment was a bit
more difficult. Arterial spectral signal demonstrated within
the main hepatic artery with good systolic upstroke, arterial
flow toward the origin of the right hepatic artery was
demonstrable, but definite intrahepatic right or left
segmental arterial flow was not demonstrated on that study.
LFTs continued to trend down with a total bili of 0.6 on
postop day 7 and an AST of 40, ALT of 115 and alk phos of
113. Creatinine preoperatively was 1.5. This slowly increased
to a high of 3.5 on postop day 8. Nephrology was consulted.
Medications were adjusted slightly to accommodate this. A
renal ultrasound was done that demonstrated slightly
echogenic appearing right kidney, which was smaller then the
left kidney that likely represented renal parenchymal
disease. The arterial and venous flow on both kidneys was
present. There was a moderate amount of free fluid seen
within the lower abdomen.
The patient was in the CICU initially. He did well there. He
was weaned from the ventilator. He continued on his
immunosuppression of Solu-Medrol taper, CellCept 1 gram
b.i.d. and he was started on Prograf on postop day 1. He was
extubated on postop day 1. Vital signs were stable. He
continued to be afebrile throughout this hospital course. On
postop day 3 he underwent an angio in the cath lab. On postop
day 3 he underwent placement of stents into stent the celiac
stenosis. He did well throughout that procedure. Vital signs
remained stable. Post crit was 28.6. It was recommended that
he be maintained on Plavix 75 mg daily for 9 months. On
postop day 3 his central line was down graded to a triple
lumen central line. He did receive IV Lasix for diuresis as
his weight was elevated. His NG tube was removed on postop
day 3. He remained on an insulin drip per protocol as he was
on Solu-Medrol for immunosuppression. On postop day 4 he was
transferred to the medical surgical unit where he remains on
his immunosuppression of CellCept, Prednisone and Prograf.
Foley continued to drain urine in the range of 600 cc up to
as high as 2600 with IV Lasix. He was again transfused with a
1 unit of packed red blood cells on postop day 6 for
hematocrit of 26 as well as 1 bag of platelets for a platelet
count of 35. Heparin induced thrombocytopenia antibody was
checked and this was negative. A repeat duplex on the 21,
there was interval development of mild diastolic flow in the
right hepatic artery, resistive indicis in the main and right
hepatic artery remained slightly elevated. There was
equivocal appearance of wave forms and diastolic flow within
the main and left hepatic arteries. All portal vessels and
hepatic veins were patent with appropriate wave forms. This
ultrasound was done postop angio with stent placement. Chest
x-ray on [**7-14**] demonstrated no cardiopulmonary process.
Patient was transferred to medical surgical unit on [**2117-7-17**]
with blood pressure 150/68, heart rate of 60 and respiratory
rate of 20, 96% on room air. He was alert and oriented.
Breath sounds were decreased at the bases. He had a
productive cough, raising some white secretions. He was
encouraged to use his incentive spirometer. He was turned and
encouraged to cough and deep breath. His abdomen appeared
distended with positive bowel sounds. He was passing flatus.
His abdominal dressing was intact. JP continued to drain
serosanguineous fluid and he did have bilateral lower
extremity edema. He did receive another unit of packed red
blood cells followed by 48 mg of IV Lasix post transfusion
for hematocrit of 26. Foley continued to drain clear yellow
urine. He was insisted to get out of bed and he did quite
well with that. Post transfusion hematocrit was 29.1.
A renal consult was obtained was obtained for rise in
creatinine post liver transplant with his baseline creatinine
of 1.6 to 2.0. Renal recommendations were doing a renal
ultrasound, sending urine for a sodium creatinine urea,
nitrogen, protein, eosinophils and serum eosinophils.
Recommendations were to avoid nephrotoxic medications and
with the consideration to switch Prograf to rapamycin when
appropriate. Possible etiologies for ATN were hypotension
during surgery and nephrotoxic medications such as Prograf.
Bactrim was maintained at every day. Valcyte was adjusted to
be given 450 mg po every other day. Prograf levels reached a
high of 13.2 on postop day 10. He was maintained on 3 mg
twice a day of Prograf and the range for Prograf levels were
10.7 to a low of 7.5 on hospital day 15. He continued on 20
mg of Prednisone and CellCept 1 gram b.i.d. Physical therapy
was consulted for weakness and decreased endurance. They
recommended continued physical therapy for strengthening,
safety and balance. A protein to creatinine ratio was done
this revealed a value of 0.3. Urine eosinophils were negative
and a FENA was 4 on Lasix, therefore not applicable. Patient
continued to be maintained on Lasix 40 mg po b.i.d. for
diuresis. His weight continued to be elevated. Preop weight
was 80.3 and he went up as high as 82.6 on hospital day 4.
This trended down to a low of 73.4 on postop day 14. He was
seen by the [**Last Name (un) **] physician for management of insulin and
glucose as he had some blood sugars in the 200 range. His
insulin was adjusted. Toward the end of his hospital course
his blood sugars were actually lower and he actually
experienced hypoglycemia on 2 successive afternoons. His
glargine was decreased as well as his sliding scale Humalog
insulin. Foley was removed. He initially was able to void,
but then developed some problems with incomplete emptying
with some post void residuals of 415 cc of urine. A Foley was
replaced temporarily for half a day and then the Foley was
removed again. He was able to void on his own independently.
Again did demonstrate some post void residual in the 400
range. Again he was recatheterized on [**7-23**] for incomplete
voiding. The Foley was removed the next day and he was able
to urinate independently for the remainder of the hospital
course.
On hospital day 10 his incision continued to drain large
amounts of ascitic fluid. Bulky dressing was applied. At that
time he was receiving Percocet for pain medication and
tolerating this. Due to a persistent leaking of ascitic fluid
through the incision a wound VAC was placed with drainage by
suction. The wound VAC drained a total of initially 325 cc
for 1 day and then on the second day of placement it drained
70 cc. On hospital day 14 he complained of loose stool x 7. A
C diff was sent off and at this time is pending. Due to
persistent thrombocytopenia HIP antibody was sent off. This
subsequently returned positive on the 22nd. The patient was
not on heparin at that time and a sign was placed above the
head for no heparin to be administered. His central line was
changed over to a peripheral IV on postop day 11. He
continued to diurese with significant decrease in edema in
his extremities.
On postop day 15 patient was stable, afebrile. Blood pressure
controlled with a high of 142/71 and a low of 120/100. Po
intake of 1660. Urine output of 1415 with a white blood cell
count of 5.7, hematocrit of 30.3, platelet count of 75 with a
creatinine of 2.7. AST was 16. ALT 30. Alk phos 134, total
bili 0.3, albumin 3.3. He remained on CellCept 1 gram b.i.d.,
Prednisone 20 mg every day and Prograf 3 mg po b.i.d. Plan
was to discharge patient on [**2117-7-27**] to skilled nursing
facility for physical therapy to continue to work with the
patient to increase endurance and balance.
MEDICATIONS ON DISCHARGE: Albuterol nebs 0.83% neb 1 neb IH
every 4 hours prn, Anzemet 12.5 mg IV prn every 8 hours,
Colace 100 mg po b.i.d. to be held if stool output greater
then 2 bowel movements per day, fluconazole 200 mg po every
24 hours, Lasix 40 mg po b.i.d., insulin sliding scale and
fixed dose of insulin. Insulin 70/30 20 units in the morning,
12 units at lunch and 17 units at bedtime of 70/30. He also
maintained insulin sliding scale of Humalog starting at 161
to 200 mg per dl 2 units to be administered at that time.
Please see discharge medications. Metoprolol 12.5 mg po
b.i.d., CellCept [**Pager number **] mg po four times a day, Percocet 1 to 2
tabs po prn every 4 to 6, Protonix 40 mg po every 24 hours,
prednisone 20 mg po every day, Phenergan 12.5 mg prn every 6
hours IV, Sevelamer 1200 mg po t.i.d., Bactrim single
strength Monday, Wednesday and Friday, Tamsulosin 0.4 mg po
at bedtime. Prograf 3 mg po b.i.d., Valcyte 450 mg po every
other day.
PLAN: Plan is for discharge [**2117-7-27**] to [**Hospital3 7**] and
Rehab Center with physical therapy with follow up appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2117-8-4**] at 10:20.
DISCHARGE DIAGNOSES: Laennec cirrhosis status post piggy
back liver transplant on [**2117-7-11**]. History of renal
insufficiency. Heparin antibody positive. History of insulin
dependent diabetes mellitus since [**2101**]. Cardiac stent
placement approximately 6 months prior to admission. Past
surgical history as previously stated.
Patient in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Doctor Last Name 31787**]
MEDQUIST36
D: [**2117-7-26**] 22:07:10
T: [**2117-7-27**] 06:36:40
Job#: [**Job Number 33759**]
|
[
"287.5",
"789.5",
"584.9",
"250.01",
"447.4",
"997.5",
"452",
"414.00",
"456.21",
"571.2",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"39.50",
"88.47",
"50.59",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
2446, 2464
|
14417, 15030
|
13210, 14395
|
3612, 13183
|
1906, 2111
|
1763, 1884
|
2484, 3273
|
184, 247
|
276, 1629
|
3288, 3594
|
1652, 1739
|
2128, 2429
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,945
| 133,658
|
12685+56395
|
Discharge summary
|
report+addendum
|
Admission Date: [**2186-3-9**] Discharge Date: [**2186-3-29**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
Lower endoscopy
Sigmoid colectomy with anastamosis
NG tube placement
Right subclavian central line placement
Power PICC placement
History of Present Illness:
HPI: 86 M w/ hx multiple strokes in the past including R-MCA,
seizures, DM, was at his nursing home, where per report, he
began
having increasing confusion over 2-3 days and this morning was
thought to have slurring of his speech, first noticed at 8:30
am.
He was last known without slurred speech last night. He was
transferred to [**Hospital1 18**] ER where a Code Stroke was called. He
received a NCHCT which showed broad areas of prior infarct, most
notably through a large R-MCA territory. There was no acute
bleed. Pt was initally very agitated/screaming in CT as well as
subsequently when an IV was attempted to be placed, but later
calmed. That said, he was minimally cooperative with further
attempts at exam.
Past Medical History:
Multiple strokes, 1st was in [**2159**] and recovered full without
sequelae, but later large R MCA stroke
hx pneumonia, likely aspiration
Hypertension
DM II
dysphagia
seizure disorder
CAD
hyperlipidemia
transitional cell carcinoma of the bladder
S/P left nephrectomy
hx DVT S/P IVC filter
trigeminal neuralgia
Social History:
No toxic habits
Family History:
unknown
Physical Exam:
96.9F 56 190/72 22 100%RA
Gen: Lying in bed, screaming intermittently, and attempting to
bite examiner, blanket, tele cords.
HEENT: NC/AT, moist oral mucosa. Sclera erythematous B/L.
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e
Neurologic examination:
Mental status: Awake and alert, very agitated at times. Able to
state name as "[**Known firstname **]" but does not state last name and does not
respond to other orientation questions. Refuses to follow
commands. States "good" when asked how he is, otherwise there is
abundant echolalia. He has fluent, accented speech without clear
dysarthria, stating things like,"Why are you bothering me?" and
"Leave me alone!"
Cranial Nerves:
Pupils: R 4->3 mm, L 4 mm and apparently nonreactive, though
also
with [**Known firstname 65**] cataract. No clear BTT from either side. On primary
gaze, there appears to be right-beating nystagmus, and during
exam later, he appears to become less responsive, with eyes
deviating right, and then slowing deviating to the left, all the
while with right-beating nystagmus. (+) R Facial droop.
Motor:
Normal bulk bilaterally. Tone increased throughout. No observed
myoclonus or tremor
RUE and RLE appear quite strong, able to provide nearly
unbreakable resistance during attempts to passively flex/extend.
LUE appears to have no mvmt, even to pain. LLE has min flexion
at
ankle and IP to painful stim.
Sensation: withdraws or screams to noxious in all 4 ext.
Reflexes:
+2 and brisk at the biceps B/L. There appears to be some
asymmetry at the knees, w/ L brisker, and R not able to elicit.
Toes upgoing bilaterally
Pertinent Results:
Admission Labs:
13.3
12.2 >-----< 260
41.1
146 | 111 | 25
---------------< 110
3.3 | 25 | 1.2
Ca: 9.8 Mg: 2.6 PO4: 4.1
Imaging/Studies/Path/Micro:
CT head [**3-9**]:
Multiple bilateral chronic cerebral infarcts and small vessel
ischemic
changes. If an acute infarct is suspected, an MRI is recommended
for further evaluation.
EEG [**3-11**]
This telemetry captured no pushbutton activations. Routine
sampling showed a moderately slow and disorganized background
with an
area of prominent focal attenuation over the right frontal
region.
There were no epileptiform features noted. Overall, the
background is
suggestive of a moderate encephalopathy.
ECHO [**3-13**]:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation.
Sigmoid colon path
Unremarkable colonic mucosa.
Two unremarkable lymph node identified.
EEG [**3-17**]
IMPRESSION: This is an abnormal portable EEG due a slow and
disorganized
background rhythm, which was also of low voltage consistent with
a mild
to moderate encephalopathy. Medications, toxic/metabolic
disturbances
and infections are common causes. Anoxia is also a possible
etiology.
No epileptiform discharges or electrographic seizures were seen
during
this recording
CT head [**3-17**]
IMPRESSION: Extensive encephalomalacic change compatible with
chronic
bilateral cerebral infarction and small vessel ischemic change.
Note that
detection for acute infarction is extremely limited in this
setting and if of clinical suspicion, MR is recommended for
further evaluation.
URINE [**3-9**]: pan-sensitive E Coli
STOOL [**3-16**]: Positive for cdiff
ENDOSCOPY
[**3-10**], sigmoidoscopy: torsion noted at 20cm, untwisting and
decompression applied
[**3-12**], sigmoidoscopy: torsion noted at 20cm, untwisting and
decompression applied
Torsion noted at 20cm, untwisting and decompression applied
Otherwise normal sigmoidoscopy to sigmoid colon
[**3-13**], colonoscopy:
Colon lumen dilated, no volvulus noted. Decompression applied. A
36 FR thoracic catheter provided by surgery placed alone the
scope at 30cm down from anal verge. Otherwise normal colonoscopy
to splenic flexure
.
CT ABDOMEN:
1. Dilated fluid and contrast-filled loops of small bowel with
interloop
fluid. Since contrast transits in to the colon, and rectum,
these findings
are compatible with a partial small-bowel obstruction. There is
no free air.
2. Region concerning for a fluid collection within the right
lower quadrant
in fact represents loops of bowel as these now fill with
contrast.
3. No obstruction at the sigmoid anastomosis.
4. Small fluid collection below the left anterior abdominal skin
staples.
5. Atelectasis with ground-glass opacities at bilateral lung
bases.
Infection at this site cannot be excluded.
6. Single right kidney containing multiple hypodensities,
compatible with
simple cysts but incompletely evaluated on this study.
7. IVC filter in place below the renal veins.
8. Anasarca.
.
Stool cx [**3-16**]:
[**2186-3-16**] 4:57 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2186-3-17**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2186-3-17**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39174**] @ 3:51A [**2186-3-17**].
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).
Brief Hospital Course:
86 year old gentleman with history of CVA and seizures, DM2,
hypertension initially Admitted with seizure now and transferred
to [**Hospital Unit Name 153**] status post partial sigmoid colectomy with course c/b
fevers and leukocytosis adn persisting altered mental status.
.
[**Hospital Unit Name 153**] course: On arrival to the ICU, patient was hypotensive
likely secondary to meds on the floor (bb/ativan) and
hypovolemia. He was also sinus tachy with fever/leukocytosis.
He responded to IVFs. He was continued on vanc/zosyn/flagyl and
pan=cultured. In regards to his seizures, patient was dialntin
loaded x1, for witnessed seizure on the floor that resolved with
iv ativan. He was continued on dilantin. His albumin corrected
phenytoin levels were adjusted for a goal of 15-20. There was
concern for status epilepticus and neurology was consulted. An
EEG was abnormal and did not show evidence of seizure activity
but was consistent with a toxic metabolic syndrome. His albumin
was low resulting in a subtherapeutic dilantin level and his
dose was increased. His stool was positive for C Diff and he was
treated with IV flagyl and enteral vancomycin via NGT. Abdominal
xrays were not consistent with illeus or toxic megacolon. A LUE
US was done for assymetric edema, but was negative for DVT.
During his ICU course he had episodes of hypotension that were
treated with ivfs and broad spec antibiotics. His
antihypertensive meds were held. Patient also had episodes of
apnea, desating to 80s and BiPap at nighttime was started.
Abx course
vanc [**Date range (1) 39175**]; [**Date range (1) 39176**]
zosyn [**Date range (1) 39176**]
cefepime [**Date range (1) 39177**]
.
FLOOR COURSE:
.
Sigmoid Ileus/Partial SBO: After admission for seizure and
confusion, he was diagnosed with a sigmoid volvulus. He was
taken for endoscopic decompression, but unfortunately this was
unable to be corrected. Surgery was consulted and the decision
was made to undergo sigmoid colectomy with anastamosis,
occurring on [**2186-3-14**]. Post op course was complicated by
abdominal distention and partial SBO. There was also concern
for possible abscess based on CT scan on [**3-22**]. However, with IV
contrast this was found to be filled bowel and NOT abscess. His
ileus was treated with NGT to suction and supportive care. He
was continued on TPN for nutrition. His sutures were removed on
[**3-24**]. He was passing bowel movements. See instructions in d/c
information for plan of progression to TF via ngt v. peg tube
.
Seizure disorder: As above. Neurology was consulted. He was
loaded with dilantin and given ativan at the time of his
seizure. His dilantin was initially 100mg [**Hospital1 **], but was changed
to 100mg TID, then back to [**Hospital1 **] based on levels. His goal
corrected dilantin level is 15-20. He remained seizure free
thereafter.
.
Aspiration PNA: During the course of admission, he was diagnosed
with aspiration pneumonia. He was treated for a 5 day course of
vancomycin and zosyn, completed on [**3-20**].
.
E. coli UTI: Treated with cefepime from [**Date range (1) 39178**]
.
Aspiration/Nutrition: Given his encephalopathy, he was deemed
unsafe to tolerate POs. Additionally, given his volvulus and
ileus he was unable to tolerate tube feeds. Medications were
given via NGT. Nutrition was provided by TPN. A power PICC was
placed on [**2186-3-23**]. NG tube was left in place for medications.
Tube feeding can be considered going forward.
.
C. diff infection: Diagnosed on [**2186-3-16**]. Given his risk he was
started on PO/PR vanco and IV flagyl. Given past antibiotic
usage, he should continue his course through [**2186-4-4**].
.
Encephalopathy: Since admission, he remained markedly
encephalopathic, not related to seizure. He would respond to
verbal/physical stimuli with moaning and heavy breathing.
Occasionally he appeared to answer with "yes" or "no." However,
he could not hold a conversation or interact meaningfully. This
was attributed to his medical/surgical insults. He improved to
being able to have conversation by discharge - on discharge is
able to answer questions appropriately, and despite moaning
frequently, he persistently denies pain.
.
Goals of care: A family meeting was held on [**3-24**] with his HCP
[**Name (NI) **] and daughter in law. Though he reversed his code status for
the surgery, the decision was made at this meeting to make the
patient DNR/DNI with no escalation of care. [**Known lastname **] tentatively
wants to give his father time to improve, though we made it
clear that the possibility of recovering to his baseline prior
to admission was unlikely. The HCP is also considering
palliative/hospice care, to be decided in the near future - at
the time of discharge, in discussion with the family, pt. is
dnr/dni, but all other care to continue. If pt. takes a turn
for the worse, then family will reconsider palliative approach,
but are not wanting this at time of discharge.
Discharge Medications:
1. Phenytoin 100 mg/4 mL Suspension [**Known lastname **]: One Hundred (100) mg PO
twice a day: check levels every 4 doses and adjust to target of
[**11-24**].
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) mL
Injection TID (3 times a day).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**2-11**]
Drops Ophthalmic PRN (as needed) as needed for dry.
4. Citalopram 20 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily).
5. Latanoprost 0.005 % Drops [**Month/Day (2) **]: One (1) Drop Ophthalmic HS (at
bedtime).
6. Lorazepam 1 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Seizure, anxiety.
7. Insulin Lispro 100 unit/mL Solution [**Month/Day (2) **]: as per sliding
scale, QID units, insulin Subcutaneous four times a day.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath.
9. Simvastatin 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY
(Daily).
10. Vancomycin 250 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO Q6H (every
6 hours): through [**4-4**].
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Last Name (STitle) **]:
Five Hundred (500) mg Intravenous Q8H (every 8 hours): through
[**4-4**].
13. vancomycin [**Month/Year (2) **]: 250 mg mg Rectal four times a day: through
[**4-4**] as rectal enema.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 86**]
Discharge Diagnosis:
Seizure, convulsive
Encephalopathy
Sigmoid volvulus
Partial SBO/Ileus
Aspiration pneumonia
E. coli UTI
C. diff colitis
Malnutrition
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound
Discharge Instructions:
Patient was admitted with seizure and confusion. He was also
found to have a sigmoid volvulus for which he underwent partial
colectomy on [**2186-3-14**] with anastamosis. His course was
complicated by encephalopathy, aspiration PNA, E. coli UTI,
unable to eat, partial SBO, and C. diff. Please continue all
medications and treatments as written.
Followup Instructions:
Please have patient follow up with his PCP as needed:
PCP: [**Name10 (NameIs) 251**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 608**]
Name: [**Known lastname 7093**],[**Known firstname **] Unit No: [**Numeric Identifier 7094**]
Admission Date: [**2186-3-9**] Discharge Date: [**2186-3-29**]
Date of Birth: [**2100-1-5**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 429**]
Addendum:
also - nightly cpap, autoset machine, 1-5 litres supplemental
o2, titrate to O2 sat greater than 88%. Verbal signout provided
to accepting attending MD [**First Name (Titles) **] [**Last Name (Titles) **] today over phone, including
above.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 430**] MD [**MD Number(2) 431**]
Completed by:[**2186-3-29**]
|
[
"401.9",
"250.00",
"507.0",
"276.0",
"599.0",
"345.90",
"560.2",
"041.4",
"V45.73",
"349.82",
"276.52",
"438.20",
"263.9",
"560.89",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"46.85",
"38.93",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
15157, 15378
|
6999, 11978
|
232, 364
|
13876, 13876
|
3309, 3309
|
14380, 15134
|
1496, 1505
|
12001, 13611
|
13721, 13855
|
14006, 14357
|
1520, 1914
|
182, 194
|
392, 1113
|
2371, 3290
|
3331, 6976
|
13890, 13982
|
1938, 1938
|
1135, 1446
|
1462, 1480
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,072
| 171,824
|
43019
|
Discharge summary
|
report
|
Admission Date: [**2184-5-23**] Discharge Date: [**2184-6-24**]
Date of Birth: [**2143-11-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
Tracheostomy
PEG-tube placement
Central line placement x 2
History of Present Illness:
40 yo F with PMHx of AFib on coumadin, CHF EF 40%, obesity BMI
62 p/w progressive dyspnea for the last 2 months. She was
admitted in [**3-3**] with influenza and found to have afib and CHF.
She has had SOB since then and has beeen evaluated by pulmonary
and cardiology. After that admission, she has gotten slightly
better intially, but since then she has had progressively
worsening DOE. Now she can only walk about 20 feet before
becoming out of breath. She has had a cough, occ productive, for
the last few months that was relieved somewhat by starting
Adviar, but has been persistant. She has left sided chest pain
when she coughs which then lingers on for longer. No radiation
to the back, neck, or arms. She has been having orthopnea and
PND the last few nights and has noticed that her legs have been
swelling.
She has also been having large amounts of anxiety related to her
breathing. She feels that her breathing will stop suddenly since
she is so SOB. Her anxiety ahs driven her to resume ETOH the
last 2 weeks. She has been drinking 4 40oz beers per night. No
blackouts. No other substances. She has also been having sucidal
ideations since she feels she is so heavy and her medical
problems are too difficult to control, she would not like to
live longer. She has not followed through on her plans which
include drinking excessive ETOH and obtaining weapons to hurt
herself.
She has not been taking her medications the last few days since
she has been drinking ETOH and was worried about the
interactions.
.
Tonight she called EMS because of the SOB. She had an O2 sat of
85% RA when EMTs arrived and was placed on NRB. in the ED vitals
were T 99.4, HR 50, BP 132/70, RR 18, O2 sat 94% 4L. She was
given Percocet for back pain and ativan for anxiety. Ddimer was
high and she was sent for a CTA that was neg for PE. She had a
UCG that was negative. She was given levaquin for PNA seen on
CTA.
.
On admission to the floor, she had an O2 sat of 68% RA and 94 %
2L. She was able to speak in full sentances and was not in resp
distress. She was given Lasix IV without significant diuresis.
Approximately 6:45 in the AM, she was noted by the RN to be
increasingly hypoxic while taking off her O2 and was
diaphoretic. ABG was 7.22/100/76 on 4L NC. She was given a neb,
Lasix 20 IV, and CXR was ordered. MICU transfer was initiated.
.
ROS: + for nightly nightsweats which her PCP told her was from
menopause. + chronic back pain and pain in her feet. + for
nausea and vomiting daily for the last 4 days. non-bloody. +
diarrhea 4x per day for the last 4 days as well. Occ blood
streaked stool. no melana. No syncope.
Past Medical History:
1. Hypertension
2. CHF diagnosed [**3-3**]. EF 40%
3. afib diagnosed [**3-3**]
4. Obesity
5. insluenza [**3-3**]
6. Mild pulm HTN
7. 2+ TR
8. PFTs with a mild restrictive defect
9. h/o hyperglycemia
10. h/o ETOH abuse
11. w/u for sleep apnea
Social History:
Single mother of two children (aged 19 and 12). Smokes [**1-27**]
cigaretts a week. Recent binge drinking the last 2 weeks for 4
40ox beers. Has been in alcohol rehabilitation last year. Used
cocaine ten years ago. Denies any IVDU. Lives in [**Location 686**],
worked as cashier at [**Last Name (un) 59330**].
Family History:
non-contributory
Physical Exam:
VS: Temp: 97.8 BP: 124/54 HR:76 RR:24 O2sat 95% 2L Weight: 319
lb (was 305 in [**3-3**]) BMI 62
GEN: pleasant, talkive, comfortable, NAD sitting in chair
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
though hard to tell with body habitus, no carotid bruits, no
thyromegaly or thyroid nodules
RESP: RLL crackles with dullness to percussion. No wheezes heard
CV: [**Last Name (un) 3526**], [**Last Name (un) 3526**], S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly;
refused rectal
EXT: mild non-pitting peripheral edema
SKIN: healed burn wound on back.
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
Labs:
[**2184-5-23**] 06:30PM BLOOD WBC-15.0* RBC-5.19 Hgb-13.9 Hct-45.3
MCV-87# MCH-26.7*# MCHC-30.6* RDW-20.8* Plt Ct-431
[**2184-6-17**] 02:56AM BLOOD WBC-16.6* RBC-4.14* Hgb-11.3* Hct-35.8*
MCV-87 MCH-27.2 MCHC-31.4 RDW-17.2* Plt Ct-526*
[**2184-6-23**] 05:05AM BLOOD WBC-17.2* RBC-4.54 Hgb-12.6 Hct-39.3
MCV-87 MCH-27.7 MCHC-32.0 RDW-17.7* Plt Ct-555*
.
[**2184-5-23**] 06:30PM BLOOD Glucose-121* UreaN-15 Creat-1.2* Na-136
K-7.9* Cl-95* HCO3-37* AnGap-12
[**2184-6-6**] 02:10AM BLOOD Glucose-96 UreaN-30* Creat-1.1 Na-145
K-3.8 Cl-99 HCO3-42* AnGap-8
[**2184-6-23**] 05:05AM BLOOD Glucose-105 UreaN-18 Creat-0.8 Na-143
K-4.2 Cl-101 HCO3-35* AnGap-11
.
[**2184-5-24**] 07:04AM BLOOD Type-ART pO2-76* pCO2-100* pH-7.22*
calTCO2-43* Base XS-8
[**2184-5-25**] 12:06PM BLOOD Type-ART pO2-66* pCO2-100* pH-7.25*
calTCO2-46* Base XS-12 Intubat-NOT INTUBA
[**2184-5-27**] 08:39AM BLOOD Type-ART Temp-37.8 Rates-12/ Tidal V-500
PEEP-5 FiO2-50 pO2-87 pCO2-83* pH-7.37 calTCO2-50* Base XS-18
-ASSIST/CON Intubat-INTUBATED
[**2184-6-1**] 08:53PM BLOOD Type-ART Temp-37.6 Rates-/36 pO2-77*
pCO2-67* pH-7.36 calTCO2-39* Base XS-8 Intubat-INTUBATED
Vent-CONTROLLED
[**2184-6-15**] 05:48AM BLOOD Type-ART Temp-37.2 Tidal V-450 PEEP-10
FiO2-40 pO2-82* pCO2-48* pH-7.43 calTCO2-33* Base XS-6
-ASSIST/CON Intubat-INTUBATED
[**2184-6-20**] 11:15PM BLOOD Type-ART Temp-37.0 FiO2-40 pO2-114*
pCO2-50* pH-7.42 calTCO2-34* Base XS-7 Intubat-INTUBATED
Comment-TRACH MASK
.
.
cta chest [**5-23**]:
IMPRESSION:
1. Enlarging small right pleural effusion with right lower lobe
atelectasis versus infiltrate.
2. Stable marked cardiomegaly.
3. No pulmonary embolus.
.
ct neck [**5-31**]:
IMPRESSION:
1. Soft tissue stranding and lymphadenopathy in the tissues
anterior and contiguous with the thyroid, which is similar to
what was seen in [**12-29**], but again suggesting acute inflammation.
2. Marked soft tissue swelling involving the entire pharynx, as
well as the supraglottic and the upper infraglottic airway.
2. No organized fluid collection identified or bony involvement.
.
[**5-31**] ct sinus:
IMPRESSION: Although endotracheal intubation confounds
interpretation, extensive opacification with multiple air-fluid
levels among the paranasal sinuses can be seen in pansinusitis.
No evidence of associated bony destruction.
.
ECHO [**2184-6-15**]:
The left atrium is mildly dilated. 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. The aortic valve
leaflets appear structurally normal with good leaflet excursion.
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Mild mitral regurgitation with grossly normal
valve morphology. Preserved global biventricular systolic
function.
Compared with the prior study (images reviewed) of [**2184-2-28**], the
severity of tricuspid regurgitation may be lower (technical
quality is suboptimal on both studies). The severity of mitral
regurgitation is similar. Left ventricular systolic function
was likely underestimated on the prior study.
Brief Hospital Course:
40 year old female with morbid obesity, CHF, and atrial
fibrillation here with progressive SOB, and ETOH relapse.
.
# Dyspnea/hypercarbic respitory failure: The patient has poor
pulmonary status which is multifactorial from heart failure,
obesity induced restrictive disease, and resultant
obesity-hypoventilation syndrome. The patient presented with
hypercarbic respiratory failure (osa and hypoventilation from
obesity). The patient failed non-invasive ventilation (due to
progressive hypercarbia) and required intubation on [**2184-5-26**].
The patient's baseline obesity hypoventilation, and continued
hypercarbia made liberation from the ventilator difficult. The
patient had multiple attempts to wean, but these were
unsuccessful. As fluid overload may have been contributing to
her failure to wean from the vent, she was aggressively diuresed
with a lasix drip. Despite remaining negative, the patient was
still unable to come off of the ventilator, so a tracheostomy
tube was placed. After placement of her trach, she continued to
be diuresed with IV lasix prn with careful observation of her
electrolytes given a history of contraction alkalosis.
Improvement was slow, and shge continued to require pressure
support ventilation, initially for 24` a day, then with
increasing amounts of time on trach mask. On [**6-20**] she was
weaned from the vent and maintained on trach mask for the entire
day. She did have 2 episodes of pulling her trach partly out,
thought to be in the setting of increased anxiety. This was
replaced and placement confirmed by CXR. She should be
maintained on PO lasix and her electrolytes monitored while at
rehab.
.
# CHF: On admission, the patient had increased weight, hypoxia
and elevated BNP which pointed to CHF excerbation. As her fluid
status contributed to her respiratory failure she was
aggressively diuresed with lasix drip. Her HCTZ was held and she
was put on a beta [**Month/Year (2) 7005**]. An ace was also started for afterload
reduction. The patient had alkalosis at times, likely related
to her diuresis, but this improved with KCL and diamox prn.
When her contraction alkalosis worsened her lasix was stopped
and it was felt she was adequately diuresed at that time. By the
end of her admission, she was transitioned to PO lasix. An echo
this admission showed diastolic dysfunction.
.
# Fevers: The patient continued to spike fevers and during her
course was noted to have GNR bacteremia (Fusobacterium). Given
this organism a concern for peritonsillar abscess and sinusitis
was raised. She did not have evidence of peritonsillar abscess,
though her infection was attributed to sinusitis given a
positive CT head. She also likely had a pneumonia given her cxr
during her course. She recieved vanc and meropenem for 14 d for
the fusiform bacteria. She was given emperic flagyl but spiked
fevers while on this. Her CVL was changed on [**6-18**] due to
persistent temperature spikes. In additon, after a CT torso
showing only a LLL pna, she was treated with a second course of
broad spectrum antibiotics (vanco and cefepime to cover
ventilator-associated pna), starting [**6-16**] for a planned eight
day course. She had LENI's to exclude DVT as a possible fever
source.
.
# Atrial fibrillation: The patient has a history of Afib/flutter
and is on CCB, BB and coumadin at home. Here, she became
modestly hypotensive while on sedation and her calcium channel
[**Month/Year (2) 7005**] was held; she was only treated with metoprolol given
hypotension and was intermittently on heparin which was later
stopped due to hematuria. She never developed RVR and remained
stable on a beta-[**Last Name (LF) 7005**], [**First Name3 (LF) **] her calcium channel [**First Name3 (LF) 7005**] was
stopped. Heamturia resolved (likely foley trauma), and her
warfarin was restarted. At discharge her INR was therapeutic
(goal INR [**2-28**]), and should be checked weekly at rehab.
.
# Alcoholism: The patient has a history of alcohlism and
relapsed. She may have had withdrawal while on the vent because
she was agitated. She responded well with sedation (fentanyl and
midazolam) and haldol prn, but she responded best to quetiapine.
Quetiapine tid provided excellent control of anxiety and
agitation, with as needed lorazepam for rare agitation.
.
# Acute renal failure: The patient presented with a Cr of 1.2.
This was likely due to her initial presentation of vomiting and
diarrhea. As she was vented during the majority of her course
her ARF resolved and was followed closely while on lasix but did
not recur.
Medications on Admission:
atenolol 50 mg daily
aspirin 81 mg daily
diltiazem CD 300 mg daily
HCTZ 50 mg daily
lisinopril 5 mg daily
warfarin (which your clinic is regulating)
remeron 30 qhs
Advair inhaler 100/50
occasional albuterol inhaler
folic acid
Tylenol-Codeine #3 30 mg-300 mg--1 -2 tablet(s) by mouth three
times a day as needed for cough or pain
iron
thiamine
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Month/Day (3) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
3. Trazodone 50 mg Tablet [**Month/Day (3) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
6. Iron 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
7. Cefepime 2 g Recon Soln [**Last Name (STitle) **]: Two (2) gm Injection Q12H (every
12 hours) for 1 days: to end [**6-24**].
8. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Month/Day (4) **]: One (1) gm
Intravenous Q 12H (Every 12 Hours) for 1 days: to end [**6-24**].
9. Quetiapine 25 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO TID (3 times a
day).
10. Warfarin 2.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at
bedtime).
11. Mirtazapine 30 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at
bedtime).
12. Lisinopril 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day.
13. Metoprolol Tartrate 50 mg Tablet [**Month/Day (4) **]: Three (3) Tablet PO
once a day.
14. Lorazepam 1 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO Q6H (every 6
hours) as needed for anxiety.
15. Furosemide 40 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Hypercarbic respiratory failure
.
Secondary:
1. Hypertension
2. CHF diagnosed [**3-3**]. EF 40%
3. afib diagnosed [**3-3**]
4. Obesity
5. insluenza [**3-3**]
6. Mild pulm HTN
7. 2+ TR
8. PFTs with a mild restrictive defect
9. h/o hyperglycemia
10. h/o ETOH abuse
11. w/u for sleep apnea
Discharge Condition:
Good, awake, alert, comfortable, stable and satting well on 40%
trach mask
Discharge Instructions:
Pt was admitted for progressive hypercarbic respiratory failure
felt to be due to obesity-hypoventilation, poor respiratory
mechanics, and modest-minimal contribution from CHF.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Follow-up as below
Followup Instructions:
You have an appointment with a lung doctor in the [**Hospital Ward Name 23**]
building, [**Location (un) 436**], as below:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-7-26**] 2:10
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-7-26**] 2:30
.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2184-9-6**] 9:20
.
You should see your primary care doctor the week after leaving
rehab.
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[]
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14724, 14801
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,873
| 148,068
|
29293
|
Discharge summary
|
report
|
Admission Date: [**2187-11-17**] Discharge Date: [**2187-11-23**]
Date of Birth: [**2140-9-4**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Tape
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
hepatic failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 19704**] is a 47yo woman with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 4516**] disease and
depression s/p several suicide attempts by "rat poison" overdose
most recently yesterday, 10 days prior, and 14 days prior to
that who presented to an OSH yesterday with complaint of feeling
weak and lightheaded and having 4 episodes of syncope at home.
In the last episode she noted falling down and hitting her head.
Denied b/b incontinence, tongue biting. Head CT negative at OSH.
She has felt nauseated and has not been eating or drinking much
for the last four days. Although she did not admit to taking
tylenol in the OSH, here she admits to taking 50 tylenol pills
along with a pack of rat poison on Tuesday.
.
In the OSH ER yesterday she was found to be orthostatic and
received 3LNS and zofran for nausea. Labs showed an INR >5.
(Unclear whether this was still elevated in setting of past rat
poison ingestion 10 days ago or whether this was a new insult).
Head CT showed no bleed or shift. EKG was reportedly remarkable
for RBBB with CEs negative. URine tox screen was positive for
methadone, which the pt admitted to taking for her headaches.
She denied tylenol ingestion for overdose, but stated that over
the last four days she had been taking it prn for her headache.
Notably she was given tylenol at the OSH for headache. She has
received no N-AC.
.
At the OSH her INR was as high as 5.[**Age over 90 **] yesterday, decreased to
4.9 today. Tbili peaked at 2.7 yesterday. ALT was 3600 at last
check up from 2115 the day prior. She was given vitamin K 5 mg
po x 1 at the OSH, however per poison control discussion with
the OSH, vit K is only indicated if evidence of bleeding for rat
poison o/d. ABG at the OSH at 5pm today was 7.38/36/86,
acetominophen level was <10 at 4pm today. She was transferred to
[**Hospital1 18**] in fulminant liver failure for possible transplant
work-up.
.
ROS: Pt reports headache mostly relieved by morphine. Mild
abdominal pain on L side only. Some nausea. Has not eaten all
day. No CP, fever, chills, RUQ pain, vomiting.
Past Medical History:
- depression s/p several suicide attempts, most recent prior to
this admission was [**11-6**] for "rat poison" overdose as well as 2 w
prior to that.
- [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease
- s/p c-section
- s/p gastric bypass [**2182**]
- s/p TAH/BSO
Social History:
used to work as teacher, currently not working. denies tobacco,
EtOH, IVDU. lives at home with husband and three children.
.
Family History:
sister with schizophrenia, sister with bipolar disorder,
physical/sexual abuse in family (pt victimized by several
different members of family).
Physical Exam:
gen: sleepy but arousable and answers questions, obese
HEENT: PERRL, constricted, flat affect, no OP injection
Neck: no LAD, supple
Cor: rrr, no r/g/m, s1s2
Pulm: CTAB
Abd: soft, NTND, +bs, no RUQ tenderness, no [**Doctor Last Name 515**], no HSM,
mild L mid abdominal tenderness to deep palpation
Ext: no c/c/e, w/w/p
Skin: no rashes
Pertinent Results:
[**2187-11-17**] 09:50PM FIBRINOGE-291 D-DIMER-[**2167**]*
[**2187-11-17**] 09:50PM PT-23.6* PTT-30.3 INR(PT)-2.3*
[**2187-11-17**] 09:50PM PLT COUNT-129*
[**2187-11-17**] 09:50PM NEUTS-73.6* LYMPHS-18.0 MONOS-3.8 EOS-4.4*
BASOS-0.2
[**2187-11-17**] 09:50PM WBC-4.8 RBC-4.11* HGB-12.5 HCT-35.3* MCV-86
MCH-30.3 MCHC-35.3* RDW-14.0
[**2187-11-17**] 09:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-11-17**] 09:50PM LIPASE-24
[**2187-11-17**] 09:50PM LIPASE-24
[**2187-11-17**] 09:50PM ALT(SGPT)-2848* AST(SGOT)-1268* LD(LDH)-153
ALK PHOS-137* AMYLASE-18 TOT BILI-2.7*
[**2187-11-17**] 09:50PM GLUCOSE-114* UREA N-16 CREAT-0.5 SODIUM-144
POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-22 ANION GAP-11
[**2187-11-17**] 10:00PM FDP-0-10
[**2187-11-17**] 11:00PM URINE GRANULAR-1*
[**2187-11-17**] 11:00PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**6-9**]
[**2187-11-17**] 11:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2187-11-22**] 04:35AM BLOOD WBC-4.9 RBC-3.81* Hgb-11.3* Hct-34.1*
MCV-90 MCH-29.6 MCHC-33.1 RDW-14.8 Plt Ct-124*
[**2187-11-22**] 04:35AM BLOOD Plt Ct-124*
[**2187-11-22**] 04:35AM BLOOD Glucose-81 UreaN-8 Creat-0.5 Na-142 K-3.8
Cl-107 HCO3-31 AnGap-8
[**2187-11-22**] 04:35AM BLOOD ALT-664* AST-64* AlkPhos-133* TotBili-1.0
[**2187-11-22**] 04:35AM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.5*
Mg-2.0
[**2187-11-17**] 09:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Ms. [**Known lastname 19704**] is a 47yo woman with h/o depression s/p several
suicide attempts most recently taking rat poison in [**Month (only) **] and
again on [**11-6**], now admits to taking rat poison as well as 50
tylenol tabs on Tuesday [**11-10**] and is transferred here
from an OSH with acute liver failure ALT 3600, INR 6.
.
1. tylenol overdose/ hepatic failure:
The pt had no encephalopathy, so the diagnosis was acute liver
failure rather than fulminant hepatic failure. Given the
severely evalated LFTs and INR>5, she was monitored in the ICU
and started on NAC continuous infusion. The LFTs trended down
and she was transferred to the floor. INR came down to 1.2.
.
# rat poison overdose:
per liver recs, she was given pt 10mg IV vitamin K x 1. INR
trended down to near normal levels.
.
# suicidality/depression:
pt with extensive psych history. Evaluated by psychiatry
consultants who recommended eventual psych hospitalization as
she is at significant suicidality risk. Had 1:1 sitter as pt
with previous history of SI and attempts at suicide while
hospitalized previously. Will be transferred to psychaitry for
inpatient psych treatment.
.
# s/p TAH/BSO:
held premarin given liver dysfunction as a contraindication. She
should follow up with her PCP regarding when to restart the
premarin.
.
# vestibulitis:
Pt developed symptoms of nausea and the sense of room spinning
around her. On neuro exam, there was no dysmetria. The symptoms
were intermittent rather than constant. Her gait which was
initially unsteady improved and she was walking with normal
gait. The intial gait instability was likeky due to
deconditioning from acute illness. Given this clinical picture
is most c/w peripheral vertigo rather than CNS pathology.
However, given the elevated INR, Head CT was performed and was
negative for acute bleed. She was treated with meclizine and
compazine and this was nearly resolved by hospital discharge.
Her walking was independent by PT assessment.
.
# Methadone use:
patient reported taking husband's methadone for headaches, given
this the patient was tapered from 10 to 5 mg and then off.
.
# [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] disease:
No active issues. NSAIDs were avoided due to risk of bleeding.
.
# Vaginal yeast infection:
the pt mentioned symptoms of vaginal itchiness which was similar
to her previous yeast infections. She was treated with
fluconazole x1, then requested vaginal cream as well.
.
# FEN: regular diet. aggressively hydrating per liver recs with
NS, replete lytes prn (KPhos tonight, likely will need more in
AM).
.
# PPX: bowel regimen, pneumoboots, PPI. holding heparin
products.
.
# presumed full code
# contact
# dispo: micu pending INR downtrend
Medications on Admission:
premarin 0.625mg po qday
cymbalta 60mg po qday
prozac 20mg po qday
colace 100mg po qday
risperdal 4mg po qday (recently increased from 0.25bid)
trazodone 200mg po qday (started recently)
ativan 2mg po qday
cetacol prn
Discharge Medications:
1. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for dizziness.
2. Outpatient Lab Work
CBC, chem-10, liver function panel, INR, PTT.
Please have these labs followed up by a physician at the
psychiatric facility or by your primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**].
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
acute liver failure
drug overdose
attempted suicide
.
Secondary Diagnosis:
depression
Discharge Condition:
stable, though at suicide risk being transferred to involuntary
inpatient psychiatric facility
Discharge Instructions:
1. If you have any symptoms of fevers, chills, please call your
physician.
2. Please note that we have stopped all of your regular
medications which include the premarin and the psychiatric
medications. The only medication which you should be taking is
the anti-nausea medications which you take as needed. From a
liver perspective, it is safe for you to restart the
medications. Please address with the psyschiatric physicians
your new psychiatric medication regimen. In terms of the
premarin, we have stopped this for now because of the risk of
blood clots. Please discuss with your primary care physician
before restarting this medication.
Followup Instructions:
1. please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1661**] to establish a follow up appointment within 1-2 weeks.
.
2. Please make sure to have labwork checked by Monday or Tuesday
of next week, see the prescption for labwork
Completed by:[**2187-11-24**]
|
[
"112.1",
"E950.0",
"570",
"989.4",
"286.4",
"386.30",
"300.00",
"V45.86",
"965.4",
"E950.6",
"305.50",
"309.81",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8553, 8568
|
4990, 7724
|
290, 296
|
8717, 8814
|
3442, 4967
|
9506, 9852
|
2925, 3071
|
7993, 8530
|
8589, 8589
|
7750, 7970
|
8838, 9483
|
3086, 3423
|
235, 252
|
324, 2454
|
8683, 8696
|
8608, 8662
|
2476, 2766
|
2782, 2909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,946
| 183,748
|
515
|
Discharge summary
|
report
|
Admission Date: [**2166-12-29**] Discharge Date: [**2167-1-2**]
Date of Birth: [**2096-10-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4272**]
Chief Complaint:
70 y/o female w/ asymptomatic LUL nodule found on routine PE
CXRAY by PCP. [**Name10 (NameIs) 4273**] constitutional symptoms.
Major Surgical or Invasive Procedure:
LUL lobectomy for LUL nodule
History of Present Illness:
70 y/o female w/ asymptomatic LUL nodule found on routine PE
CXRAY by PCP, [**Name10 (NameIs) **] Constitutional symptoms.
Past Medical History:
HTN, MR, RA, Lumbar fusion [**2161**],
TTE: LVEF >60%, mild AS and 1+ MR
Cigs: 15pk yr- quit 30 yrs ago; occ ETOH
Social History:
Married lives w/ husband; 4 children.
Family History:
non-contributory
Physical Exam:
General appearance: Well appearing 70 y/o female, NAD
HEENT- sclera anicteric, conj pink, muc mem moist, no pharyngeal
erythema.
Neck- supple, nontender, no lymphadenopathy
Lungs- CTAB
CV-RRR, grade 3/6 SEM radiating to axilla
ABD- Soft, ND, NT, +BS
EXT-No clubbing,cyanosis or edema; volar derivation of fingers,
MCP nodules
Vascular- 2+ DP/PT, symetrical bilat.
Neuro-A&Ox3
Pertinent Results:
[**2166-12-29**] 01:00PM BLOOD WBC-15.7*# RBC-3.77* Hgb-10.1* Hct-31.4*
MCV-83 MCH-26.7* MCHC-32.1 RDW-13.5 Plt Ct-306
[**2167-1-1**] 07:05AM BLOOD WBC-7.6 RBC-3.41* Hgb-9.1* Hct-29.0*
MCV-85 MCH-26.6* MCHC-31.2 RDW-13.9 Plt Ct-228
[**2166-12-29**] 01:00PM BLOOD Plt Ct-306
[**2167-1-1**] 07:05AM BLOOD Plt Ct-228
[**2166-12-29**] 01:00PM BLOOD Glucose-145* UreaN-11 Creat-0.4 Na-142
K-4.3 Cl-110* HCO3-25 AnGap-11
[**2167-1-1**] 07:05AM BLOOD Glucose-110* UreaN-12 Creat-0.5 Na-141
K-4.6 Cl-108 HCO3-29 AnGap-9
[**2166-12-29**] 01:00PM BLOOD Calcium-8.2* Phos-4.7* Mg-1.6
[**2167-1-1**] 07:05AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.7
SPECIMEN SUBMITTED: LEFT UPPER LOBE WEDGE FS, 11 L NODE X2, LT.
UPPER LOBE & BRONCHIAL RESECTION MARGIN.
DIAGNOSIS:
1. Left upper lobe wedge (A-G):
Bronchioloalveolar adenocarcinoma, see synoptic report.
2. 11L lymph node (H):
One lymph node with sinus histiocytosis, and
non-necrotizing
granulomas, no
carcinoma seen (0/1).
Special stain for AFB and fungi will be reported in an
addendum.
3. 11L lymph node (I):
Lymphoid tissue with sinus histiocytosis
and anthracosis, and non-necrotizing granulomas; no
carcinoma seen.
4. Left upper lobectomy lobe, (J-L):
(1). Lung parenchyma with marked congestion, no
malignancy identified, see synoptic report.
(2). Four lymph nodes with sinus histiocytosis, anthracosis,
and non- necrotizing granulomas;
no malignancy identified.
5. Bronchial resection margin (M):
Bronchial mucosa with no malignancy identified.
Histologic Type: Bronchioalveolar carcinoma.
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor 3 cm or less in greatest dimension,
surrounded by lung or visceral pleura, without bronchoscopic
evidence of invasion more proximal than the lobar bronchus (ie,
not in the main bronchus).
CHEST (PORTABLE AP) [**2166-12-30**] 10:53 AM
IMPRESSION:
Chest tubes in good position within the left lung apex. No
evidence of pneumothorax or hemothorax. Overall, no interval
change since prior study one day before.
CHEST (PA & LAT) [**2166-12-31**] 9:05 AM
IMPRESSION:
Two chest tubes unchanged in position. Left apical tiny
pneumothorax. Left small effusion.
Brief Hospital Course:
70 y.o. female s/p Thoracoscopy video assisted wedge resection,
[**Doctor Last Name **] lobectomy for LUL nodules [**2166-12-29**], c/b small R pulmonary
artery tear which was quickly controlled intraop w/ digital
compression. EBL- 800cc, hemodynamically stable.(refer to OP
note-[**2166-12-29**].
POD #0-Remained in PACU [**2166-12-29**] overnight for brief Neo
administration, volume resuscitation, 1U PRBC, and observation.
Neo quickly weaned overnight. Pain controlled by epidural
w/dilaudid .1% and BUP, d/c b/c itching. Pain controlled w/ MSO4
PCA.
POD#1-
Hemodynamically stable off NEO and transferred to floor early
am. CT x2 sx, no leak, minimal drainage. Pain controlled w/ MSO4
PCA. Tolerating reg diet.
POD#2
Hypotensive, asymptomatic, from volume depletion and anemia. Tx
w/ IVF, 1U PRBC.
CT to W/S, min drainage, then D/C.
POD#3
VSS, no c/o. Ambulating.
Medications on Admission:
[**Last Name (un) 1724**]: zestril 20', atenolol 50', zetia 10', premarin 0.312mg',
centrum, Ca + Vit D 1200mg', ASA 81 qod, arava 20', Fosamax 70'
Discharge Medications:
1. Medication list
Continue the following preop medications: atenolol, premarin,
centrum, aspirin, arava & fosamax. DO NOT RESUME YOUR ZESTRIL
OR ZETIA UNTIUL FOLLOW-UP WITH DR. [**Last Name (STitle) **].
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
3. Other medications
You should take over the counter colace & drink plenty of water
whenever using narcotics to prevent constipation. You may also
take milk of magnesia or dulcolax suppositories if you have
problems.
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left upper lobe lung nodule
Discharge Condition:
Good
Discharge Instructions:
Keep all follow-up appointments
Call Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for: fever, chills,
redness, swelling or drainage at incision site; shortness of
breath,or chest pain.
Followup Instructions:
You have a follow up appt with Dr. [**Last Name (STitle) 175**] on [**1-8**] at 9:30am.
Call [**Telephone/Fax (1) 170**] with questions.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4274**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2167-5-11**] 10:30
Completed by:[**2167-1-2**]
|
[
"276.5",
"285.1",
"492.8",
"998.2",
"162.3",
"714.0",
"401.9",
"396.2",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.29",
"39.31",
"99.04",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
5346, 5352
|
3569, 4440
|
448, 479
|
5424, 5430
|
1269, 3546
|
5673, 6034
|
839, 857
|
4638, 5323
|
5373, 5403
|
4466, 4615
|
5454, 5650
|
872, 1250
|
282, 410
|
507, 631
|
653, 768
|
784, 823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,208
| 136,814
|
54998
|
Discharge summary
|
report
|
Admission Date: [**2183-8-18**] Discharge Date: [**2183-8-21**]
Date of Birth: [**2118-2-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Malaise, abdominal pain
Major Surgical or Invasive Procedure:
Ultrasound-guided drainage of gall bladder abscess
History of Present Illness:
Mr. [**Known lastname 112301**] is a 65 year old man with a history of pancreatic
cancer s/p CBD stent placement in [**2-/2183**] with subsequent
revisions in [**4-/2183**] and [**7-/2183**] who presents from OSH with
malaise and mild abdominal pain. He was diagnosed with
pancreatic cancer in early [**2183**] and underwent an attempted
Whipple in [**3-/2183**] that was aborted when metastatic disease to
the liver was discovered at laparotomy. He started chemotherapy
shortly thereafter, and reports feeling malaise shortly after
his chemotherapy sessions, the most recent of which was on
Friday [**8-15**]. He has also been feeling increasingly weak since
[**Month (only) 958**], sometimes tiring after 10 minutes of walking. He denies
accompanying chest pain, dizziness, lightheadedness, orthopea,
or PND.
The weekend prior to admission, the patient had poor appetite
and did not eat or drink very much. He syncopized twice, and
each episode was preceded by presyncope. He reports brief LOC
but no head strike or abnormal movements. He also reports
measuring a low blood pressure at home to 85/61 (baseline in the
110s systolic) though was asymptomatic. His wife grew worried
given apparently increasing weakness and took him to [**Hospital1 **] ED. At [**Hospital3 **], he received 5L NS, 2U
PRBCs, and vanc/cefepime. He was in Afib with RVR and was
started on a ditliazem drip at 10mg/hr. He was given vancomycin
and cefepime and transferred to [**Hospital1 18**].
In the ED, initial VS were: T:100.2 HR:150 BP:113/73 RR:18
O2:97%. A CTA was negative for PE and showed numerous lung and
liver lesion and an air-filled strucutre at the anterior border
of the liver that could represent gallbladder with pneumobilia,
bowel, or a necrotic lesion. A RUQ u/s showed a CBD dilated to
8-11mm and the same incompletely characterized air-filled
structure at the anterior border of the liver. His Afib with RVR
broke with the diltiazem gtt and he was given tylenol 1g for
pain.
On arrival to the MICU, patient's VS were 99.4 134 109/85 22
96%/RA. He denied dizziness, lightheadedness, cheset pain, or
SOB.
Past Medical History:
- Type II diabetes mellitus
- Atrial fibrillation: per patient report, developed 12 years
ago, resolved 8 years ago after switching jobs
Social History:
[**Country 3992**] war veteran, worked as chemical and mechanical engineer.
Now retired. Denies tobacco, etOH, drugs.
Family History:
No cancer. Otherwise, nonncontributory.
Physical Exam:
Vitals: 99.4 134 109/85 22 96%/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Irregular, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops. JVP 7-8cm.
Lungs: Decreased breath sounds at bases and bibasilar rales, L >
R. Otherwise clear to auscultation bilaterally, no wheezes,
ronchi
Abdomen: soft, non-distended, TTP in RUQ w/o rebound or
guarding, hypoactive bowel sounds, Liver edge palpable 4cm below
costal margin
GU: no foley
Ext: Warm, well perfused, 2+ pulses, trace pitting edema to
shins bilaterally, no clubbing, cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
Admission Labs:
[**2183-8-18**] 07:30PM PT-11.8 PTT-23.6* INR(PT)-1.1
[**2183-8-18**] 07:30PM PLT COUNT-354
[**2183-8-18**] 07:30PM NEUTS-94.0* LYMPHS-3.1* MONOS-0.9* EOS-1.8
BASOS-0.1
[**2183-8-18**] 07:30PM WBC-9.2 RBC-4.26* HGB-11.2* HCT-35.0* MCV-82
MCH-26.3* MCHC-32.0 RDW-15.9*
[**2183-8-18**] 07:30PM ALBUMIN-2.7*
[**2183-8-18**] 07:30PM LIPASE-175*
[**2183-8-18**] 07:30PM ALT(SGPT)-49* AST(SGOT)-40 ALK PHOS-374* TOT
BILI-2.1*
[**2183-8-18**] 07:30PM estGFR-Using this
[**2183-8-18**] 07:30PM GLUCOSE-326* UREA N-29* CREAT-0.9 SODIUM-133
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-17
[**2183-8-18**] 07:51PM LACTATE-2.1*
[**2183-8-18**] 08:30PM URINE MUCOUS-RARE
[**2183-8-18**] 08:30PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2183-8-18**] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
[**2183-8-18**] 08:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2183-8-18**] 08:30PM URINE GR HOLD-HOLD
[**2183-8-18**] 08:30PM URINE HOURS-RANDOM
Discharge Labs [**8-21**]:
WBC 10.4 (N:89.1 L:5.5 M:4.2 E:0.9 Bas:0.4)
HGB 9.5
HCT 29.6
PLT 253
Na 133
Cl 102
Bicarb 22
K 3.8
BUN 22
Cr 0.7
Glucose 135
Ca: 7.8 Mg: 1.7
ALT: 32 AP: 312 Tbili: 0.7
AST: 25 LDH: 184
Imaging:
[**8-20**] CT ABDOMEN/PELVIS WITH CONTRAST
ABDOMEN:
Few small pulmonary nodules are seen in the imaged portion of
the left lower lobe, the largest measuring 7 mm (2a:4). There
is a small right pleural effusion with compressive atelectasis
of the right lower lobe.
Multiple hypoenhancing lesions are seen throughout the liver,
with the
largest in segment V measuring 4.2 x 4.1 cm (2ae:28). The
portal vein is
patent. Small amount of pneumobilia, relates to the presence of
a CBD stent.
Inflammatory changes are seen around the gallbladder, consistent
with acute cholecystitis. There is disruption of the
gallbladder wall at the level of the fundus, with a 9.6 x 2.7 cm
hepatic subcapsular fluid collection which communicates freely
with the gallbladder. This collection contains a small amount
of air which may be due to superinfection or due to the presence
of a biliary stent.
An adjacent rim enhancing fluid collection is seen in the right
lateral abdominal wall musculature measuring 4.0 x 2.0 cm
(300b:16).
The adrenal glands are normal. Both kidneys enhance and excrete
contrast symmetrically, without evidence of hydronephrosis. The
spleen is mildly enlarged measuring 13.8 cm.
There is an ill-defined hypodense mass centered in the region of
the pancreatic head/uncinate process, measuring approximately
3.1 x 2.7 cm. There is encasement of the common hepatic artery
by the mass. An additional hypoechoic lesion measuring 3.7 x
2.5 cm (2a:32) in the portocaval region may represent a lymph
node or posterior extension of the known pancreatic tumor.
Reactive inflammation seen in the distal portion of the stomach.
A duodenal stent is in place. The administered oral contrast
passes freely through the stent into the proximal small bowel.
There is no evidence of bowel obstruction. The abdominal aorta
has mild atherosclerotic calcification without aneurysmal
dilation.
Small retroperitoneal lymph nodes are seen, with the largest in
the aortocaval region measuring 10 mm (2a:46). There is mild
stranding of the mesenteric fat along the right paracolic
gutter. A mesenteric nodule in the right lower quadrant of the
abdomen measuring 15 x 12 mm (2a:54), concerning for metastatic
disease. There is a small amount of simple pelvic ascites.
PELVIS:
The urinary bladder and prostate are unremarkable. There is a
small amount of pelvic free fluid. The rectum and sigmoid colon
are unremarkable. No significant pelvic lymphadenopathy or free
fluid is seen. Incidental note of a small fat-containing right
inguinal hernia is made.
BONES AND SOFT TISSUES: Few small lucent lesions are seen in
the lumbar spine, the largest in L2 vertebral body measuring 7
mm (2a:44). and a lucent lesion in the right iliac bone
(300b:43), are concerning metastatic disease.
IMPRESSION:
1. Presumed gangrenous cholecystitis with perforation.
Subcapsular hepatic fluid collection communicating with the
gallbladder. These findings have not significantly changed
since the earlier study of [**2183-8-18**] but are better
characterized on this study given the abdominal coverage today.
A rim enhancing fluid collection in the right lateral abdominal
wall musculature, concerning for abscess, likely communicating
with the larger collection.
2. Multiple hypoenhancing liver lesions, in the setting of
known pancreatic cancer may represent metastatic disease or
multiple abscesses. Comparison to prior imaging might provide
assistance in evaluating temporal change for assistance in
differentiating the two.
3. Poorly defined hypoenhancing mass in the pancreatic
head/uncinate process, represents known pancreatic cancer.
Additional hypoechoic lesion in the portacaval region may
represent posterior tumor extension versus a lymph node.
4. Patent duodenal stent.
5. Peritoneal metastasis and possible osseous metastasis.
[**8-21**]
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess line.
Comparison is made with prior study, [**8-20**].
Right PICC tip is difficult to visualize can be followed to the
mid to lower SVC. There are low lung volumes with persistent
elevation of the right hemidiaphragm. Right lower lobe
atelectasis has increased. Cardiomegaly and widened mediastinum
are stable. Small right pleural effusion is unchanged.
Multiple lung nodules described in prior CT are not clearly
visualized in this examination and are below the resolution of
this exam. rib fractures are again noted.
[**8-18**] CTA CHEST W&W/O C&RECONS, NON-CORONARY
IMPRESSION:
1. No evidence of pulmonary embolism although with suboptimal
opacification of distal vessels.
2. Multiple lung parenchymal nodules which, given history, are
concerning for metastatic disease though the appearance is not
typical and infectious or inflammatory etiologies may also be
considered.
3. Small right-sided pleural effusion and associated opacity,
in the setting of right hemidiaphragm elevation, likely due to
atelectasis although it is difficult to completely exclude an
infectious process.
4. Partially imaged upper abdomen demonstrating hypodense
lesions within the liver concerning for metastatic disease. Low
density areas with air along the anterior margin of the liver
are incompletely imaged and could represent gallbladder with
pneumobilia, bowel or possibly even necrotic lesions. If
further evaluation is needed, a CT of the abdomen may be
obtained if clinically indicated, noting that the anatomy of the
area is not well delineated by this study, or an accompanying
ultrasound performed around the same time. Correlation to prior
outside imaging, if any prior abdominal CT is available, may
also be helpful.
[**8-18**] RUQ ULTRASOUND
1. Predominantly hypoechoic structure with internal echoes and
containing air. This cannot be connected to bowel and may
represent distended gallbladder with sludge and pneumobilia;
however noting limited assessment, stomach or bowel, or
potentially a necrosis lesion are difficult to exclude. If more
definitive characterization is needed clinically, CT abdomen may
be obtained, preferably with intravenous contrast is possible.
2. The CBD measures up to 11 mm shortly above the stent, but
there is no intrahepatic biliary dilatation.
3. Heterogeneous liver with several hypoechoic foci concerning
for metastatic disease.
Brief Hospital Course:
# Fever/Malaise: The patient presented with RUQ tenderness,
elevated transaminases, and elevated TBili. He was started on
cipro 400mg IV q12h and flagyl 500mg IV q8h for empIric coverage
for potential intra-abdominal infection. His transaminases, alk
phos, and TBili were downtrending during his admission. GI/ERCP
evaluated the patient and felt that his symptoms were unlikley
to be due to cholangitis or biliary obstruction and felt that an
ERCP was unnecessary. Early imaging in the [**Hospital1 18**] ED suggested
the presence of a possible liver abscess. A CT abdomen/pelvis
showed perforated cholecystitis with an adjacent fluid
collection that was concerning for abscess. A gram stain of the
fluid showed polymicrobial infection and cultures were pending.
He was discharged on cipro 400mg IV q12h and flagyl 500mg IV q8h
with a planned 4 week course ([**Date range (1) 112302**]). Day 1 of antibiotics
was [**8-19**]. Pending culture results, the proposed antibiotic plan
was to obtain repeat imaging upon discharge from [**Hospital1 2436**] to
ensure that the fluid collection was being drained adequately,
to continue IV antibiotics for 2 weeks (last day of IV abx
[**9-2**]), to reimage the abdomen, and then to potentially
transition to PO antibiotics for the last two weeks of his 4
week course (ending [**9-16**]).
# Afib with RVR: The patient presented from [**Hospital3 **]
in Afib with RVR to the 150s on a diltiazem gtt at 10mg/hr. He
returned to sinus rhythm in the [**Hospital1 18**] ED and his diltiazem gtt
was stopped. He returned to Afib with RVR on the floor that
reverted to NSR with diltiazem gtt at 15mg/hr. He was
transitioned to diltiazem PO 90mg q6h with good rate control,
though remained in and out of AFib.
# Hyperglycemia: The patient presented with a glucose level of
326, glucosuria, and ketonuria. He was given his home lantus 25
units QHS and placed on an insulin sliding scale. His blood
sugars were better controlled with this regimen.
Medications on Admission:
insulin glargine 25U qHS
actos 15mg PO daily
glipizide 5mg PO daily
omeprazole 20mg PO daily
aspirin 81mg PO daily
zenpep 10,000 TID
prescribed diltiazem, metoprolol, and lisinopril, but not taking
Discharge Medications:
1. Ciprofloxacin 400 mg IV Q12H Day 1 = [**8-19**]
2. Aspirin 81 mg PO DAILY
3. Diltiazem 90 mg PO Q6H please hold for HR<60, SBP<100
4. Glargine 25 Units Bedtime
5. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H D1 [**8-19**]
6. Mirtazapine 7.5 mg PO HS
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Perforated cholecystitis with abscess
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you were feeling unwell. We initially felt your symptoms
might have been due to a bile duct obstruction or a bile duct
infection (cholangitis), but your labs normalized and we did not
feel an ERCP was necessary. We did a CT scan that showed you had
a perforated gall bladder that was infected. We took a sample of
the infected fluid and the culture results are pending in the
[**Hospital1 18**] microbiology lab.
You were given ciprofloxacin and Flagyl (metronidazole) for
antibiotics, which were started on [**8-19**]. Your antibiotics may
change depending on the final culture results. You will need IV
antibiotics for at least two weeks (last day of IV antibiotics:
[**9-2**]). You were given a PICC line for getting IV antibiotics at
home. You should have another imaging study to see if the fluid
collection is improving. If it looks better, you should switch
to oral antibiotics for two more weeks (last dose on [**9-16**], for a
total 4 week course).
You were also in rapid atrial fibrillation while in the
hospital. You were given diltiazem 90mg by mouth every 6 hours
to control your heart rate. You should continue to take this
medication at home.
Your blood sugars were elevated during your hospitalization. In
addition to your usual evening long-acting insulin dose, you
were placed on a short-acting insulin sliding scale. You should
check with your doctors [**First Name (Titles) **] [**Hospital3 **] about continuing
this at home.
Change the dressing around the biliary drain daily. Wash the
skin with 1/2 strength hydrogen peroxide, rinse with a
saline-moistened QTip, and apply a new sterile dressing.
The percutaneous drain should be flushed daily according to the
following instructions:
Flush with 10cc sterile saline and aspirate back.
Repeat this until aspirate is clear. Do not continue to flush if
the volume out is significantly less than the volume in.
If there is pain with flushing this may mean that the abscess
cavity has collapsed.
In this case, please call [**Hospital1 18**] operator ([**Telephone/Fax (1) 2756**]) and ask
for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with the radiology nurse practitioner's
office for further instructions.
Troubleshooting: If catheter stops draining suddenly:
1) Check that the stopcock is open.
2) Remove dressing carefully and inspect to make sure that there
is no kink in the catheter.
3) Inspect to be sure that there is no debris blocking the
catheter. If there is, then firmly flush 5 cc of sterile saline
into the catheter.
Followup Instructions:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Oncologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
You should follow up with your PCP and oncologist in the next
1-2 days.
You should have your gall bladder reimaged in [**2-7**] days, and
again in 2 weeks.
Completed by:[**2183-8-21**]
|
[
"427.31",
"V87.41",
"790.4",
"401.9",
"157.0",
"V45.89",
"250.00",
"575.4",
"276.2",
"575.0",
"780.52",
"564.00",
"198.5",
"197.6",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.01",
"38.97",
"87.41"
] |
icd9pcs
|
[
[
[]
]
] |
13792, 13807
|
11267, 13246
|
328, 380
|
13940, 13940
|
3628, 3628
|
16730, 17075
|
2826, 2867
|
13494, 13769
|
13828, 13919
|
13272, 13471
|
14090, 16707
|
2882, 3609
|
265, 290
|
408, 2515
|
3645, 11244
|
13955, 14066
|
2537, 2675
|
2691, 2810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,349
| 123,952
|
30133
|
Discharge summary
|
report
|
Admission Date: [**2147-3-24**] Discharge Date: [**2147-4-7**]
Date of Birth: [**2074-5-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
transfer from OSH for further evaluation of pancreas
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
70yo female, HTN, DM, admitted 3 weeks ago with pulmonary
symptoms incl. effusions, CT scan of her lungs also revealed
inflammation of pancreas in the upper abdomen (mild stranding),
with normal amylase/lipase; no stones, no biliary dilation. Did
well; went home and then returned with upper abdominal pain and
shortness of breath req intubation (acute hypoxia) for 24 hours.
Extubated and did well so transferred to floor. Repeat CT scan
now showing diffusely enlarged pancreas with pressure on
duodenum and antrum of stomach with ileus; no elevation
amylase/lipase, normal biliary ducts. CA [**58**]-9 normal. Kept
NPO, started on TPN. No nauseau, vomitting. Not tender.
Returned to unit for repeat hypoxia last weekend, believed from
infiltrates and effusion, required bipap. Now back to nasal
cannula--placed on antibiotics and improved. Repeat CT scan 2
days ago, worsening peripancreatic inflammation and beginning
pseudocyst or cyst/malig. Able to advance diet to clears and
tolerating.
Past Medical History:
Asthma
DM II
Hyperlipidemia
HTN
Social History:
nonsmoker, nondrinker, no h/o IVDU
Family History:
NC
Physical Exam:
VS: T 96 / 130/60 / 77 / 18 / 94% 4L
GEN: Pleasant, A&Ox3, not in acute distress
HEENT: No JVD, no LAD, OP clear, MMM, EOM intact, anicteric
sclerae
LUNGS: inspiratory wheezes BL, no rales/rhonchi
HEART: RRR no MRG
ABD: normoactive, obese, soft tender in RUQ, epigastric regions
EXTR: Warm, 2+ PT pulses symmetric BL,no CCE
NEURO: CN II- XII in tact, [**4-15**] upper and lower extremity
strength, sensation grossly intact
SKIN: No rash, warm and dry
Pertinent Results:
141 98 28
-------------< 167
4.0 32 0.7
Ca: 8.5 Mg: 2.2 P: 3.6
ALT: 17 AP: 99 Tbili: 0.3 Alb: 2.5
AST: 18 LDH: Dbili: TProt:
[**Doctor First Name **]: 42 Lip: 22
19.1 > 8.8 < 271
25.3
PT: 13.7 PTT: 29.6 INR: 1.2
CXR [**2147-3-24**]: Cardiomediastinal contour is unremarkable. Aside
from a discoid atelectasis in the left lower lobe, the lungs are
grossly clear. Increased density in the left CP angle laterally
is most likely consistent with pleural thickening. There is no
pneumothorax. Left subclavian vein catheter terminates in the
mid SVC.
CTA [**2147-3-31**]:
1. No evidence of acute pulmonary embolism or aortic dissection.
No evidence of extrinsic airway compression. CT trachea study
may be ordered for better assement of airway pathology.
2. Questionable small amount of fluid within the distal trachea
and right mainstem bronchus likely place patient at risk for
aspiration. A more focal area of consolidation is noted along
the right minor fissure which appears slightly retracted
superiorly.
3. Bilateral small pleural effusions and subsegmental
atelectasis with a more significant atelectasis noted within the
left lower lobe posterior basal segment.
4. Intra-abdominal ascites.
5. Coronary and aortic vascular calcifications.
Brief Hospital Course:
70 yo female with h/o asthma presented to OSH with asthma flare
found to have new pancreatic [**Hospital **] transferred to [**Hospital1 18**] for
further w/u.
.
# ASTHMA FLARE: She has h/o asthma which had been inactive for
several years until recently she had 3 hospitalization within
the past few months for asthma flare. Twice she was intubated
including this recent hospitalization at OSH before transfer to
[**Hospital1 18**] on [**2147-3-24**]. PFTs from OSH demonstrated clear obstructive
picture. On transfer here, her respiratory status was improving
and she was kept on nebs and finished a course of antibiotics
while her steroids were weaned off. Then she decompesated on
[**2147-3-31**] with tachypnea and increased work of breathing. She was
admitted to the MICU for closer observation and required brief
period of bipap. CTA was negative for PE and there was
questionable pneumonia. She was put on steroids again and was
started on a course of levofloxacin. She was transferred back
on the regular medicine service on [**2147-4-3**] when he respiratory
status stabilized once again and was followed by pulmonary
consult team. She was on room air on discharge, and she should
continue standing xopenex/ipratroprium nebs. She should also
continue montelukast, advair and a long steroid taper starting
with prednisone 40mg daily x 1 week and tapering by 5mg each
week. She recieved 6 days of Levofloxacin and Pulmonary consult
agreed with stopping abx.
.
Of note, sputum culture grew out MRSA on [**2147-4-4**] but this was
felt to be from colonization since she currently does not have
signs and symptoms of PNA: afebrile and stable on room air
without cough or sputum.
.
Apparently, RAST at OSH was positive for dust mites. Her ANCA
was negative. Bedside evaluation from speech and swallow did
not demonstrate aspiration.
.
She has followup at Pulmonary Clinic on [**6-5**] for management
of her chronic asthma.
.
# PANCREAS: During workup for her asthma flare at OSH, her
pancreas was imaged for unclear reasons. The CT report reads:
"Extensive cystic change throughout the pancreas and
peripancreatic soft tissue. This is most suggestive of
pancreatic pseudocyst formation with associated phlegmonous
tisse and presumed acute pancreatitis. A cystic neoplasm,
however, cannot be excluded and would be reason within the
different diagnosis. The cystic formation is somewhat more
extensive than previously seen." There was no elevated in
amylase and lipase and her biliary ducts were normal. CA [**58**]-9
was normal. She was initially put on bowel rest and TPN per
recommendations from the ERCP team. Later, she was transitioned
to a diet and tolerated that without a problem. Surgery was
consulted and felt that there was no urgent need for surgery at
this time. She needs to follow up as an outpatient and has a
scheduled appointment with Dr. [**Last Name (STitle) **] in surgery on [**4-14**].
.
There was a concern from the pulmonary team that this could be
autoimmune pancreatitis because there may be a link to asthma.
Dr. [**Last Name (STitle) 174**] from GI was consulted and agreed with the possibilty
given her asymptomatic presentation of pancreatitis. IgG4
levels and CFRT mutation panel were sent and were pending at
discharge. She will taper her steroids slowly starting at 40mg
daily and tapering down by 5mg each week. She has followup
arranged with Dr. [**Last Name (STitle) 174**] 0n [**4-25**].
.
# DM II: managed with RISS and glargine 8 U at bedtime. Since
she is on steroids, her blood sugars have some variation. She
will need outpatient follow up also.
.
# Hyperlipidemia - conitinued PO lipitor.
.
# HTN - continued diltiazem.
.
# Anxiety - continued zolpidem and lorazepam.
.
# Code: full
.
Medications on Admission:
sporanox
theophylline
lasix
colace
cardizem
SSI
Tylenol
Protonix
Ativan
Dilaudid
Levoflox
Albuterol
Spiriva
Lovenox
Advair
prednisone
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours.
5. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR.
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
14. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation every six (6) hours.
19. Insulin Glargine 100 unit/mL Solution Sig: Eight (8)
Subcutaneous at bedtime: Also cover patient with regular insulin
sliding scale.
20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): TAPER:
40mg x 1 week, first day [**2147-4-5**].
35mg x 1 week
30mg x 1 week
25mg x 1 week
20mg x 1 week
15mg x 1 week
10mg x 1 week
5mg x 1 week
off.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. Idiopathic Pancreatitis - Pseudocyst.
2. Acute Exacerbation of COPD.
3. Deconditioning - Immobility.
4. Malnutrition.
Secondary:
1. Obesity.
2. Diabetes Mellitus Type II.
3. Hypertension.
4. Hyperlipidemia.
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
Please take all medications as prescribed
If you have chest pain, shortness of breath, palpitations,
nausea, vomitting, diarrhea please call the doctor on call or go
to the emergency room.
Followup Instructions:
Please make a follow up appointment with your primary care
doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 71812**] ([**Telephone/Fax (1) 71813**]) within 2 weeks of discharge
Please follow up with Surgery Clinic about your pancreas. This
is an important appointment to keep:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2147-4-14**] 8:30
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] at [**Hospital **] Clinic for further
evaluation for your pancreas:
Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2147-4-25**] 9:20
Completed by:[**2147-4-7**]
|
[
"577.2",
"511.9",
"285.9",
"300.00",
"272.4",
"278.00",
"493.22",
"577.0",
"707.03",
"250.02",
"263.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9246, 9316
|
3325, 7087
|
367, 392
|
9580, 9615
|
2040, 3302
|
9853, 10634
|
1550, 1554
|
7271, 9223
|
9337, 9559
|
7113, 7248
|
9639, 9830
|
1569, 2021
|
274, 329
|
420, 1426
|
1448, 1482
|
1498, 1534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,983
| 197,226
|
32576
|
Discharge summary
|
report
|
Admission Date: [**2164-10-24**] Discharge Date: [**2164-10-27**]
Date of Birth: [**2099-8-31**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
metastatic renal cell CA
Major Surgical or Invasive Procedure:
right femoral IM nail
History of Present Illness:
65 year old man with history of metastatic renal cell carcinoma
with metastasis to right femur
Past Medical History:
1. Renal cell carcinoma. He has been treated with both IL-2
followed by a nephrectomy after progression following his IL-2
treatment. He has no metastases to the spine and to an area
surrounding the lung.
Social History:
The patient is a former tobacco user. He is
currently retired.
Family History:
The patient notes a history of cancer in his
sisters. [**Name (NI) **] other family history.
Physical Exam:
On examination today, the patient is alert and oriented
x4, in no apparent distress. He appears his stated age. The
patient on exam today is 5 feet 6 inches tall
and 177 pounds.
MUSCULOSKELETAL: The patient's right lower extremity
demonstrates an intact sensation to light and dull sensation
throughout all distributions. Sensation appears to be somewhat
decreased compared to the left side; however, his sensation is
intact. He has a palpable dorsalis pedis pulse. His posterior
tibialis is 1+. He shows decreased hair distribution about the
lower calf, but no skin changes associated with venous
congestion. Dressing is c/d/i, no c/c/e.
Pertinent Results:
INR 2.2
Brief Hospital Course:
MICU Course:
The patient was admitted to the ICU overnight for hypoxemia
which was attributed to OSA and sedation. Oxygen was weaned
overnight and vitals were stable.
On the surgical floor he has been OOB with PT, using a walker.
His O2 sats have dropped at night and with ambulation but
maintained on O2, which he will go home on. He is tolerating
food, voiding, and moving his bowels.
Medications on Admission:
1. Fluoxetine 40 mg tablets one p.o. daily.
2. Flonase p.r.n.
3. Ibuprofen p.r.n.
4. Pravastatin 40 mg one p.o. daily.
5. Trazodone 50 mg two tablets p.o. at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
1. Metastatic renal cell cancer to right femur
Discharge Condition:
Stable with home oxygen
Discharge Instructions:
1. Discharge to home.
2. Follow-up with Dr. [**First Name (STitle) 4223**] in [**11-2**] days.
3. Call with problems
4. Regular diet
5. Home oxygen 3L/min during day, 4L/min during night
Followup Instructions:
followup with Dr. [**First Name (STitle) 4223**] in [**11-2**] days
|
[
"V07.8",
"V43.64",
"198.5",
"585.9",
"V10.52",
"V15.82",
"V87.41",
"327.23",
"V45.73",
"799.02",
"369.60",
"272.0",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.55"
] |
icd9pcs
|
[
[
[]
]
] |
2230, 2281
|
1619, 2008
|
335, 358
|
2372, 2398
|
1587, 1596
|
2633, 2703
|
810, 906
|
2302, 2351
|
2034, 2207
|
2422, 2610
|
921, 1568
|
271, 297
|
386, 482
|
504, 712
|
728, 794
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,798
| 185,564
|
647
|
Discharge summary
|
report
|
Admission Date: [**2196-4-15**] Discharge Date: [**2196-4-21**]
Service: MEDICINE
Allergies:
Penicillins / Amiodarone Hcl
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
dark stools
Major Surgical or Invasive Procedure:
EGD on [**2196-4-16**]
Capsule Study [**2196-4-18**]
History of Present Illness:
Mr. [**Known lastname 4924**] is a [**Age over 90 **] year-old man with a history of coronary
arteryd disease, diabetes, hypertension, ischemic/radiation
proctitis and colon cancer who presents with a GIB.
.
Two recent admission. The first ([**3-17**] - [**3-25**]) was for a lower GI
bleed. A colonoscopy was notable for stigmata of a recent
internal hemorrhoid bleed with post radiation proctitis.
.
Then readmitted ([**4-5**] - [**4-11**]), this time with lower extremity
edema thought to be secondary to a CHF exacerbation. He was
diuresed 18 liters of fluid via Lasix gtt and Diuril with a dry
weight of 68.5kg achieved.
.
Since discharge from hospital has been relatively stable, though
has been less active (previously could do 30 minutes on the
treadmill daily, but now cannot do any). Over the last day he
reports approximately 10 hours of dark black stools. This has
not been associated with any abdominal pains, nausea/vomiting,
chest pains, shortness of breath, fevers/chills. He called PCP
and was advised to come to ED.
.
In the ED, initial vitals showed T 97.9, HR 70, BP 122/42, 100%
RA. His hematocrit was noted to be 22, down from mid 33 just
four days prior. One liter of NS was given and unit of blood was
hung. Protonix IV was also given.
.
Past Medical History:
1. Coronary artery disease
- CABG ([**5-/2181**]) with LIMA to LAD, SVG to PDA, SVG to OM3
- Cath ([**1-/2187**]) with 20% LM, native 3VD and patent LIMA to LAD and
SVG to OM3. Occluded SVG to the PDA.
2. Congestive heart failure
- Echo ([**3-19**]) with EF 40% (secondary to dyskinesis of the basal
inferior and posterior (inferolateral) walls and mild LVH
3. Mitral regurgitation (3+)
4. Pulmonic regurgitation ("significant")
5. Moderate pulmonary artery systolic hypertension
6. Diabetes
7. Hypertension
8. Atrial fibrillation
9. NSVT with dual chamber pacer
[**98**]. Ischemic bowel disease in the setting of over diuresis
Social History:
He lives at home with his wife. Ex-[**Name2 (NI) 1818**], quit 40 years ago.
Family History:
Non-contributory.
Physical Exam:
Vitals - T 95.6, BP 118/62, HR 70, 100% on 2 liters.
GEN - Thin man, lying in bed in no distress. Able to provide
clear history.
HEENT - Dry mucous membranes. Conjunctival palor. No icterus. No
LAD.
CV - Regular. III/VI systolic murmur best heard at the base.
PULM - Clear. No wheeze/rales.
ABD - Soft and mildly distended. Minimally tender in LLQ.
EXT - Warm. No edema.
NEURO - Alert and oriented x3. Able to provide clear history
Pertinent Results:
[**2196-4-15**] 11:24AM BLOOD WBC-7.5 RBC-2.46*# Hgb-7.0*# Hct-21.2*#
MCV-86 MCH-28.7 MCHC-33.3 RDW-19.5* Plt Ct-243
[**2196-4-15**] 11:24AM BLOOD PT-21.5* PTT-37.1* INR(PT)-2.0*
[**2196-4-15**] 11:24AM BLOOD Glucose-145* UreaN-161* Creat-2.4* Na-133
K-5.5* Cl-94* HCO3-28 AnGap-17
[**2196-4-15**] 11:24AM BLOOD ALT-38 AST-50* LD(LDH)-382* AlkPhos-43
TotBili-0.7
[**2196-4-17**] 07:10AM BLOOD calTIBC-430 VitB12-1410* Folate-GREATER
TH Hapto-34 Ferritn-89 TRF-331
[**2196-4-20**] 06:00AM BLOOD WBC-6.0 RBC-3.24* Hgb-9.7* Hct-29.3*
MCV-90 MCH-30.0 MCHC-33.3 RDW-18.7* Plt Ct-186
[**2196-4-20**] 06:00AM BLOOD PT-14.0* PTT-32.9 INR(PT)-1.2*
[**2196-4-20**] 06:00AM BLOOD Glucose-79 UreaN-30* Creat-1.4* Na-142
K-4.4 Cl-108 HCO3-25 AnGap-13
.
EKG: Ventricular paced rhythm. Compared to the previous tracing
of [**2196-4-6**] no change.
.
CXR: FINDINGS: In comparison with the study of [**4-8**], there is
no interval change. Again there is enlargement of the cardiac
silhouette without vascular congestion. Pacemaker device is
again seen in a patient with intact midline sutures and evidence
of previous CABG. No acute pneumonia.
IMPRESSION: No interval change
Brief Hospital Course:
[**Age over 90 **] y/o male with MMP including CAD, CHF with an EF of 40%, DM,
h/o colon cancer s/p resection & XRT with recent adm for BRBPR
found to have internal hemorrhoids & radiation proctitis now
presenting with black stools and a drop in hct.
.
#. GI bleed/Anemia: Pt presented with report of melena and hct
of 21 (baseline 30s)and INR of 2. Pt was admitted to the MICU,
transfused with a total of 6upRBCs over the hospitalization and
was given po Vitamin K to reverse INR. Pt was transferred to
the floor once hct was stabilized. Given the history of melena,
this was thought more likely to be an UGIB. However, EGD was
unrevealing so a small bowel etiology was thought possible. Pt
underwent a bowel prep and had a capsule study performed on
[**2196-4-18**] to evaluate the entire GI tract. Pt's last melenotic
stool was on [**4-18**] and last tranfusion on [**4-17**]. Pt was monitored
in house for 3 additional days and hematocrit remained stable
off coumadin with an INR of 1.2. After discussion with patient &
family, decision was made to stop Coumadin given his recurrent
GI bleeds and there is no plan for ongoing anti-coagulation. Pt
was discharged on Protonix 40mg [**Hospital1 **]. Pt will be following up
with his PCP on [**4-22**] and will follow up with GI if capsule
study is positive.
.
#. CAD: Pt denied any symptoms throughout admission. There were
no events noted on telemetry, ventricular paced rhythm on EKGs.
Pt was continued on ACE-I, ASA 81mg & Carvedilol 3.125mg [**Hospital1 **].
.
#. Acute on chronic kidney disease: Baseline creatinine ranges
anywhere from 1.5-2.5 over the last month. BUN was noted to be
elevated on adm likely due to the GI bleed and it trended down
to baseline in house. Creatinine stable at baseline of 1.4 and
pt was continued on his ACE Inhibitor.
.
#. Atrial fibrillation: Pt with a history of Atrial Fibrillation
and NSVT s/p pacemaker and was paced with a rate in the 70s.
All anti-hypertensives were held on admission and Carvedilol was
added back at a lower dose of 3.125mg [**Hospital1 **]. Pt was continued on
digoxin and ASA 81mg. Coumadin was held of admission due to GIB
and after discussion with family/patient, decision was made to
stay off anti-coagulation indefinitely due to recurrent GI
bleeds.
.
#. Congestive heart failure: Pt remained dry to euvolemic
throughout admission off any diuretics. He denied SOB, lungs
were clear on exam and maintained his sats well on RA. SBP
remained in the 110s, pt was continued on Ace-i, lower dose
Carevdilol & Digoxin. Pt was instructed to stop Bumex & HCTZ
and PCP was notified, pt may need these restarted in the future.
.
#. Diabetes: Pt was switched to glipizide 2.5mg daily in place
of glyburide due to baseline impaired renal clearance.
Medications on Admission:
1. Aspirin 81 mg daily
2. Carvedilol 12.5 mg [**Hospital1 **]
3. Digoxin 125 mcg one half Tablet every other day
4. Bumex 1 mg [**Hospital1 **]
5. Hydrochlorothiazide 25 mg every other day
6. Lisinopril 5 mg daily
7. Warfarin 3.75 mg daily
8. Glyburide 5 mg daily
9. Potassium Chloride 10 mEq daily
10. Gabapentin 100 mg TID
11. Allopurinol 200mg daily
12. Folic acid
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
GI Bleed
.
Secondary:
Coronary artery disease s/p CABG
Congestive heart failure
Moderate pulmonary artery systolic hypertension
Diabetes II
Hypertension
Atrial fibrillation
NSVT with dual chamber pacer
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with black tarry stools and had an EGD that
did not show any evidence of bleeding. You had a capsule study
that was essentially normal and also did not show any evidence
of bleeding. Your blood counts have been stable for the last
three days since your INR has come down. After discussion with
your family & your doctors, you have decided to stop taking
Coumadin.
.
Please note the changes that we have made to your medications:
1. decrease Allopurinol to 100mg daily
2. stop Coumadin
3. decrease Carvedilol to 3.125mg twice daily
4. stop Bumex for now
5. stop Hydrochlorothiazide
6. stop Glyburide
7. stop Potassium Chloride
8. start Glipizide XL 2.5mg daily
9. start Pantoprazole 40mg twice daily
.
It is important for you to weigh yourself every morning and if
your weight increases by more than 2 lbs, you should restart
taking Bumex 1mg daily. If you gain more than 5lbs, you should
take Bumex 1mg twice daily. Please call Dr. [**Last Name (STitle) 58**] to
[**Last Name (STitle) **] a follow up appointment sooner if you are restarting
the Bumex.
.
If you develop any chest pain, shortness of breath, bright red
blood in your stools, dark black stools or any other general
worsening of condition, please call your PCP or go directly to
the ED.
[**Last Name (STitle) **] Instructions:
Please keep your follow up appointment with Dr. [**Last Name (STitle) 4966**] on
[**4-22**] at 11:15am.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2196-9-6**]
3:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2196-9-6**] 4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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icd9cm
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|
8447, 10260
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,563
| 171,663
|
8076+8077+55910+55911
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2109-12-22**] Discharge Date: [**2110-1-8**]
Date of Birth: [**2047-4-16**] Sex: M
Service: MEDICAL ICU
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
male with a past medical history of noninsulin dependent
diabetes mellitus, chronic renal insufficiency, hypertension,
congestive heart failure, questionable alcohol use who was
transferred from [**Hospital6 5016**] for management of acute
renal failure, acute coronary syndrome, non Q wave myocardial
infarction, respiratory failure requiring intubation possible
DTs. The patient initially presented to [**Hospital3 **] on
[**12-15**] after having two to three weeks of a viral
syndrome with cough. The patient was markedly sleep deprived
and having hallucinations. On hospital day number two the
patient became progressively delirious and had decrease in
mental status and was seen by neurology and thought to be in
alcohol withdraw. On the following day [**12-19**] the patient
was transferred to the Intensive Care Unit at [**Hospital3 **]
where he was intubated for a decrease in respiratory function
and was intubated. He developed pulmonary edema and most
likely had a non Q wave myocardial infarction with increase
in creatinine to 6.47. His baseline creatinine is 2.5. The
patient's initial arterial blood gas was 7.06, 64 and 60.
Troponins at that time were 6.47. The patient had an
echocardiogram at the outside hospital,which showed an EF of
35 to 40%, mitral regurgitation, hypokinesis in the mid
distal septum and apex. Neurological consult showed
agitation confusion likely manifestation of withdraw. The
patient started on Ativan, multivitamins, thiamine and
folate. Nephrology was consulted for the increased
creatinine in the setting of worse failure and chest x-ray.
Lasix was started. Head CT was negative. Sodium was 121 and
subsequently corrected.
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes mellitus.
2. Chronic renal insufficiency, baseline creatinine 2.5.
3. Anemia.
4. B-12, folate deficiency.
5. Hypertension.
6. Congestive heart failure.
7. Obstructive sleep apnea.
8. Coronary artery disease status post angioplasty and three
vessel coronary artery bypass graft and bilateral carotids
stenosis.
9. Retinal hemorrhage.
HOME MEDICATIONS: Pravachol, Hydralazine, Zoloft,
Metoprolol, Actos, Cardura and Lasix.
MEDICATIONS AT OUTSIDE HOSPITAL: Insulin sliding scale,
Unasyn, Clindamycin, Alphagan, Trusopt, Thiamine, folate,
Metoprolol 12.5 b.i.d., Ativan drip.
INITIAL PHYSICAL EXAMINATION: Temperature 99.6, heart rate
94, blood pressure 135/57. Settings on ventilator were AC
tidal volume 800, rate of 8, 5 of PEEP, .5 FIO2, initial gas
7.38, 47 and 142. The patient is sedated and intubated
following commands. with hepatojugular reflex, questionable
JVD, regular rate and rhythm, S1 and S2, right lung crackles
two thirds of the way up on the left lung rales at base.
Abdomen soft, distended, nontender, good bowel sounds. Lower
extremities trace edema. Upper extremity 1+ edema.
INITIAL LABORATORIES: CBC white blood cell count 8.4,
hematocrit 28.5, platelets 200, coags 17.4, 35.7, 2.0. Chem
7 141, 3.8, 105, 28, 38, 2.7, 167, AST 30, ALT 20, LDH 271,
alkaline phosphatase 85, amylase 69, albumin 2.7.
Electrocardiogram normal sinus rhythm, heart rate 97, primary
AV block, T wave inversions in V2 to V4, 1 and AVL. No ST
abnormalities. Initial chest x-ray showed right lung
opacification throughout left lung base effusion.
HOSPITAL COURSE: The patient's oxygenated and ventilated
well on a C. Blood culture, sputum culture, urine cultures
were sent. [**12-23**] the patient spiked a temperature to
101.6. The patient was transfused 1 unit of packed red blood
cells. The patient had an MRI of the head, which showed
sinusitis. No cerebral abscesses or empyema. Small focus of
increased T2 signal in the right frontal lobe, which could
represent small cortical infarct undetermined age. Please
note sinusitis with mucosal thickening in the sphenoid sinus
and maxillary and ethmoid air cells, fluid levels identified
in the posterior ethmoid and the left sphenoid sinus. The
patient was evaluated by nutrition, which recommended tube
feeds, Critical at goal 65 cc. [**12-22**] the patient was
started on Vancomycin and Levaquin. [**12-23**] A line was
placed. Nasogastric tube was discontinued for the sinusitis.
Multiple attempts at OG tube unable to place OG tube.
[**12-23**], repeat echocardiogram showed ejection fraction of
25 to 30%, moderate dilation of the left ventricular cavity,
severe left ventricular systolic dysfunction with near
akinesis of the distal half of the inferior septum, anterior
wall, distal third of the inferior wall. Also showed 1+
mitral regurgitation. Pulmonary systolic pressure is normal
and a trivial pericardial effusion likely physiologic.
The patient weaned from ventilator. The patient exhibiting
increased agitation requiring Ativan. Another temperature
spike to 101.2 requiring pan cultures on [**12-25**].
Hematocrit dropped from 30 to 27 requiring another
transfusion. Bronchoscopy [**12-25**] showing severe
supraepiglottic edema moderate secretions in the right lower
lobe, OG tube placed under direct visual. The patient self
extubated on [**12-26**] and placed on nonrebreather with
increased apnea. The patient was reintubated secondary to
sedation and apnea. [**12-27**] the patient was noted to hve
an erythematous rash on his chest and right lower extremity
cellulitis. The wound was cultured, which was negative. The
patient on Vancomycin for coverage. [**12-29**] bronchial
lavage showed MRSA. [**12-30**] the patient had a bedside
swallow evaluation, which was failed on thick liquids. The
patient was extubated on [**12-29**] doing well for a couple
of days and reintubated secondary to declining mental status.
On [**12-31**] the patient was reintubated. On [**12-30**]
the patient had a right upper extremity ultrasound secondary
to swelling to rule out upper extremity deep venous
thrombosis where he had his right subclavian line placed,
that was negative. Thought decreased mental status possible
secondary to benzodiazepine withdraw. The patient started on
Ativan around the clock and then weaned to Valium. The
patient's mental status declined while on benzodiazepines
making likelihood of withdraw less.
The patient had a left subclavian line placed and right
subclavian line removed secondary to fevers. On [**1-1**]
the patient was started on total parenteral nutrition due to
inability and difficulty with replacing OG tube. The patient
noted to have increased purulent sputum from his nasopharynx
and bleeding, hematocrit and coags checked, which were within
normal limits. On [**1-5**] MRI of head to reevaluate the
patient due to persistent decreased mental status. No change
from prior MRI. No evidence of infarct. No evidence of
abnormal enhancement or abscess. LP was performed on the
floor due to difficulty with multiple attempts by neurology
to obtain spinal fluid. No evidence of bacterial meningitis.
Cultures negative. The patient had repeat echocardiogram
[**1-7**] to evaluate cardiac function 45 to 55% EF. Left
ventricular systolic function much improved. The patient had
labile blood pressures elevated control with Hydralazine.
Intermittently Clonidine patch and Labetalol. [**1-2**] the
patient was started on Ceptaz for purulent sputum for a total
course of seven days. Vancomycin was renally dosed,
continued per ID recommendations . The patient was started on
Epogen for low retic count 0.4. The patient had repeated
temperature spikes and multiple cultures. Nasopharyngeal
drainage cultures showed heavy MRSA growth. The patient
extubated and reintubated a third time and failed again.
Nitro drip was started for elevated blood pressures.
Neurological was consulted for the persistent decreased
mental status, recommended an MRI results noted above. LP
results also noted above. Electroencephalogram showed mild
diffuse slowing consistent with encephalopathy. Renal was
also consulted on the patient for elevated BUN, thought
mental status changes might be secondary to uremia. Renal
thought it was unlikely due to the low level and history of
chronic renal insufficiency. The patient's mental status
remained stunted after decreasing the BUN with D5W drip.
Recommended check for upper gastrointestinal bleed, although
the patient was guaiac negative. Study deferred as repeat
bronch showed limited access due to airway edema. The
patient developed a likely chemical pancreatitis with a
lipase to 299, which resolved after a couple of days.
Patient's belly nontender. The patient receiving total
parenteral nutrition. ENT evaluated the patient for the
persistent purulent drainage. Normal nasolaryngoscopy view
of the sinuses. Recommended discontinuing the antibiotic.
No intervention.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 28844**]
MEDQUIST36
D: [**2110-1-8**] 08:28
T: [**2110-1-9**] 08:46
JOB#: [**Job Number 28845**]
Admission Date: [**2109-12-22**] Discharge Date: [**2110-1-22**]
Date of Birth: [**2047-4-16**] Sex: M
Service:
ADDENDUM TO DISCHARGE SUMMARY DICTATED [**2110-1-14**]:
The patient has been stable throughout the hospitalization
since [**2110-1-14**]. The patient has been noted to have several
episodes of hypertension concurrently associated with
agitation during movement of the patient, as well as during
cleaning episodes. Outside of the intermittent agitation
associated with cleaning and movement of the patient, this
patient's blood pressures remained stable in the 140s to 150s
over 70s diastolic. The patient's blood pressure has been
well controlled on the four blood pressure medications.
The patient was weaned off propofol sedation on [**2110-1-20**].
His amount of Haldol was increased from 2 mg tid to 5 mg tid.
A Psychiatry Consult was obtained on [**2110-1-21**] to help with
further recommendations of outpatient antidepressant /
antipsychotic medication regimen.
DISCHARGE CONDITION: Stable.
DISPOSITION: To rehab.
ALLERGIES: No known drug allergies.
DISCHARGE MEDICATIONS:
1. NPH 18 U at breakfast, 18 U at bedtime with standard
sliding scale starting at 150 and increasing by 50, 2 units
per increase of 50 U of blood sugar, with 150 to 200
requiring 2 U, 200-250 requiring 4 U, 250-300 requiring 6 U,
300-350 requiring 8 U, and 350-400 requiring 10 U of regular
insulin.
2. Pantoprazole 30 mg twice a day.
3. Haldol 5 mg po three times a day.
4. Isosorbide dinitrate 10 mg three times a day.
5. Clonidine 2 patches q Monday.
6. Hydralazine 60 mg po q 6.
7. Metoprolol 50 mg three times a day.
8. Heparin 5,000 subcu q 8.
9. Aspirin 325 qd.
10. Bromadine tartrate drops 0.15% to each eye twice a day.
11. Epogen 10,000 U subcu q Friday.
12. Sertraline 50 mg po qd.
13. Lipitor 20 mg po qd.
14. Folic acid 1 mg po qd.
15. Senna tablets one p.o. twice a day.
16. Lactulose 30 ml po qd p.r.n.
DISCHARGE DISPOSITION: To rehabilitation.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**MD Number(1) 28846**]
MEDQUIST36
D: [**2110-1-21**] 02:37
T: [**2110-1-21**] 13:40
JOB#: [**Job Number 28847**]
Name: [**Known lastname 1292**], [**Known firstname 63**] J Unit No: [**Numeric Identifier 5052**]
Admission Date: [**2109-12-22**] Discharge Date: [**2110-1-14**]
Date of Birth: [**2047-4-16**] Sex: M - 62 year old
Service: MEDICAL ICU
This is an Addendum to the Discharge Summary dictated on
[**1-8**]. Please note the change in Attending. It should
be [**First Name8 (NamePattern2) **] [**Doctor Last Name 781**] not Dr. [**Last Name (STitle) **]. Please make that
change.
HOSPITAL COURSE CONTINUATION: The patient had a renal
ultrasound to evaluate for persistent labile hypertension,
the recommendation of the Renal Service. It showed no
evidence of hydronephrosis, no evidence of renal artery
stenosis.
The patient completed Ceptaz which was discontinued on
[**1-8**]. The patient had a tracheostomy tube placed
without difficulty on [**1-9**] with a #6 Shiley. On
[**1-10**], the patient had a percutaneous endoscopic
gastrostomy placed. Tube feeds were started. Ultracal with
a goal of 80 cc an hour. Later that evening, the patient had
an episode of right nasal epistaxis after suctioning. ENT
was consulted. ENT did a nasal laryngoscope which saw some
oozing in the right posterior naris. The area was packed.
Recommended five days packing and continuing antibiotics.
Vancomycin was continued. Blood pressure control was
improved with p.o. medication.
Once on the tracheostomy, the patient tolerated trach mask.
[**1-11**] bronchoscopy showed persistent oozing of blood
from an upper airway source, likely the naris. No blood seen
below the trach site. Unable to visualize from above
secondary to supraglottic edema. On [**1-12**], right radial
A line site showed some erythema. Was removed. Repeated
attempts for an A line on the left radial and ulna were
unsuccessful. Eventually, right brachial A line was
obtained.
On [**1-13**], with repeated temperature spikes, right
subclavian was placed without difficulty. Left subclavian
was removed. Catheter tip cultures which was negative. On
[**1-13**], the patient was evaluated by Speech Therapy. The
patient was able to produce some voice with the
.................... valve but unable to tolerate valve for
longer than a couple of minutes secondary to repeated
coughing with excessive secretions. On [**1-13**], the
patient had temperature spike to 101. Flagyl was added for
additional anaerobic coverage with nasal packing in place.
The patient worked with Physical Therapy and Occupational
Therapy which recommended acute rehabilitation three times
per week. The patient was ordered for an MRA of the kidneys
to evaluate for renal artery stenosis. SPAP and UPAP were
sent to evaluate for multiple myeloma with the renal disease
of unclear etiology and some evidence of erosion into the
clivus on previous MRI which turned out to be negative.
Urine pheochromocytoma studies were sent which included urine
VMA and metanephrines to evaluate secondary to labile and
difficult to control blood pressure, even with multiple
medications. These were pending at the time of this
dictation.
The patient's mental status dramatically improved after trach
was placed. The patient is interactive, following commands,
able to communicate.
DISCHARGE CONDITION: Stable.
DISCHARGE DISPOSITION: To rehabilitation.
DISCHARGE DIAGNOSIS:
1. Methicillin resistant Staphylococcus aureus pneumonia,
status post Vancomycin. Pulmonary, the patient tolerated
trach mask at 40%.
2. Status post myocardial infarction with troponin of 10.
Flat CKs. The patient on Aspirin 325 mg p.o. q day.
3. Hypertension. The patient's blood pressure was
controlled with Isosorbide Dinitrate 10 mg p.o. t.i.d.,
Clonidine transdermal patch q Tuesday with Metoprolol 25 mg
p.o. t.i.d. No Captopril was used secondary to chronic renal
insufficiency. The patient received Hydralazine HCl 50 mg
p.o. q 6.
4. Hyperlipidemia. Atorvastatin 20 mg p.o. q day.
5. Digoxin was discontinued secondary to improved ejection
fraction, 45 to 50 percent.
6. Noninsulin dependent diabetes mellitus. The patient was
placed on NPH 16 and 16 while on 24 hour cycled tube feeds.
7. Constipation. The patient was given 30 ml p.o. q day prn
of Lactulose and Bisacodyl 10 mg p.o. q day prn. Senna 1 tab
p.o. b.i.d., Colace 100 mg p.o. b.i.d.
8. For nutrition, Ultracal at 80 cc per hour. Folic Acid 1
mg p.o. q day. B12 injection once per month. Last given
approximately [**1-11**].
9. Renal, the patient received chronic renal insufficiency
Epogen 10,000 units subcutaneously q Friday.
10. For his cough, Guiafenesin 5 to 10 mg p.o. q 6 prn.
11. Sertraline 50 mg p.o. q day for depressed mental status,
which improved dramatically. MRI, negative. EEG consistent
with encephalopathy. Lumbar puncture negative for bacterial
meningitis. Held sedation.
FOLLOW UP: The patient should follow up with Nephrology.
[**First Name8 (NamePattern2) 77**] [**Name8 (MD) **], M.D. [**MD Number(1) 3616**]
Dictated By:[**First Name3 (LF) 5053**]
MEDQUIST36
D: [**2110-1-14**] 20:53
T: [**2110-1-14**] 21:32
JOB#: [**Job Number 5054**]
Name: [**Known lastname 1292**], [**Known firstname 63**] J Unit No: [**Numeric Identifier 5052**]
Admission Date: [**2109-12-22**] Discharge Date:
Date of Birth: [**2047-4-16**] Sex: M
Service: MED ICU
ADDENDUM TO PREVIOUS DISCHARGE SUMMARY DICTATED [**2110-1-14**].
HOSPITAL COURSE: (Continued)
On [**1-14**], the patient had a temperature spike. Flagyl
was added to his prophylaxis for his nasal packing. The
patient had intermittent episodes of agitation and was given
small doses of Ativan with good effect. The patient was able
to use Passe-Muir valve for small amounts of time and was
able to phonate actually even without the valve. The
patient's mental status continued to improve.
Physical Therapy worked with patient and recommended two to
three times per week physical therapy and Occupational
Therapy also recommended one to three times per week. The
patient was complaining of abdominal pain and chest pain.
The patient was ruled out by enzymes. EKG showed
pseudo-normalization in V5, V6 leads. The patient had
intermittent elevations of blood pressure with pharmacologic
control. The patient developed a large leak in the
tracheostomy. The patient tolerated a trach mask at 40%
during the day.
The patient's cultures were negative since the previous
dictation. The patient, on [**1-15**], developed a gout in
his left third proximal interphalangeal joint which was
tapped. Cultured negative. Urate crystals seen. The
patient was given a total of two doses of colchicine on two
separate days with improvement in the erythema of his digits
and decreased pain and increased motion. The patient
continued to work with Physical Therapy with good progress.
On [**1-16**], nasal packs were discontinued and antibiotics
were stopped. Had an extensive meeting with case manager and
Mrs. [**Known lastname **] regarding rehabilitation options. Eventually agreed
on rehabilitation with vent weaning. The patient had a
bronchoscopy on [**1-16**] which showed mild bleeding from
the superior edge of the tracheal orifice. Otherwise,
unremarkable.
On [**1-17**], the patient had an episode of hypotension with
blood pressures down to the 90s after receiving a total of 14
mgs of Haldol for intermittent agitation. The patient got
three liters of fluid. Had a brief episode of desaturations
to 70% and quickly responded to bagging and being placed on
pressor support and subsequently the patient's blood
pressures remained stable without repeated fluid boluses and
able to tolerate tracheostomy mask with good oxygenation.
For Nutrition evaluation, the patient was recommended
Ultracal at 80 cc. an hour. As noted, the patient had a PEG
placed and evaluated by gastrointestinal and in good
position. The patient had repeated transfusions for
declining hematocrits to maintain hematocrit greater than 30.
Follow-up hematocrit remained stable.
CONDITION ON DISCHARGE: Again, discharge condition is
stable.
DISPOSITION: To rehabilitation.
ALLERGIES: No known drug allergies.
DISCHARGE MEDICATIONS: This is an addended list and they are
as follows:
1. NPH 18 units at breakfast, 18 units at bedtime.
2. Sliding scale insulin 150 to 200, 2 units; 200 to 250, 4
units; 250 to 300, 6 units; 300 to 350 blood sugar 8 units;
350 to 400 10 units; greater than 400 12 units; 0 to 50, give
juice oral, one ampule D50.
3. Lentoprazol 30 mg via nasogastric tube twice a day.
4. Haldol 2 mg p.o. three times a day.
5. Isosorbide Dinitrate 10 mg p.o. three times a day.
6. Clonidine, two patches q. Tuesday.
7. Hydralazine 60 mg p.o. q. six.
8. Metoprolol 50 mg p.o. three times a day; hold for blood
pressure less than 140; heart rate less than 60.
9. Heparin 5000 units subcutaneously q. 8.
10. Aspirin 325 mg p.o. q. day.
11. Brimonidine tartrate 0.15% ophthalmic one drop to each
eye twice a day.
12. Dorzolamide 2% Ophthalmologic solution, one drop o.s.
twice a day.
13. Epogen 10,000 units subcutaneously q. Friday.
14. Sertraline 50 mg p.o. q. day.
15. Lipitor 20 mg p.o. q. day.
16. Folic acid 1 mg p.o. q. day.
17. Senna one tablet p.o. twice a day.
[**First Name8 (NamePattern2) 77**] [**Name8 (MD) **], M.D. [**MD Number(1) 3616**]
Dictated By:[**Last Name (NamePattern1) 5055**]
MEDQUIST36
D: [**2110-1-18**] 15:43
T: [**2110-1-18**] 18:30
JOB#: [**Job Number 5056**]
|
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icd9cm
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icd9pcs
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[]
]
] |
14754, 14774
|
14721, 14730
|
19665, 20978
|
14795, 16284
|
16917, 19502
|
2299, 2531
|
16296, 16899
|
2554, 3504
|
169, 1882
|
1904, 2280
|
19528, 19641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,679
| 181,905
|
51189+51190
|
Discharge summary
|
report+report
|
Admission Date: [**2148-2-26**] Discharge Date:[**2148-3-4**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old man
with a history of hepatitis C cirrhosis, complicated by
gastric varices; portal hypertension and encephalopathy. He
is scheduled for a liver transplant on [**2-26**]. The
patient's donor, who was his sister, was found to be
inappropriate; however, and the patient presented to the
liver clinic for follow-up on [**2-26**]. While in clinic,
the patient was noted to be lethargic with a several day
history of nausea, vomiting and poor appetite. The patient
was sent to the Emergency Room where his total bilirubin was
found to be increased to 19.9. The patient has a baseline T
bili of 4 to 9 and a creatinine of 5.3 from a baseline of
1.0. The patient's white count was also noted to be
increased to 18; sodium decreased to 127; potassium increased
to 7.6. The patient was given albumin 50 grams and
[**Doctor First Name 233**]-Exalate and the Intensive Care Unit was called for
evaluation of his hepatorenal syndrome. On admission, the
patient denied any fevers or chills. The patient did note
that he has chronic abdominal pain in his right upper
quadrant; history of chronic diarrhea, without any recent
changes and increasing confusion in the several days prior to
admission. The patient denied any dysuria.
PAST MEDICAL HISTORY: The patient's past medical history
includes hepatitis C cirrhosis, complicated by gastric
varices; portal hypertension and encephalopathy. The patient
also has a history of infectious colitis in [**2147-5-2**].
The patient's medications on admission were as follows:
1. Protonic 40 mg q. day.
2. Multi-vitamins.
3. Nadolol 40 mg q. day.
4. Calcium with Vitamin D.
5. Lactulose 30 grams twice a day.
6. Actigall 300 mg three times a day.
7. Magnesium oxide 400 mg three times a day.
8. Lasix 40 mg q. day.
9. Aldactone 200 mg q. day.
10. Mycelex troche five times a day.
ALLERGIES: The patient is not allergic to any medications.
FAMILY HISTORY: The patient's brother had a myocardial
infarction at the age of 50 and also has diabetes.
SOCIAL HISTORY: He lives alone at home. He has a 15 pack
year tobacco history. He quit [**Holiday **] of [**2147**]. The
patient does not have an alcohol history. The patient has a
history of remote intravenous drug use years ago. The
patient contracted hepatitis C, most likely through sexual
contact according to the patient. The patient used to work
for the [**Company 2318**] service. The [**Hospital 228**] health care proxy is his
daughter, [**Name (NI) 11923**], whose phone number is [**Telephone/Fax (1) 106231**].
LABORATORY DATA: Laboratory studies on admission showed a
white count of 18.2; hematocrit of 31.2; platelets of 79.
The patient's chemistry 7 showed a sodium of 127; potassium
of 7.6; chloride of 96; bicarbonate 21; BUN 78; creatinine
5.3; glucose of 97. His AST was 162; ALT 65; alkaline
phosphatase 146; LDH 549; amylase 218; lipase 210; total
bilirubin was 19.9; albumin was 2.0. His PT was 18.8; PTT was
45.4 and his INR was 2.3.
Chest x-ray did not show any evidence of pneumonia or
congestive heart failure. The patient's urinalysis showed a
specific gravity of 1.005 and moderate blood. The patient's
liver ultrasound on admission with Doppler was consistent
with cirrhosis, ascites and there was appropriate flow seen
in all of his portal vessels and no hepatic masses were seen.
HOSPITAL COURSE: 1.) Hepatorenal syndrome. The patient had
several surfaces following him throughout his hospital stay,
including the liver, renal and transplant services. The
patient was given albumin daily for volume expansion. The
patient's medications were renally dosed for a creatinine
clearance of less than 10. The patient was not dialyzed and
his urine sodium, urine osmolytes and urine creatinine were
checked daily. The patient's goal [**Doctor First Name **] was less than 1. The
patient had his potassium and creatinine monitored daily and
[**Doctor First Name 233**]-Exalate was given if the patient's potassium was
elevated. The patient was also started on Octreotide and
Midodrine to increase his urine output and increase his mean
arterial pressures. The patient's hepatorenal syndrome
improved once the Octreotide and the Midodrine were started.
The patient had a PA catheter placed to monitor his response
to the Octreotide and the Midodrine with a goal wedge
pressure of 20 to 25 and a central venous pressure of 12 to
16. The PA catheter was then discontinued after several days
in the Intensive Care Unit. The patient's creatinine slowly
improved and decreased from 5.3 on admission to 2.3 by
hospital day number seven. The patient's potassium also
decreased from 7.3 on admission to 4.3 on day six of his
hospital stay.
2.) Bacteremia: The patient had leukocytosis on admission
with a white count of 18.2. This decreased to 6.7 on day six
of his hospital course. The patient remained afebrile;
however, one out of four blood culture bottles taken on
[**2-26**] in the Emergency Room grew out gram negative rods
in the anaerobic bottle. The patient was started on
Levofloxacin and Flagyl to cover the patient's infection.
The gram negative rods later returned to be consistent with
Bacteroides fragilis and no changes in the antibiotics were
made per liver recommendations. The patient's other blood
culture, peritoneal fluids, and urine culture bottles all
grew out negative.
3.) Cirrhosis and hepatic failure. The patient's total
bilirubin on admission was 19.9 and this decreased and
improved to a low or a nadir of 14.1 after the patient was
hospitalized. The patient was started on Lactulose and
Ursodiol and was continued on this throughout his hospital
course. The patient's electrolytes and glucose were checked
twice a day and the patient was continued on Octreotide and
Midodrine according to renal and liver recommendations. The
patient's total bilirubin then increased from 14.1 on day
four of his hospital course back to 20.5 on day 7 of his
hospital course. The patient was kept at the top of the
liver transplant list and, at the time of this dictation, is
awaiting a cadaveric liver transplant.
4.) Coagulopathy: The patient had an elevated coagulopathy
secondary to his hepatic cellular cirrhosis. The patient was
transfused with FFP and platelets twice without any
complications. Both times, the transfusions were given prior
to the patient's central lines being placed or changed.
5.) Anemia: The patient was transfused for a hematocrit less
than 30. The patient did not require any transfusions for the
first seven days of his hospital course for his hematocrit,
as it remained around 30 to 32 during these days. The patient
was guaiac negative on admission.
6.) Fluids, electrolytes and nutrition: The patient was
given [**Doctor First Name 233**]-Exalate for hyperkalemia. The patient was also
given phosphate binders for increased phosphate levels. The
patient was continued on albumin daily for volume expansion.
The patient was started on a low renal, low phosphorus and
low potassium diet and advanced as tolerated.
7.) Access: The patient had a right internal jugular and
left A line placed on [**2-26**]. The patient's right
internal jugular was then switched to a PA catheter on
[**2-27**] and this then was switched back to a right
internal jugular on [**2-29**].
8.) Prophylaxis: The patient was maintained on proton pump
inhibitor and Pneumo boots throughout his hospital stay.
9.) The patient was kept full code throughout his hospital
stay.
10.) Communication was maintained with the patient and the
patient's daughter who is his health care proxy.
The remainder of the dictation for the [**Hospital 228**] hospital
course will be done by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
DR [**First Name8 (NamePattern2) **] [**Name (STitle) **] 12.ACV
Dictated By:[**Name8 (MD) 749**]
MEDQUIST36
D: [**2148-3-3**] 03:19
T: [**2148-3-4**] 05:27
JOB#: [**Job Number 106232**]
Admission Date: [**2148-2-26**] Discharge Date: [**2148-3-18**]
Date of Birth: [**2097-9-27**] Sex: M
Service: [**First Name9 (NamePattern2) **] [**Last Name (un) **]
CHIEF COMPLAINT: Hepatitis C cirrhosis.
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
gentleman with a history of decompensated cirrhosis secondary
to hepatitis C. He has a history of portal hypertension with
ascites, gastric varices and hepatic encephalopathy. The
patient has been listed for liver transplantation and his
sister was approved as a living donor. The patient was
admitted through the [**Hospital1 18**] emergency department with a three
day history of vomiting and increased jaundice. The patient
was admitted to the medicine service up in the MICU.
MEDICATIONS ON ADMISSION: Lansoprazole, ursodiol,
levofloxacin 250 mg p.o. q.48 hours, octreotide 100 mg p.o.
t.i.d., Flagyl 500 mg p.o. t.i.d., insulin, albumin 25 q.d.,
lactulose p.r.n.
PHYSICAL EXAMINATION: In general, the patient was a middle
aged gentleman with noticeable jaundice and gynecomastia.
Neck was supple, nontender. Pulmonary was clear to
auscultation bilaterally. Cardiac exam regular rate and
rhythm with no murmurs, rubs or gallops noted. Abdomen was
grossly distended, nontender. Extremities 3+ pitting edema,
warm and well perfused. Neurologic exam positive for mild
asterixis.
LABORATORY DATA: On admission white blood cells 9.0,
hematocrit 30.7, platelets 39. Chemistries sodium 137,
potassium 4.9, chloride 105, bicarb 24, BUN 70, creatinine
2.3, blood glucose 119. Calcium 8.6, magnesium 2.4,
phosphorus 3.0. PT 23.3, PTT 56.6, INR 3.6. Albumin 2.5,
total bili 17.6, lipase 65, amylase 76, LDH 237, AST 78, ALT
36, alka phos 98, fibrinogen 101.
HOSPITAL COURSE: The patient was admitted to the MICU for
treatment of his hepatorenal syndrome as well as was heavily
cultured for questionable bacteremia. Following a brief stay
in the PACU, the patient underwent a living related liver
transplant on [**2148-3-5**]. The procedure was performed
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. There were no complications during the
procedure and the patient tolerated the procedure very well.
For full details, please see the operative note dictated on
[**2148-3-5**]. Following a brief stay in the post
anesthesia recovery unit, the patient was transferred to the
SICU. The patient remained sedated with propofol and
intubated. The patient was started on a Lasix drip as well
as an insulin drip to control his blood sugars which were
over 200 at that time. The patient was initially started on
vancomycin and Unasyn. On the first night following his
operation the patient was given one unit of packed cells and
two units of fresh frozen plasma. The patient was started on
CVVHD.
On postoperative day one the patient had right internal
jugular line. There was no attempt to wean the patient off
intubation as the patient was not making any attempt for
spontaneous breathing. The patient was weaned off
Neo-Synephrine with a cardiac index of 8.0. The patient was
continued on CVVHD for 100 percent ultrafiltration. The
patient was started on fluconazole, Valcyte and Flagyl as
well as given 1 gm of Solu-Medrol and 1000 mg of MMF b.i.d.
The patient continued to have low platelet counts and was
transfused with two units of five pack platelets. The
patient was seen by several consults including renal, which
managed his hemodialysis; infectious disease for management
of hepatitis C.
By postoperative day two the patient's Lasix drip was
discontinued as the blood sugars were under control at this
time. The patient continued to be intubated on SIMV with
pressure support. ABG reflected an unconstituted metabolic
acidosis and the patient was producing copious amounts of
thick white sputum. The patient continued to remain on CVVHD
for hemodialysis. By postoperative day three the patient was
able to follow commands, but still lightly sedated with
propofol. The patient was not able to be extubated as yet,
but he was weaned down on his SIMV with anticipation of
extubation within a couple of days. The patient was able to
tolerate CPAP briefly as long as he was up in a sitting
position, but was having difficulty breathing when in bed.
On [**3-10**], postoperative day five, the patient was
successfully extubated and was able to maintain his oxygen
saturation greater than 95 percent on 40 percent face mask.
The patient continued to remain on CVVHD for renal support.
The patient was transfused with a six pack of platelets for a
platelet count of 67,000. The following day, postoperative
day seven, the patient had his Swan catheter changed to a
central venous line. The patient began to pass flatus at
this time. The patient was awake and appropriate. The
patient continued to remain on CVVHD. Infectious disease
recommended increasing the amount of fluconazole,
ganciclovir, Bactrim now that his CVVHD was to be finished.
While in the ICU the patient was noted to be in sinus
bradycardia. The patient had an EKG which showed nonspecific
changes, but with small T wave inversions. The patient had a
bedside echocardiogram which showed an ejection fraction of
35 to 40 percent, 2+ mitral regurgitation, 1+ tricuspid
regurgitation, 1+ aortic insufficiency. The patient also was
noted to have inferior/posterior/lateral hypokinesis. All of
these findings were new since his last cardiac workup in
[**2146**]. Following this, the patient was started on a low dose
beta blocker and was added on isosorbide dinitrate 30 mg q.d.
The patient was also instructed to have a followup
echocardiogram prior to discharge or shortly thereafter. The
patient was followed closely by cardiology and had several
EKGs during the remainder of his stay, none of which showed
any new findings.
On [**3-13**] the patient was transferred out of the ICU to
the floor. While on the surgical floor, the patient had a
relatively uneventful recovery for the remainder of his
period in the hospital. The patient was seen by physical
therapy. Physical therapy recommended that the patient
undergo a short term stay at acute rehabilitation for
strengthening, conditioning prior to being discharged to
home. The patient was up and ambulating with assistance.
The patient was tolerating an oral diet without difficulty.
The patient's pain was well controlled on oral medications.
The patient continued to be followed by cardiology, renal,
infectious disease with no new recommendations as per his
medication dosing.
By [**3-16**] the patient was deemed ready by the surgical
team that he was to be discharged to an acute care
rehabilitation facility. The patient had placement issues
which caused him to remain in hospital until [**3-18**]. By
[**3-18**] the patient was discharged to [**Hospital **]
Rehabilitation. The patient was instructed to follow up with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] according to the schedule as set out by the
transplant team.
DISCHARGE DISPOSITION: The patient will be discharged to
[**Hospital **] Rehabilitation Institute.
FOLLOWUP: The patient was instructed to follow up in the
transplant center on [**3-20**] at 10:00 in the morning with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient was also instructed to follow
up with the transplant social worker, [**Name (NI) 3403**] [**Last Name (NamePattern1) 805**], also
on [**3-20**] at 11:00 o'clock. The patient was to return
for a second followup a week later on [**3-27**] at 10:00
o'clock.
CONDITION ON DISCHARGE: The patient's condition was good,
afebrile, tolerating a regular diet without difficulty,
ambulating with assistance, pain well controlled on oral
medications.
DISCHARGE DIAGNOSES:
1. Status post orthotopic liver transplant.
2. Hepatitis C.
3. Portal hypertension.
4. Hepatic encephalopathy.
5. Status post Swan-Ganz placement.
6. Status post pulmonary artery catheterization.
7. Difficult extubation.
DISCHARGE MEDICATIONS:
1. Fluconazole 200 mg p.o. q.d.
2. CellCept [**Pager number **] mg p.o. b.i.d.
3. Hydralazine 10 mg p.o. q.six hours.
4. Isosorbide mononitrate 30 mg sustained release one tablet
q.24 hours.
5. Prednisone 25 mg p.o. q.d.
6. Protonix 40 mg p.o. q.d.
7. Bisacodyl 10 mg p.o. q.d.
8. Colace 100 mg p.o. q.d.
9. Percocet one to two tablets p.o. q.four to six hours
p.r.n. pain.
10. Metoprolol 25 mg p.o. b.i.d.
11. Cyclosporine 300 mg p.o. b.i.d.
12. Ganciclovir 250 mg p.o. q.d. times 10 days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name8 (MD) 846**]
MEDQUIST36
D: [**2148-3-18**] 12:32
T: [**2148-3-18**] 12:43
JOB#: [**Job Number 106233**]
|
[
"572.2",
"571.5",
"789.5",
"276.1",
"584.9",
"572.4",
"070.54",
"038.49",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"50.11",
"99.07",
"39.95",
"38.93",
"50.59",
"99.04",
"89.64",
"96.04",
"54.91",
"99.15",
"51.22",
"99.05",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15196, 15733
|
2087, 2178
|
15940, 16169
|
16192, 16954
|
8924, 9087
|
9901, 15172
|
9110, 9883
|
8330, 8354
|
8383, 8897
|
1427, 2070
|
2195, 3502
|
15758, 15919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,215
| 158,685
|
29671
|
Discharge summary
|
report
|
Admission Date: [**2138-1-12**] Discharge Date: [**2138-1-18**]
Date of Birth: [**2097-11-19**] Sex: M
Service: MEDICINE
Allergies:
Toradol
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40 year old male with history of HCV, HBV, amd alcohol abuse
(without h/o withdrawal seizures or DTs) was transferred from
[**Hospital1 882**] to [**Hospital1 **] ED for concerns of alcohol withdrawal. On
Friday, he drank 1-6pack and 1 pint of vodka. Later that night,
he was slurring his speech and urinated on the floor so he went
to [**Hospital1 882**] ED. At [**Hospital1 882**], his serum ETOH was 0.44. He was
tachycardic and tremulous. He was given ativan and librium. A UA
was notable for WBCs and nitrites so he was given 2 doses of
cipro. He stayed at [**Hospital1 882**] for 24 hours and was sent to [**Hospital1 18**]
for continued concern of alcohol withdrawal.
In the [**Hospital1 18**] ED, his BP was 150/70, HR 120, he was given valium
q1h for ciwa >8. On admission to the medical ICU, he noted
shakiness and sweats. He denied fevers, chills, chest pain, SOB,
nausea, vomiting. He notes mild suprapubic tenderness without
dysuria, along with increased abdominal girth.
Past Medical History:
1) HBV/HCV - followed by GI doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 882**]. Per the patient
he was hospitalized 6 months ago for liver failure for which he
was "comatosed" for agitation. Risk factor - tattoos.
- GI: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71093**] [**Telephone/Fax (1) 19410**]
2) Asthma
3) alcohol abuse: no history of DTs or alcohol withdrawal
seizures
Social History:
He lives with his wife and kids. He works as a [**Hospital1 **] cop. He
drinks on average 2-6 packs of beer per week. He denies tobacco
use/IVDU.
Family History:
Father - colon cancer, No DM, HTN, MI
Physical Exam:
Physical Exam on Admission
Wt 120 kg Temp 99 BP 173/70 Pulse 110 Resp 24 O2 sat 99% RA
Gen - Alert, no acute distress, no increased wob/diaphoresis
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist, no OP lesions. Abrasion on bridge of nose.
(+)telengectasia on right cheek.
Neck - no JVD, no thyromegaly
LN - no cervical, inguinal lymphadenopathy
Chest - Clear to auscultation bilaterally, (+)gynecomastia.
CV - Tachy, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds. (+)HSM. No fluid wave
Back - No costovertebral angle tenderness, no spinal tenderness
Extr - No clubbing, cyanosis, or edema. No [**Location (un) **] erythema. 2+
DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**1-13**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact. No nystagmus or asterixes.
Pertinent Results:
Laboratory studies on admission:
[**2138-1-12**]
WBC-6.9 HGB-10.5 HCT-29.5 MCV-96 RDW-15.5 LT COUNT-90
NEUTS-82.8* BANDS-0 LYMPHS-12.1* MONOS-4.3 EOS-0.3 BASOS-0.5
AMMONIA-73*
Utox: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
calTIBC-433 VIT B12-528 FOLATE-GREATER TH FERRITIN-273 TRF-333
ALBUMIN-4.3 CALCIUM-8.5 PHOSPHATE-1.9* MAGNESIUM-1.7 IRON-101
ALT(SGPT)-60* AST(SGOT)-105* ALK PHOS-177* AMYLASE-41 TOT
BILI-1.9* DIR BILI-0.7* INDIR BIL-1.2
LIPASE-62*
GLUCOSE-94 UREA N-9 CREAT-0.7 SODIUM-135 POTASSIUM-4.7
CHLORIDE-105 TOTAL CO2-18
U/A: BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-SM RBC-[**5-11**]* WBC-21-50*
BACTERIA-OCC YEAST-NONE EPI-<1
PT-13.8* PTT-31.3 INR(PT)-1.2*
LACTATE-1.5
ABG: PO2-96 PCO2-26* PH-7.50* TOTAL CO2-21 BASE XS-0
Laboratory studies on discharge:
[**2138-1-18**] 10:00AM BLOOD WBC-2.8* RBC-3.11* Hgb-10.2* Hct-29.8*
MCV-96 MCH-32.7* MCHC-34.2 RDW-15.3 Plt Ct-125*
[**2138-1-18**] 10:00AM BLOOD Plt Ct-125*
[**2138-1-18**] 10:00AM BLOOD Glucose-128* UreaN-10 Creat-1.0 Na-138
K-3.8 Cl-110* HCO3-21* AnGap-11
[**2138-1-18**] 10:00AM BLOOD ALT-101* AST-75* AlkPhos-147* TotBili-1.0
[**2138-1-18**] 10:00AM BLOOD Lipase-129*
[**2138-1-12**] 03:30PM BLOOD calTIBC-433 VitB12-528 Folate-GREATER TH
Ferritn-273 TRF-333
Radiology
[**1-13**] Abdominal ultrasound with dopplers: The liver is diffusely
echogenic (consistent with fatty infiltration). No focal lesions
are identified. There is no intra- or extra-hepatic biliary
ductal dilation. The main, anterior right, posterior right, and
left portal veins are patent with normal waveforms. The right
kidney measures 11.7 cm. The left kidney measures 12.5 cm. There
is no hydronephrosis or nephrolithiasis. The gallbladder is not
distended, and contains no intraluminal stones or sludge. The
patient was not tender over the right upper quadrant. There is
no ascites. The spleen is enlarged measuring 17.8 cm. The
pancreatic head and body appear normal. The abdominal aorta is
of normal caliber.
[**1-15**] CT: The lung bases are clear apart from dependent
atelectasis. The visualized heart and pericardium appear
unremarkable. The liver is diffusely low in attenuation
consistent with fatty infiltration. No focal lesions are
identified. The gallbladder is collapsed. The adrenal glands,
pancreas, loops of bowel, and kidneys appear normal. The spleen
is enlarged measuring 18 cm. There are nonspecific borderline
lymph nodes in the celiac region measuring up to 12 mm in short
axis. There is no ascites, free intraperitoneal air, or
drainable fluid collections. Small retroperitoneal lymph nodes
are seen, which do not meet criteria for pathologic enlargement.
The abdominal aorta is of normal caliber throughout. The ureters
appear unremarkable throughout their course. The bladder,
prostate, seminal vesicles, and rectum appear unremarkable.
There is no evidence of nephrolithiasis. There is no
hydronephrosis. Small bilateral fat containing inguinal hernias
are seen. There is no free fluid in the pelvis. No pathologic
pelvic or inguinal lymphadenopathy is seen.
Brief Hospital Course:
40 year old male with history of HCV, HBV, Alcohol abuse
(without h/o withdrawal seizures or DTs) transferred from
[**Hospital1 882**] with alcohol withdrawal.
1) Alcohol withdrawal: The patient was admitted to the medical
ICU for closer monitoring given large benzodiazepine
requirements. He was started on ativan q1 hr, which was
gradually decreased by 25%/day. He was transferred to the
general medical floor on [**2138-1-14**]. There, he was continued on an
ativan taper. The day prior to discharge, he received 10 mg PO
valium X 3 days in order to "load" prior to discharge. Valium
was then discontinued, and >12 hours later, the patient had no
evidence of withdrawal. The social work and addictions services
were consulted and followed the patient closely throughout his
hospital stay. He was continued on thiamine and folate.
2) Cirrhosis due to HBV, HCV, and EtOH: A fatty liver was noted
on abdominal ultrasound and abdominal CT, without patent
portal/hepatic vessels, and no ascites noted. The patient had a
persistant transaminitis (see results section), which remained
stable. He was continued on his home dose of spironolactone.
3) Diarrhea: The patient reported that he typically has [**1-4**]
loose bowel movements a day. While in the ICU, however, he was
having up to 10 a day. There was no associated fevers, chills,
nausea, or vomiting. C. diff was (-) X 2, O&P (-) X 2, and
stool cultures were negative. His diarrhea gradually improved to
his baseline, 2 BM/day, by the time of discharge. He should
follow-up with his gastroenterologist as as an outpatient for
possible further work-up, including colonsocopy.
4) UTI: (+) U/A although ucx <10k organisms (received cipro
prior to transfer). GC/chlamydia PCR negative, and CTU was
without evidence of ureteral abnormality, hydronephrosis, or
nephrolithiasis. He was discharged to complete a 14 day course
of ciprofloxacin. Given recurrent urinary tract infections,
referral to urology may be considered as an outpatient.
5) Pancytopenia: At time of discharge, the patient's CBC was
stable (wbc 2.8, HCT 29.8, plt 125). His pancytopenia is most
likely related to bone marrow suppression by alcohol as well as
liver disease. The patient was without evidence of iron, vitamin
B12, or folate deficiency. His CBC should be monitored as an
outpatient to ensure stability.
6) Acute respiratory alkalosis with metabolic compensation: This
is most likely due to hyperventilation from agitation and
alcohol withdrawl superimposed on chronic respiratory alkalosis
of liver disease. The patient's bicarb remained stable at
discharge.
7) Alcoholic pancreatitis: The patient's lipase gradually rose
to 139, although is abdominal exam remained benign and he
tolerated food well. At the time of discharge, the lipase was
129. As mentioned above, Abd CT/abdominal ultraasound did not
show evidence of biliary obstruction.
Full code
Medications on Admission:
MEDS:
Spironolactone 100 daily
Combivent qid
Lomotil prn
Creon with meals
Paxil 10 mg daily
Folic acid 1 mg daily
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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-3**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 mdi* Refills:*2*
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
Disp:*60 Cap(s)* Refills:*0*
8. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: alcohol withdrawal
Secondary: urinary tract infection, cirrhosis, chronic hepatitis
B, chronic hepatitis C, diarrhea NOS, respiratory alkalosis,
pancytopenia, alcoholic pancreatitis.
Discharge Condition:
Stable
Discharge Instructions:
1) Please follow-up as indicated below
2) Please take all medications as prescribed. You have 7 more
days of ciprofloxacin to treat a urinary tract infection.
3) You are encouraged to abstain from alcohol use.
4) Please come to the emergency room if you develop abdominal
pain, nausea, vomiting, tremor, fevers or chills.
Followup Instructions:
1) Gastroenterology: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71093**]
[**Telephone/Fax (1) 19410**] within 1-2 weeks following discharge.
2) Primary Care: You can call [**Hospital6 733**]
([**Telephone/Fax (1) 250**]) to schedule an appointment with a new primary
care physician.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2138-1-18**]
|
[
"599.0",
"303.01",
"577.9",
"276.3",
"571.2",
"291.81",
"070.54",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10209, 10215
|
6062, 8954
|
288, 295
|
10451, 10460
|
2913, 2932
|
10831, 11312
|
1933, 1973
|
9118, 10186
|
10236, 10430
|
8980, 9095
|
10484, 10808
|
1988, 2894
|
3773, 6039
|
230, 250
|
323, 1309
|
2946, 3758
|
1331, 1753
|
1769, 1917
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,910
| 154,264
|
43223
|
Discharge summary
|
report
|
Admission Date: [**2141-7-12**] Discharge Date: [**2141-7-20**]
Date of Birth: [**2071-10-30**] Sex: F
Service: GU
Allergies:
Codeine
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Bladder CA
Major Surgical or Invasive Procedure:
cystectomy with ileal loop conduit
History of Present Illness:
69yo F with PMHx of TIA vs. CVA , COPD, HTN and ?Lupus presents
for cystectomy and ileal loop conduit. Pt with four month h/o
dysuria with incr. frequency treated ast UTI. Pt referred to Dr. [**Name (NI) 44614**] office who got US that showed 4.7x3.2x3.2cm mass in
bladder projecting through wall towards vagina. Since Bone scan
-, CT showed mass, Bilateral hydronephrosis, R>L, marked
enhancement of L sided urothelium suggestive of infection, Bil
lesions in kidneys likely cysts, Dilation of common bile duct
extending to the ampulla. Chest Ct only shows COPD , no
nodules. ERCP [**Last Name (un) 22975**] stricture in distal common bile duct and
distal pancreatic duct which could represent benign strictures
although underlying malignancy cannot be excluded- brush samples
were sent for cytology and were neg for malignancy.
Pt with h/o skin lesions called lupus since early [**2126**]. No
bleeding disorders.
Past Medical History:
COPD
Hyperlipidimia
osteopenia
CVA vs. TIA
GERD
Lupus-Discoid?
PSH: c-section
L patella
R hip replacement
D&C
Social History:
h/o Tobacco
h/o ETOH
Physical Exam:
Gen: A&O
HEENT: bil bruites,no JVD
CV: RRR, loud S1 and S2 with 4/6 crescendo-decrescendo systolic
murmur
best heard at L sternal border 5th intercostal space,
+thrill
Lungs: course, decreased breath sounds
Abd: nondistended, normal bowel sounds, nontender, ileal loop
pink and intact
incision: minimal erythema, no induration no tenderness
Neuro: Left facial droop, hyperreflexive and R Babinski
Ext: +2pitting edema,no calf tenderness
Pertinent Results:
[**2141-7-12**] 08:14PM WBC-9.6 RBC-3.67* HGB-10.9* HCT-33.0* MCV-90
MCH-29.8 MCHC-33.1 RDW-14.0
[**2141-7-12**] 08:14PM PLT COUNT-508*
[**2141-7-14**] 03:50AM BLOOD WBC-11.4* RBC-3.70* Hgb-11.3* Hct-33.2*
MCV-90 MCH-30.6 MCHC-34.2 RDW-14.6 Plt Ct-283
[**2141-7-13**] 04:29PM BLOOD WBC-17.2*# RBC-4.13* Hgb-12.7 Hct-37.1
MCV-90 MCH-30.6 MCHC-34.1 RDW-14.5 Plt Ct-329
[**2141-7-12**] 08:14PM BLOOD WBC-9.6 RBC-3.67* Hgb-10.9* Hct-33.0*
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.0 Plt Ct-508*
[**2141-7-14**] 03:50AM BLOOD Plt Ct-283
[**2141-7-13**] 04:29PM BLOOD Plt Ct-329
[**2141-7-12**] 08:14PM BLOOD Plt Ct-508*
[**2141-7-19**] 07:20AM BLOOD K-4.1
[**2141-7-18**] 07:30AM BLOOD Glucose-108* UreaN-4* Creat-0.6 Na-136
K-3.2* Cl-100 HCO3-29 AnGap-10
[**2141-7-17**] 05:56PM BLOOD K-3.8
[**2141-7-17**] 05:15AM BLOOD Glucose-109* UreaN-4* Creat-0.7 Na-137
K-3.2* Cl-103 HCO3-28 AnGap-9
[**2141-7-16**] 05:42AM BLOOD Glucose-99 UreaN-7 Creat-0.8 Na-139 K-3.5
Cl-109* HCO3-26 AnGap-8
[**2141-7-15**] 07:00AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-142
K-3.3 Cl-110* HCO3-23 AnGap-12
[**2141-7-14**] 03:50AM BLOOD Glucose-91 UreaN-10 Creat-1.0 Na-143
K-4.6 Cl-113* HCO3-24 AnGap-11
[**2141-7-13**] 04:29PM BLOOD Glucose-118* UreaN-11 Creat-1.1 Na-143
K-4.4 Cl-111* HCO3-23 AnGap-13
[**2141-7-14**] 03:50AM BLOOD Calcium-7.4* Mg-2.6
[**2141-7-13**] 04:29PM BLOOD Calcium-8.3* Mg-1.5*
[**2141-7-14**] 04:01AM BLOOD Type-ART Temp-37.1 pO2-186* pCO2-43
pH-7.35 calHCO3-25 Base XS--1 Intubat-INTUBATED
[**2141-7-13**] 07:40PM BLOOD Type-ART Rates-/10 Tidal V-450 PEEP-5
O2-50 pO2-131* pCO2-63* pH-7.21* calHCO3-27 Base XS--4
Intubat-INTUBATED Vent-IMV
[**2141-7-13**] 05:49PM BLOOD Type-ART O2 Flow-6 pO2-83* pCO2-58*
pH-7.19* calHCO3-23 Base XS--6 Intubat-NOT INTUBA Comment-SIMPLE
FAC
[**2141-7-13**] 01:57PM BLOOD Type-ART pO2-187* pCO2-52* pH-7.30*
calHCO3-27 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2141-7-13**] 11:32AM BLOOD Type-ART Rates-/8 Tidal V-400 O2-50
pO2-193* pCO2-43 pH-7.35 calHCO3-25 Base XS--1 Intubat-INTUBATED
Vent-CONTROLLED
[**2141-7-13**] 09:15AM BLOOD Type-ART Rates-/6 Tidal V-400 O2-50
pO2-196* pCO2-41 pH-7.43 calHCO3-28 Base XS-3 Intubat-INTUBATED
Vent-CONTROLLED
[**2141-7-14**] 04:01AM BLOOD Lactate-1.3
[**2141-7-14**] 01:34AM BLOOD Glucose-128* Lactate-1.6 K-3.4*
[**2141-7-13**] 01:57PM BLOOD Glucose-114* Lactate-1.7 Na-140 K-3.7
Cl-111
[**2141-7-13**] 11:32AM BLOOD Glucose-134* Lactate-1.9 Na-141 K-3.1*
Cl-112
[**2141-7-13**] 09:15AM BLOOD Glucose-105 Lactate-3.1* Na-138 K-3.1*
Cl-110
[**2141-7-14**] 04:01AM BLOOD O2 Sat-98
[**2141-7-14**] 01:34AM BLOOD Hgb-12.1 calcHCT-36
[**2141-7-13**] 05:49PM BLOOD O2 Sat-93
[**2141-7-13**] 01:57PM BLOOD Hgb-12.5 calcHCT-38
[**2141-7-13**] 11:32AM BLOOD Hgb-12.1 calcHCT-36
[**2141-7-13**] 09:15AM BLOOD Hgb-8.3* calcHCT-25
[**2141-7-14**] 04:01AM BLOOD freeCa-1.14
[**2141-7-14**] 01:34AM BLOOD freeCa-1.19
[**2141-7-13**] 01:57PM BLOOD freeCa-1.21
[**2141-7-13**] 11:32AM BLOOD freeCa-0.86*
[**2141-7-13**] 09:15AM BLOOD freeCa-1.00*
Brief Hospital Course:
Pt was extubated post operatively but required reintubation for
respiratory support and Resp acidosis 7.19. Pt extubated POD#1
and has done well without further complications.
Medications on Admission:
1. Atrovent 18meq 2puffs QID
2. Fosamax 70mg PO Qweek
3. Lipitor 10mg PO QD
4. Pulmicort 100mg PO TID
5. Serevent Diskus 50meq One Puff [**Hospital1 **]
6. Wellbutrin SR 150mg PO BID
7. Nicotine Patch
8. Tylenol PM
Discharge Medications:
1. Cephalexin 250 mg/5 mL Suspension for Reconstitution Sig: Two
(2) total of 500mg q6 PO Q6H (every 6 hours) for 4 days: finish
through [**2141-7-23**].
Disp:*32 total of 500mg q6* Refills:*0*
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
4. Restart all outpatient meds:
1. Atrovent 18meq 2puffs QID
2. Fosamax 70mg PO Qweek
3. Lipitor 10mg PO QD
4. Pulmicort 100mg PO TID
5. Serevent Diskus 50meq One Puff [**Hospital1 **]
6. Wellbutrin SR 150mg PO BID
7. Nicotine Patch
8. Tylenol PM
***Don't restart Plavix till cleared by Dr.[**Name (NI) 10529**] office***
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p cystectomy with ileal loop conduit for Bladder CA
Asthma
chronic obstructive pulmonary disease
CVA
Discharge Condition:
Good: afebrile, tolerating regular diet, pain well controlled on
oral medications.
Discharge Instructions:
1. Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink or not making urine.
If any of these occur, please contact your physician
[**Name Initial (PRE) 2227**].
2. Ambulate a minimum of three to four times a day.
3. Finish seven day course of Keflex through [**2141-7-23**].
4. Don't restart plavix till Dr. [**Last Name (STitle) **] [**Last Name (STitle) 7876**] ok.
5. Restart all other outpatient meds.
Followup Instructions:
Please call Dr.[**Name (NI) 10529**] office for an appointment in 7-10days.
Completed by:[**2141-7-20**]
|
[
"276.2",
"V43.64",
"695.4",
"458.29",
"188.8",
"305.1",
"401.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"68.8",
"56.51",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6146, 6218
|
4944, 5122
|
274, 311
|
6365, 6449
|
1907, 4921
|
6950, 7057
|
5387, 6123
|
6239, 6344
|
5148, 5364
|
6473, 6927
|
1446, 1888
|
224, 236
|
339, 1258
|
1280, 1393
|
1409, 1431
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,183
| 189,610
|
37919
|
Discharge summary
|
report
|
Admission Date: [**2103-10-31**] Discharge Date: [**2103-11-7**]
Date of Birth: [**2053-4-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
[**2103-11-1**]: Emergent Thoracic Laminectomy, T3-T6, epidural
abscess evacuation, placement of 2 drains
History of Present Illness:
50 year old male transferred from an OSH with severe back pain
for 3-4 days, with question of a possible epidural abscess.
Initially had pain in his chest as well, and underwent a
completely negative cardiology work up. Back pain is in thoracic
region, and spreads in a band-like distribution across both
lanks. He has an extensive spinal surgery history which includes
3 cervical fusions (C5-C7) and 4 Lumbar surgeries
(laminectomies). His last surgery was over 4 years ago. He has
baseline RLE weakness and numbness across his proximal anterior
thighs. He denies any new acute changes at time of admission,
and denies fevers as well.
Past Medical History:
1. Numerous spinal surgeries, (Cervical and Lumbar, last [**2098**])
2. Chronic sinusitis with surgery for severe sinus infection in
[**2102**].
Social History:
He is a banana supplier and also works with cash and carry. He
binge drinks every Friday with 6 drinks of EtOH. Ne denies
smoking. He does do cocaine. He lives with his wife.
Family History:
His brother and father have HTN and hyperlipidemia. His father
had prostate CA and his brother has large cell non-[**Name (NI) 4278**]
lymphoma.
Physical Exam:
Exam on Admission:
PHYSICAL EXAM:
O: T: 98.2 BP: 164/105 HR: 115 R:20 O2Sats
Gen: WD/WN, in acute pain, agitated in bed.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 4+ 5 5 5 5
L FULL
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Reflexes: Pa Ac
Right 0 2 (this is chronic finding)
Left 2 2
Examination on Discharge:
Oriented x 3. Motor [**6-12**] in upper extremities. Full in lower
extremities with exception of 5-/5 in bilateral [**Last Name (un) 938**] and AT. He
has some decreased sensation in RLE. Coordination is decreased
in the RLE compared to the LLE. His incision is clean dry and
intact with sutures in place. There are also staples over the
drain sites.
Pertinent Results:
Labs on Admission:
[**2103-10-31**] 09:25PM BLOOD WBC-9.3 RBC-4.36* Hgb-12.2* Hct-34.3*
MCV-79* MCH-27.9 MCHC-35.5* RDW-12.9 Plt Ct-254
[**2103-10-31**] 09:25PM BLOOD PT-12.8 PTT-40.5* INR(PT)-1.1
[**2103-10-31**] 09:25PM BLOOD Glucose-131* UreaN-24* Creat-1.2 Na-134
K-3.5 Cl-98 HCO3-26 AnGap-14
[**2103-10-31**] 09:25PM BLOOD Calcium-8.9 Phos-2.0* Mg-1.7
Misc Labs:
[**2103-11-3**] 05:21AM BLOOD CRP-174*
[**2103-11-3**] 05:21AM BLOOD ESR-90*
IMAGING:
MRI T-Spine [**11-1**]:
FINDINGS: At the T3, T4 and T5 level, there is indentation on
the posterior
aspect of the spinal cord seen. There is a subtle area of low
signal
identified within the right side of the spinal cord extending
from T3-T5 level which measures approximately 2.5 cm in vertical
dimension and approximately 6mm in the anterior-posterior
dimension. These findings are highly suspicious for an epidural
abscess within the posterior epidural fat at these levels. There
is displacement of the thecal sac to the right side with mild to
moderate narrowing of the spinal canal which is between 25 and
50% with indentation on the spinal cord. No definite abnormal
signal is seen within the spinal cord. Multilevel degenerative
changes are seen within the thoracic intervertebral discs with
disc bulging at T7-8 indenting the thecal sac. Small disc
herniation is also seen at T8-9 level slightly indenting the
thecal sac. An incidental hemangioma is seen in the T10
vertebra. There is no evidence of abnormal signal within the
discs or the vertebral bodies to indicate discitis or
osteomyelitis. Although subtle increased signal is seen in the
interspinous region in the upper thoracic region no definite
abnormal signal is seen within the facet joints or the articular
processes or spinous processes to indicate osteomyelitis.
IMPRESSION: Findings indicative of an epidural collection most
likely an
abscess within the right side of the spinal canal from T3-T5
level as
described above with indentation on the thecal sac and narrowing
of the spinal canal with displacement of the spinal cord with
mild to moderate compression of the cord. No definite abnormal
signal is seen within the cord. No evidence of discitis or
osteomyelitis. If the surgical intervention is contemplated, a
focused study of the thoracic spine with gadolinium and fat
suppression can help for better assessment of the abscess.
CT w & w/out contrast T-Spine: [**11-2**]
FINDINGS: The patient is status post laminectomy of T3 through
T6. There are two epidural catheters identified within this
location. There is no large hematoma or thecal sac compression,
although evaluation is limited. There is no area of abnormal
enhancement identified or large fluid collection identified.
Bibasilar atelectasis and tiny bilateral pleural effusions are
noted.
IMPRESSION:
Expected post-surgical changes spanning T3 through T6. No large
obvious
hematoma identified. Evaluation of thecal sac and spinal canal
is limited by CT.
CXR(post-PICC placement) [**11-2**]:
FINDINGS: AP line has been placed and can be traced down to the
lower SVC.
The line introduced over the right upper extremity shows a
normal course.
There is no evidence of complications, notably no pneumothorax.
Minimal
increase in cardiac size. No overhydration. No pleural
effusions. Cervical
vertebral fixation.
MRI T-Spine [**11-4**]:
FINDINGS: The patient is status post laminectomy from T3 through
T6. No
evidence of residual epidural abscess is detected. However, note
that the
axial images did not extend through the full surgical level,
beginning at the bottom of the surgical site. Thus, there is no
axial imaging through the area where the epidural abscess had
been noted on the preoperative studies. The patient should
return for axial imaging from T1 through T6. If this is done
within two days of the current examination, it would be better
to avoid a repeat administration of intravenous contrast. Images
of the remainder of the spine appear unchanged. Again
demonstrated is cervical fusion and a T10 hemangioma.
CONCLUSION: Limited study demonstrates apparent complete removal
of the
spinal epidural abscess noted on the examination of [**2103-11-1**].
However, axial images were not performed through the surgical
level, and a repeat examination is recommended as discussed
above.
Additional imaging: Complete removal of the spinal epidural
abscess.If necessary a contrast enhanced MR scan can be done
tomorrow.
MRI T-Spine [**11-7**]: formal read is pending at time of discharge
but this was reviewed with the attending neurosurgeon and
appears stable compared to previous study
Brief Hospital Course:
Patient is a 50M transferred from OSH for definitive management
for a presumed thoracic epidural abcess. He was admitted to the
neurosurgical floor for pain managment, and futher evaluation.
Upon arrival to [**Hospital1 18**], OSH imaging was reviewd, and found to be
of poor diagnostic quality, and MRI needed to be repeated. This
was done so in the AM of [**11-1**]. On admission to [**Hospital1 18**], his motor
function of his lower extremities was found to be at his
baseline s/p multi spine surgeries. In the early afternoon of
[**11-1**], he complained of increased weakness of the lower
extremities, sensory deficit extending upward to the umbilicus,
and urinary retention. He was bladder scanned for nearly 1L of
urine. Foley catheter was placed, and he was then taken
emergently to the Operating room for surgical decompression of
the compressive lesion. He tolerated this procedure well.
Post-operatively he was admitted to the ICU for close
monitoring. On [**11-2**], a PICC line was placed and infectious
disease was consulted for antibiotic management. He was started
on Vancomycin immediately post-operatively. OSH called with
results of blood cultures obtained there, revealing MSSA; and
antibiotics were changed to Nafcillin. In the afternoon of [**11-2**],
Mr. [**Known lastname 84765**] was transferred out of the ICU to the neurosurgical
floor. His motor function and sensory continued to greatly
improve. His foley catheter was discontinued on [**11-4**], but
required replacement approx 8hours later when he was unable to
void. His neurological examination remained unchanged at this
time. On [**11-5**], urology was consulted to assist in the management
of bladder re-training. It was determined for him to have one
week of bladder "rest" and he would be re-evaluated by the
urology clinic in that time frame for bladder-retraining. On
[**11-6**] the patient has increased pain and a repeat MRI was
obtained which was stable. His pain improved again and his neuro
exam remained stable. He was evaluated by PT and OT who
determined that he would be appropriate for disposition to a
rehab facility. This was arranged on [**11-7**], and he was
discharged.
Medications on Admission:
1. Vitamin D3
2. ASA
3. Morphine and Dilauded IV at Hospital
4. Neurontin
5. Toradol, D/C'd
6. Percocet PO at Hospital
Discharge Medications:
1. Outpatient Lab Work
You will require WEEKLY blood work to evaluate:
CBC with differential, BUN/Cr, Liver Function Tests. These
results should be faxed to [**Telephone/Fax (1) 84766**]
2. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 6 weeks.
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
14. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Thoracic Epidural Abcess(T3-6)
Discharge Condition:
Neurologically Improved
Discharge Instructions:
Spine Surgery
Diet:
?????? You may resume your normal diet.
?????? You can help avoid constipation by eating a balanced diet
including: fruits, vegetables, and
whole grains (like multi-grain bread, cereals, and bran
muffins).
?????? You may also take fiber supplements and over-the-counter stool
softeners or laxatives such as Colace or Dulcolax
Activity:
?????? Walk at least three times a day and gradually increase your
distance and light activities each day.
?????? Do not exercise other than walking until after your first
6-week office visit.
?????? Do not sit longer than one hour at a time for the first two
weeks ?????? get up and move around.
?????? You will be more comfortable reclining in an easy chair or on
pillows in bed than sitting upright.
?????? Avoid twisting, turning, stopping, bending or reaching over
your head for six weeks.
?????? Do not return to the gym, play golf, swim, run, mow grass
until 3 months after surgery.
?????? Avoid exercises like aerobics, heavy house cleaning and
lifting over [**6-17**] pounds (a gallon of milk weighs 8.5 pounds).
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you are
awake.
?????? Do not drive if you are taking pain medications, muscle
relaxants, or if you are in pain.
?????? You may resume sexual activity when this is comfortable for
you.
?????? You can return to work when you feel ready. However, you must
stay within the [**6-17**] pound weight lifting restriction ?????? half
days might be better at first.
Spine patients:
?????? Do not drive 1-2 weeks after surgery.
?????? Do not ride in the car longer than one hour at a time ?????? get
out to stretch your back each hour.
Wound Care:
?????? You may shower after sutures have been removed. Prior to that
time frame, you may take a sponge bath, or shower such that the
water does not directly run over your incision. You [**Month (only) **] NOT soak
the incision in a bathtub or pool for 4 weeks. If your wound
gets wet, gently [**Last Name (LF) **], [**First Name3 (LF) **] NOT RUB the wound dry.
?????? Your incision was closed with stitches.
?????? The dressing is removed 2 days after surgery. If there is
still a small amount of bloody drainage, you can place a new
sterile gauze dressing, otherwise you can leave the wound open
to air
Pain:
?????? The second day after surgery will be the most painful due to
swelling and the anesthetic wearing off, and increased muscle
spasms as the lower back muscles begin to heal.
?????? You may also experience some back pain from muscle spasm as
you increase your daily activity, this is to be expected and
will improve with time.
?????? Around the fifth week after surgery, you may experience
discomfort for a few days due to scar tissue forming.
?????? You may also have some pain, numbness and tingling in the legs
and feet for the first 6-8 weeks as normal nerve function
returns.
?????? Some pain is normal as you resume your daily activities. You
may tire more easily for several months after surgery.
Medications:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and be comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
?????? Narcotic pain medication such as Dilaudid, Percocet or Vicodin
?????? Muscle relaxant such as Robaxin, Flexeril or Valium. Take
these as needed for muscle spasm. They will make you sleepy, so
do not drive while taking these medications
?????? You may be prescribed an anti-inflammatory medication such as
Indomethacin or Ibuprofen.
?????? Take these as prescribed on a regular basis to reduce
inflammation and pain
?????? An over the counter stool softener for constipation (try
Dulcolax, Milk of Magnesia or
?????? Correctal at first and Magnesium Citrate or Fleets enema if
needed).
Miscellaneous:
* Do not smoke. Smoking delays healing by increasing the
risk of complications (e.g., infection) and inhibits the bones'
ability to heal.
**Foley Catheter; Per the urology physicians, you will require
one week of bladder "rest", and will begin clamping trails at
rehabilitation to help regain your bladder sensation. You can be
alternatively be taught to self-catheterize if you prefer.
WHEN TO CALL THE DOCTOR
?????? Call the doctor at ([**Telephone/Fax (1) 88**] if you have:
?????? A temperature of 101??????F or above
?????? Increased redness, soreness, swelling or foul-smelling
drainage from the incision
?????? Clear drainage from the incision
?????? Inadequate pain relief
?????? Nausea or vomiting
?????? Shortness of breath
?????? Pain in your calf
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-17**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????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 thoracic spine with & without
contrast.
??????You will not need an MRI.
**Infectious Disease Follow up
-Follow up with Dr. [**First Name (STitle) 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. in the infectious
disease clinic this week. This appointment is scheduled for
[**2103-11-15**] 2:00pm Please call [**Telephone/Fax (1) 84767**] for directions to the
clinic. You also have an appointment scheduled for [**12-14**]
@9:30am with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD. You will need to have
weekly blood work while you are on your antibiotics. These
results will have to be faxed to [**Telephone/Fax (1) 84766**].
****UROLOGY FOLLOW UP
Please call to schedule an appointment to be seen by the urology
clinic within one week to facilitate your bladder re-training.
This appointment can be made by calling: ([**Telephone/Fax (1) 772**]
Completed by:[**2103-11-7**]
|
[
"344.1",
"704.00",
"305.60",
"V45.4",
"790.7",
"473.9",
"336.3",
"041.11",
"788.29",
"324.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11038, 11108
|
7286, 9473
|
329, 438
|
11183, 11209
|
2670, 2675
|
16706, 18195
|
1483, 1630
|
9643, 11015
|
11129, 11162
|
9499, 9620
|
11233, 12957
|
1679, 1830
|
2299, 2651
|
280, 291
|
12969, 16683
|
467, 1105
|
2689, 7263
|
1845, 2285
|
1127, 1274
|
1290, 1467
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,019
| 176,284
|
51418
|
Discharge summary
|
report
|
Admission Date: [**2122-6-5**] Discharge Date: [**2122-6-13**]
Date of Birth: [**2061-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
61 yo male with h/o HTN, DM, OSA (BIPAP at home), no known CAD,
who presented to OSH with 5 day h/o intermittent CP found to
have ST changes, increase troponin c/w MI and transfered to
[**Hospital1 18**] for cath. Pt was in usual good state of health until 5
days ago when he developed intermittent L sided chest pain at
rest, radiating down L arm and back. Last ~ 1 hr. +diaphoresis.
minimal relief with tylenol/advil at home. Went to hospital last
night as CP associated with SOB/DOE. At [**Hospital1 1474**], O2 92% RA,
tachypnic, [**7-12**] SSCP. pt given SL nitroX3, morphine(4mg IV),
325mg ASA, 40 IV lasix and then nitro ggt. Troponin 4.6, CK 85.
In ED, no ST/T wave changes and CP relieved with nitro ggt.
Admitted to CCU and then continued to have intermittent CP
despite inc nitro ggt and inc ST elevation in II/AVF. Transfer
for cath.
.
Cath results:
LAD - 90% lesion after D1
LCX -90% proximal
RCA - 50%mid, 70%postlat branch
PCW - 40, PA 65/37
CI: 3.7
Intervention: s/p 3 stent to LAD and 1 stent to Lcx; balloon
pump
Of note, pt hypotensive on transfer to [**Hospital1 18**], but after stenting
in cath lab, pressures improved. Intubated [**2-4**] agitation.
Propofol started--> became hypotensive 50s--> balloon pump
inserted--> started on dopamine and propofol changed to
fentanyl/versed.
..
Past Medical History:
HTN, DM, OSA with home BIPAP, obesity
Social History:
hx: + tob 1.5 ppd X50 yrs
Family History:
nc
Physical Exam:
On admission:
PE:
T: 96.3 BP: 160/83 (SBP: 53-160) HR: 80-102 O2: 100% on
AC control: TV: 650 X RR 20 X PEEP 5 XFIO2 1.00
GEN: pt obese male, intubated/sedated, NAD
HEENT: pupils ~2mm equal, mmm/pink
CHEST: equal breath sounds/chest mov't bilat; no crackles noted
on ant exam; whooshing of balloon pump heard on ins/exp
CARDIAC: rrr, no m/g/r
ABD: protuberant, soft, nt
EXT: cool/dry; bounding L DP pulse; very faint R DP pulse, but
dopplerable; no femoral bruits appreciated; R femoral access -
balloon pump
Neuro: sedated
Pertinent Results:
Labs at OSH: glucose 312, creatinine - 0.8, k - 3.6, CK - 85,
MB-2 troponin 4.6, wbc - 9, hct 40.4
...
EKG: OSH: [**6-4**] 6:36 PM: NSR @ 90, nml axis, flat T I/avL; jpoint
--> 2mmSTE V2-V3
OSH: [**6-5**] 1:12am: nsr @80, nml axis, TWI 1, AVL
[**Hospital1 18**] [**6-5**] after cath: nsr @80, nml asix, 2mm STE V3-V4
Brief Hospital Course:
A/P: 61 yo male with h/o HTN, DMII, +tob, p/w USA s/p cardiac
cath with PCI to LAD/LCx and evidence of R/L inc filling
pressures.
1. CAD - Post MI care including ASA, plavix load - 300mg IV
after cath, followed by 75mg daily X3months, and lipitor 80mg
daily. He received integrilling X18hrs after cath. Mr [**Known lastname 10083**]
was hyptotensive immediately after his cardiac cath and outpt
antihypertensives were held. However, once abx were started and
he was extubated, his hypotension resolved and carvedilol and
ace-I were started. CPK was monitored during admission, but
never bumped. Discussed smoking cessation with patient prior to
discharge, to which he stated that this hospitalization was a
wake up call to him to stop smoking.
.
2. PUMP: Elevated r/l filling pressures values were obtained
during the cardiac cath, and balloon pump initially put in for
afterload reduction. Of note, adequate cardiac output/index
values were obtained during the cath. PCWP was monitored via
arterial line, with goal wedge pressure 15-20. He was given
lasix to maintain goal wedge pressures. Mr. [**Known lastname 10083**] was initally
hypotensive s/p intubation (SBP in 50s) - which was thought
likely to be secondary to the propofol; blood pressures improved
with dopamine and sedation medications were changed to
versed/fentanyl, whic hthe patient tolerated well. Dopamine was
eventually weaned, but took few days due to pneumonia. Echo
[**6-5**]--> EF 40%, anterior/ distal septal AK and apical AK. Inital
extubation failed, likely [**2-4**] fluid overload, and patient was
subsequently diuresed and successfully extubated [**6-10**]. He was
continued on lasix after extubation, and discharged on 40mg PO
daily. THis can likely be weaned on f/u with cardiologist within
few weeks of discharge. Given akenesis seen on echo [**6-5**], patient
was started on coumadin 2mg qHS prior to d/c. Spoke with
covering PCP in [**Name9 (PRE) 1474**], who agreed that Dr. [**Name (NI) 3314**], pts
PCP, [**Name10 (NameIs) **] follow INR. Will need repeat echo in 3 months, at
which time, length of anticoagulation can be readressed.
.
3. rhythm: nsr, bb for cad; goal HR 50-60 as BP tolerates
.
4. Resp failure/PULM: Initially intubated during cath for pt
safety. However, right sided infiltrate on CXR (liekly
aspiration PNA based on r-sided dependent infiltrate) delayed
extubation. Given infiltrate on CXR and spike, pt was initially
started on broad spectrum abx with ceftriaxone and flagyl, which
then were changed to meropenem and vanc as patient contiued to
spike fevers, grew GNR in sputum, and was difficult to wean off
vent. ULtimately, his sputum grew pan sensitive E.Coli and abx
were changed to levofloxacin, which he will continue PO as an
outpt to complete a 14 day course of abx. After extubation, pt
remained on oxygen via NC throughout admission, with ambulatory
O2 sats in low 80s. He was discharged on home O2 with VNA to
help monitor respiratory status. He is to follow up with PCP for
reevaluation of oxygen requirement on week of d/c.
Pt
.
5. DMII - H/o diabetes on metformin/glyburide as outpt. HgbA1c
was checked during admission and found to be 11.9. Discussed
importance of adhering to diabetic diet/wt loss for improved
glycemic control. Patient was initially on insulin ggt while
intubated and then restarted on glyburide(10mg
[**Hospital1 **])/metformin(500mg [**Hospital1 **]). He is to follow up with PCP [**Last Name (NamePattern4) **]:
adjusting diabetic medications for improved control.
02
.
6. Hypernatremia - Pt with increased serum Na (147-149) while
intubated. Resolved with free water bolus.
.
Medications on Admission:
glyburide
metformin
antihypertensive meds
no asa
Discharge Medications:
1. oxygen - continuous
2-4 Liters oxygen continuous. Use as directed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 3 months: please continue this medication for
3 months.
Disp:*30 Tablet(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): please have your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**], follow your
coumadin levels and adjust the medication as appropriate.
Disp:*30 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: please
have your primary care doctor adjust this medication as
necessary.
Disp:*30 Tablet(s)* Refills:*2*
12. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
13. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
14. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
16. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
17. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day for
3 days.
Disp:*12 Tablet(s)* Refills:*0*
18. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
19. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
1. Unstable angina s/p cardiac cathterization with PCI to LAD
and LCx
2. Pneumonia
Secondary Diagnosis:
1. Diabetes Mellitus
2. HTN
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP or return to the emergency department if
you develop chest pain, shortness of breath, bloody stools or
other worrisome symptom.
Please take all medications as prescribed.
Please continue your antibiotics, levofloxacin, as prescribed
until [**2122-6-8**]
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**], at [**Telephone/Fax (1) **] to schedule
a follow up appointment within the next week. He should adjust
your diabetes medications, follow your coumadin levels, and
refer you to a cardiologist in your area. Please also have Dr.
[**Last Name (STitle) 3314**] adjust your lasix dose as appropriate.
|
[
"V58.67",
"V58.61",
"482.82",
"038.9",
"305.1",
"428.30",
"428.0",
"458.29",
"E938.4",
"518.81",
"278.01",
"478.29",
"995.92",
"780.57",
"482.2",
"414.01",
"507.0",
"410.71",
"276.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"99.20",
"96.04",
"36.05",
"89.64",
"88.56",
"96.72",
"36.07",
"37.23",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
8795, 8850
|
2723, 6358
|
325, 350
|
9045, 9053
|
2376, 2700
|
9376, 9760
|
1811, 1815
|
6457, 8772
|
8871, 8871
|
6384, 6434
|
9077, 9353
|
1830, 1830
|
275, 287
|
378, 1691
|
8994, 9024
|
8890, 8973
|
1844, 2357
|
1713, 1752
|
1768, 1795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,125
| 105,323
|
52550
|
Discharge summary
|
report
|
Admission Date: [**2187-2-8**] Discharge Date: [**2187-2-16**]
Date of Birth: [**2112-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Procanbid / Norpace / Zestril / Celebrex / Betapace / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain on Exertion
Major Surgical or Invasive Procedure:
[**2187-2-9**] CABG X 2 (LIMA->LAD, SVG->OM)
[**2187-2-8**] Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 108521**] is a delightful 75 year old gentleman with a
history of a past myocardial infarction who reports new chest
pain and dyspnea over the past couple of months. He has a past
history of atrial fibrillation with tachy brady syndrome for
which a permenant pacemaker was placed. He underwent a stress
test in [**12-30**] which was stopped secondary to fatigue and chest
pain. His ejection fraction was noted to be 39% on scan. Mr.
[**Known lastname 108521**] was admitted today for a follow-up cardiac
catheterization which revealed an 80% stenosed left main
coronary artery, a 50% stenosed proximal right coronary artery
and an ejection fraction of 35%. Due to the severity of his
disease, the cardiac surgical service was consulted for surgical
revascularization.
Past Medical History:
Hypercholesterolemia
Tachy-brady syndrome
Atrial fibrillation
Myocardial infarction
Depression
Carotid artery stenosis
S/P Paer implantation [**2175**]
GERD
Osteoarthritis
Social History:
Lives with daughter in [**Name (NI) 3146**]. Retired chef. Quit smoking 40
years ago after a 30 pack year history. Drinks a couple of
glasses of wine per week.
Family History:
No known coronary artery disease
Physical Exam:
Ht 69" Wt 210 lbs
VS: 105 AF BP 155/70 96% room air oxygen saturation
GEN: Laying flat in bed s/p catheterization in no apparent
distress.
NEURO: Moves all extremities, nonfocal.
LUNGS: CLear
CARDIAC: Irregular rhythm, no murmur.
ABD: Soft, nontender, nondistended, normoactive boel sounds.
EXT: Warm, well perfused. No edema, no varisocities.
PULSES: 2+ radial, femoral, dorsalis pedis and posterior tibial
bilaterally.
Pertinent Results:
[**2187-2-8**] 10:30AM INR(PT)-1.3
[**2187-2-8**] 08:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2187-2-8**] 01:30PM GLUCOSE-127* UREA N-18 CREAT-0.8 SODIUM-142
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12
[**2187-2-8**] 01:30PM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-73
AMYLASE-21 TOT BILI-0.8 DIR BILI-0.2 INDIR BIL-0.6
[**2187-2-8**] 01:30PM WBC-6.7 RBC-3.89* HGB-11.6* HCT-35.1* MCV-90
MCH-29.8 MCHC-33.1 RDW-13.8
[**2187-2-16**] 07:15AM BLOOD WBC-10.2 RBC-3.41* Hgb-10.4* Hct-31.5*
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.8 Plt Ct-290
[**2187-2-16**] 07:15AM BLOOD PT-20.8* PTT-114.7* INR(PT)-2.7
[**2187-2-16**] 07:15AM BLOOD Glucose-167* UreaN-25* Creat-1.0 Na-139
K-3.7 Cl-98 HCO3-33* AnGap-12
[**2187-2-8**] CXR
No previous films are available on PACS for direct comparison at
this time. There is a mild thoracic scoliosis convex to the
right. There is slight cardiomegaly with LV predominance but no
evidence for CHF. A dual chamber right sided pacemaker is
present with atrial and ventricular leads in situ, in good
location. The lungs are clear. There is minimal blunting of
posterior costophrenic angle. Degenerative changes are present
in the thoracic spine and there are surgical clips in the right
upper abdomen presumed s/p cholecystectomy.
[**2187-2-14**] CXR
AP & lateral chest views have been obtained in this patient now
demonstrating status post sternotomy, and the presence of
multiple surgical clips in the left-sided anterior mediastinum
are consistent with bypass surgery. A right-sided permanent
pacer in anterior axillary position is connected to two
intervavitary electrodes terminating in positions compatible
with right atrial appendage and apical portion of right
ventricle correspondingly. There is no evidence of pneumothorax.
The right-sided diaphragm is well delineated, but the left-sided
diaphragm is obliterated and blunted. Lateral pleural sinus is
consistent with postoperative pleural effsion of moderate
degree. Review of the patient's radiologic records demonstrates
that the preoperative chest examination in PA & lateral
technique was performed on [**2187-2-8**], then demonstrating
mild cardiac enlargement, moderately widened and elongated
thoraic aorta with calcium deposits in the wall. The pulmonary
vasculature did not demonstrate any congestive pattern. The
right-sided permanent pacer with dual-electrode system existed
already at that time. Comparison of today's fourth postoperative
examination, now in PA/lateral technique, demonstrates
considerable postoperative mediastinal widening to persist, and
the left lower lobe atelectasis-pleural density is new and has
not normalized as yet. Further postoperative follow-up exam is
advised. There is no evidence of remaining pneumothorax.
[**2187-2-8**] Cardiac Catheterization
1. Selective coronary angiography revealed a right-dominant
system. The LMCA was calcified with an 80% lesion. The LAD and
Lcx both had mild disease. The RCA had a 50% ostial lesion with
no flow limiting stenoses.
2. Left ventriculography revealed a moderately decreased
ejection
fraction (EF 35%) with global hypokinesis. There was 1+ mitral
regurgitation.
3. Resting hemodynamics revealed mild/moderately elevated left
and
right-sided filling pressures (RA mean 9mmHg, PA mean 28mmHg,
PWCP mean
13mmhg). The estimted cardiac index was 2.0 l/min/m2. There
was no
gradient on pull back across the aortic valve.
[**2187-2-8**] EKG
Atrial fibrillation, average ventricular rate 100-115, and
rate-related left bundle-branch block. Non-specific
repolarization abnormalities. Compared to the previous tracing
of [**2176-2-19**] the overall ventricular rate is slightly faster and
rate-related left bundle-branch block is new.
[**2187-2-14**] EKG
Atrial fibrillation with a ventricular response of 93. Left
bundle-branch
block. Compared to the previous tracing of [**2187-2-9**] the
ventricular response has slowed. Otherwise, no diagnostic
interim change.
[**2187-2-8**] Carotid duplex ultrasound
Minimal plaque with bilateral less than 40% carotid stenosis.
[**2187-2-9**] Pathology
Cardiac tissue consistent with atrial appendage, with myocyte
hypertrophy.
Brief Hospital Course:
Mr. [**Known lastname 108521**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2187-2-8**] for a cardiac catheterization. This was
significant for an 80% stenosed left main coronary artery, a 50%
stenosed right coronary artery and an ejection fractionof 35%.
Due to the severity of his disease, the cardiac surgical service
was consulted for surgical revascularization and Mr. [**Known lastname 108521**]
was worked-up in the usual preoperative manner. His coumadin was
stopped and his INR was allowed to drift towards normal. A
carotid duplex ultrasound was obtained which showed less then a
40% stenosis in the bilateral internal carotid arteries. On
[**2187-2-9**], Mr. [**Known lastname 108521**] was taken to the operating room where he
underwent coronary artery bypass grafting to two vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. His pacemaker was interrogated
following surgery and was found to be functioning within normal
limits. He remained in atrial fibrillation which was treated
with diltiazem and digoxin for rate control. Mr. [**Known lastname 108521**] had
some postoperative delerium which resolved over several days
without further workup. On postoperative day two, Mr. [**Known lastname 108521**] [**Last Name (Titles) **]e neurologically intact and was extubated. Coumadin was
started for anticoagulation for atrial fibrillation. Gentle
diuresis was initiated. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. Heparin was started while his INR was subtherapeutic
on coumadin. On postoperative day four, Mr. [**Known lastname 108521**] was
transferred to the cardiac surgical step down unit for further
recovery. He continued to work with physical therapy for
postoperative mobility. As his INR became therapeutic on
coumadin, his heparin was discontinued. His chest tubes were
removed per protocol. Mr. [**Known lastname 108521**] continued to make steady
progress and was discharged home on postoperative day seven. He
will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
Cardizem 120mg once daily
Multivitamin
Lopressor 100mg once in the morning and 75mg once in the evening
Coumadin 3mg once daily adjusted for INR btween 2.0-3.0
Aspirin 81mg once daily
Zantac 150mg once daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
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. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a day
for 1 doses: NO COUMADIN ON [**2-16**], and [**2-17**], then give 1mg on
[**2-18**]. INR to be drawn on [**2-19**], and called to Dr.[**Name (NI) 9920**] office
for continued dosing.
Disp:*90 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
CAD
AFib
Discharge Condition:
good
Discharge Instructions:
no lifting > 10 # or driving for 1 month
no creams or lotions to any incisions
may shower, no bathing or swimming for 1 month
Followup Instructions:
with Dr. [**Last Name (STitle) **] in 4 weeks
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks
with Dr. [**Last Name (STitle) **] in [**3-1**] weeks
Completed by:[**2187-3-22**]
|
[
"746.89",
"427.1",
"433.30",
"414.01",
"429.3",
"427.31",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.99",
"36.15",
"36.11",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10278, 10335
|
6383, 8647
|
349, 435
|
10388, 10394
|
2135, 6360
|
10568, 10774
|
1642, 1676
|
8905, 10255
|
10356, 10367
|
8673, 8882
|
10418, 10545
|
1691, 2116
|
287, 311
|
463, 1254
|
1276, 1449
|
1465, 1626
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,453
| 145,436
|
55071
|
Discharge summary
|
report
|
Admission Date: [**2200-10-2**] Discharge Date: [**2200-11-15**]
Date of Birth: [**2143-6-15**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
G-tube insertion
Intubation for EGD showing malignant stricture
Stenting of malignant esophageal stricture
PICC Line placement
History of Present Illness:
Pt is a 57M from [**Country 3396**] who moved to [**Location (un) 86**] [**8-/2200**], diagnosed
[**9-/2200**] with stage III SCC of the esophagus admitted for PEG and
concurrent chemoradiation since he has no insurance. Pt
initially diagnosed in [**Country 3396**] with throat mass and was treated
with herbal remedy. Then saw Dr. [**Last Name (STitle) **] in clinic early
[**9-/2200**] and admitted for workup of progressive dysphagia and
hyponatremia from [**Date range (1) 112390**]/12. Pt underwent EGD showing SCC of
the esophagus. Pt found to have strep viridans bacteremia; pt
unable to undergo TEE to r/o IE because of esophageal mass, so
plan for 4wk course of IV ceftriaxone. Pt had PET [**2200-9-23**] and
was staged as stage III SCC of the esophagus.
Seen by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] (rad/onc) and Dr. [**First Name (STitle) **]
(thoracic [**Doctor First Name **]) and IP in clinic today. Has stage 3 squamous
cell carcinoma and needs concurrent xrt and chemo for locally
advanced cancer. Pt also only able to take in liquids so needs
feeding tube. Plan for endobronchial u/s at time of feeding tube
to r/o airway compromise. Pt without insurance, so plan is to be
admitted for these interventions. Dr. [**Last Name (STitle) **] is working on
arranging radiation planning for tomorrow. 5FU/cisplatin
sometime next week.
On arrival to the floor, pt without complaints. Reports
persistent dysphagia and odynophagia. Pt has been tolerating PO
liquid diet including puddings and ensure with occasional
sensation that foods like jello or oatmeal get stuck in throat.
Pt reports 2kg wt loss over the past few weeks. Pt denies
fevers. Reports heartburn sensation after PO liquids. Pt also
reports some feelings of anxiety after all of the news today. Pt
denies urinary symptoms, including urinary retention. Pt denies
n/v. Last BM normal today.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Mr. [**Known lastname 112389**] initially presented to clinic on [**2200-9-10**], at
which time he had five to seven months of pain in his throat and
difficulty swallowing. He had undergone a CT
scan in [**Country 3396**] and was told that he had throat narrowing,
which
was causing him that difficulty. According to his report, he
had
an endoscopy there, but no biopsy. Following my visit, he was
hyponatremic and thus was admitted to the hospital for this and
for workup of his new malignancy. He underwent a CT neck on
[**2200-9-10**], which showed some question of a mass-like lesion
within the esophagus, but no neck abnormalities. He underwent a
CT torso on [**2200-9-11**], which showed proximal dilation of the
esophagus with thickening of the esophagus distal to the level
of
the carina as well as some small pulmonary nodules. He had a
barium swallow on [**2200-9-12**], which showed a mid esophageal
lesion concerning for esophageal carcinoma. He went on to
undergo an endoscopy on [**2200-9-16**]. Biopsy of the esophageal
mass revealed an invasive squamous cell carcinoma. He underwent
a PET scan on [**2200-9-23**], which showed high-level FDG avidity at
the site of the biopsy-proven squamous cell carcinoma as well as
scattered subcentimeter mediastinal and bilateral hilar lymph
nodes limited FDG avidity with an SUV mass of 3.7.
PAST MEDICAL HISTORY:
Mitral regurgitation
BPH
Extensive alcohol/tobacco use
H/o CAD
Social History:
Lives with his sister and wife; Recently moved to the US from
[**Country 3396**]. 30+ pack-year smoking history. Heavy alcohol use in
past, up to 1 bottle vodka daily for many years.
Family History:
Father: Murdered
Mother: Diabetes
Physical Exam:
Admission PE:
Vitals - T: 98.3 BP: 124/64 HR: 77 RR: 18 02 sat: 100% RA
GENERAL: well appearing male, sitting up on edge of the bed, in
NAD
HEENT: PERRLA, anicteric sclera, MMM, oropharynx clear, no
evidence of mucositis or thrush
NECK: nontender supple neck, no cervical/supraclavicular LAD
CARDIAC: RRR, [**4-15**] holosystolic murmur heard best at apex
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, +BS, nontender, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no LE edema or
tenderness, no obvious deformities
NEURO: 5/5 strength in UE and LE bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge PE:
Vitals - 99.2 current and max. 110/70 (100s/60s-70s) 97
(90s-100s) 18 92%RA
1435 po + 708 IV / 2475 urine + 2BM guaiac negative
GENERAL: thin male, good affect, lying in bed, in NAD
SKIN: Stable blanching erythema on back with stable
maculopapular blanching erythema on upper anterior chest.
HEENT: Oropharynx clear. No JVD.
CARDIAC: RRR, stable [**4-15**] holosystolic murmur heard best at apex
LUNG: CTAB
ABDOMEN: soft, nondistended, +BS. G-tube site clean, dry, and
intact.
EXTREMITIES: Stable swelling over left lateral malleolus,
mildly-erythematous, non-tender. Tenderness over dorsal right
foot resolved.
PENIS: Retracting foreskin reveals no evidence of balanitis
without candidal thrush. No pubic discomfort to palpation or
other lesions noted.
Pertinent Results:
Admission Labs:
[**2200-10-2**] 04:50PM GLUCOSE-89 UREA N-16 CREAT-1.0 SODIUM-133
POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-28 ANION GAP-13
[**2200-10-2**] 04:50PM ALT(SGPT)-11 AST(SGOT)-26 ALK PHOS-74 TOT
BILI-0.1
[**2200-10-2**] 04:50PM CALCIUM-10.2 PHOSPHATE-4.9* MAGNESIUM-1.9
[**2200-10-2**] 04:50PM WBC-7.0 RBC-3.66* HGB-10.4* HCT-30.5* MCV-83
MCH-28.3 MCHC-34.0 RDW-15.2
[**2200-10-2**] 04:50PM PLT COUNT-303
[**2200-10-2**] 04:50PM PT-10.9 PTT-29.9 INR(PT)-1.0
DISCHARGE LABS:
[**2200-11-8**] 05:30AM BLOOD WBC-13.3* RBC-3.47* Hgb-10.2* Hct-30.5*
MCV-88 MCH-29.3 MCHC-33.3 RDW-16.3* Plt Ct-328
[**2200-11-3**] 07:35AM BLOOD Neuts-90.4* Lymphs-3.3* Monos-5.7 Eos-0.4
Baso-0.2
[**2200-11-8**] 05:30AM BLOOD Glucose-165* UreaN-18 Creat-1.4* Na-129*
K-3.7 Cl-90* HCO3-28 AnGap-15
[**2200-11-8**] 05:30AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.6
OTHER RELEVANT:
[**2200-11-3**] 01:35PM BLOOD WBC-24.2* RBC-3.45* Hgb-9.9* Hct-30.1*
MCV-87 MCH-28.6 MCHC-32.8 RDW-15.8* Plt Ct-493*
[**2200-11-4**] 10:15PM BLOOD WBC-22.4* RBC-3.34* Hgb-9.7* Hct-28.3*
MCV-85 MCH-29.0 MCHC-34.2 RDW-16.3* Plt Ct-439
[**2200-11-7**] 07:05AM BLOOD WBC-10.5 RBC-3.30* Hgb-9.7* Hct-28.5*
MCV-87 MCH-29.4 MCHC-34.0 RDW-15.7* Plt Ct-384
[**2200-11-1**] 10:06PM BLOOD Na-120* K-4.7 Cl-85*
[**2200-11-6**] 06:30AM BLOOD Glucose-120* UreaN-21* Creat-1.6* Na-128*
K-3.9 Cl-88* HCO3-31 AnGap-13
[**2200-11-5**] 06:50AM BLOOD ALT-10 AST-21 LD(LDH)-186 AlkPhos-80
TotBili-0.3
[**2200-11-5**] 06:50AM BLOOD Albumin-3.3* Calcium-9.1 Phos-4.5 Mg-3.0*
[**2200-11-7**] 07:05AM BLOOD Osmolal-272*
[**2200-11-2**] 01:39AM BLOOD Osmolal-271*
[**2200-11-3**] 07:35AM BLOOD TSH-1.4
[**2200-11-3**] 07:35AM BLOOD Cortsol-32.6*
[**2200-10-17**] 07:27AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2200-10-17**] 07:27AM BLOOD HCV Ab-NEGATIVE
[**2200-10-15**] 07:05AM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test
Strongyloides Antibody, IgG ([**Doctor First Name **])
Strongyloides IgG 1.48 H
<1.00
[**2200-11-15**] 09:30PM BLOOD WBC-16.8* RBC-3.32* Hgb-9.8* Hct-30.0*
MCV-90 MCH-29.6 MCHC-32.8 RDW-15.4 Plt Ct-224
IMAGING:
CXR [**2200-11-1**]: Esophageal metallic stent is in place. Heart size
and mediastinum are stable. Interval improvement in bilateral
pleural effusions with still present minimal bibasilar
atelectasis and minimal amount of pleural fluid is noted. There
is no pneumothorax. Lungs are essentially clear.
CT CHEST W/O CONTRAST [**10-23**]:
CONCLUSION:
1. The patient has a new esophageal stent for mid-esophageal
cancer. There
is no sign of perforation. New wall thickening proximal to the
stent could be
due to radiation induced edema or esophagitis secondary to the
new stent.
2. Bilateral new consolidation in right lower lobe, lingula and
right middle
lobe is compatible with large scale aspiration and/pneumonia.
3. Mild pulmonary edema.
4. Previously noted right middle lobe nodule is a calcified
granuloma. PET
negative stellate left upper lobe lesion accompanied by
calcification and
bronchiectasis is likely scarring from the same etiology.
MR W/WO CONTRAST RIGHT FOOT [**10-30**]:
IMPRESSION:
1. No evidence for osteomyelitis.
2. Tenosynovitis of the flexor hallucis longus associated with
a small right
subtalar joint effusion.
3. Moderate degenerative joint disease of the right mid foot.
4. No evidence for focal abnormality subjacent to the fiducial
marker on the
anterior aspect of the patient's ankle.
MR W/WO CONTRAST LEFT FOOT [**11-4**]:
IMPRESSION:
1. Subcutaneous edema and small joint effusion.
2. No osteomyelitis.
CT CHEST WITH CONTRAST [**11-4**]:
IMPRESSION:
1. Resolution of previous bilateral opacities.
2. No CT evidence of vertebral osteomyelitis, but MRI is more
sensitive for
early osteomyelitis.
3. Long esophageal stent has migrated slightly cephalad by 2
cm. The overall
extensive esophageal thickening is unchanged. Retained contrast
material is
presumably inspissated.
These findings were discussed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] with [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) **] at 10:10
p.m. on [**2200-11-4**].
[**11-7**] PICC LINE PLACEMENT:
IMPRESSION: Successful placement of a right PICC with tip
terminating in the mid SVC.
Brief Hospital Course:
HOSPITAL COURSE
57M from [**Country 3396**] who moved to [**Location (un) 86**] [**8-/2200**], diagnosed [**9-/2200**]
with stage III SCC of the esophagus. Admitted for placement of
feeding tube and initiation of concurrent chemoradiation in the
setting of no insurance. Patient tolerated placement of tube
well and tube feeds were eventually titrated to goal. Previously
had been admitted for strep viridans bacteremia, likely related
to his MVP and treated with one month of ceftriaxone. On [**10-11**],
one day before finishing this course, he spiked a fever and BCx
grew out Abiotrophia (a nutrient deficient enterococcus). A
surveillance culture subsequently grew out Capnocytophagia
(GNR). He was transitioned through several antibiotics before
being treated with Gent/Zosyn. His sodium was noted to be
trending downwards so urine lytes were obtained and found a
picture consistent with SIADH--likely either cisplatin toxicity
or from tumor effect. He was then placed on fluid restriction,
but became relatively [**Name2 (NI) 112391**] and hypotensive with SBPs
90-100s with transient runs of tachycardia. On [**10-19**] and [**10-20**]
patient had two episodes of bright red emesis with clot without
airway compromise or shortness of breath. HgB at that time was
noted to be stable. He was transfered to the ICU for EGD which
found a malignant stricture with clot below it. This was stented
on [**10-22**] and patient was transfered back to the floor.
Subsequently became febrile, tachycardic and desat'd to the 80s.
CT chest performed that noted bilateral new consolidation in
right lower lobe, lingula and right middle lobe is compatible
with large scale aspiration and/pneumonia. No esophageal
perforation was noted. Patient was treated with IVFs and briefly
had antibiotic regimen broadened to vancomycin. Gentamicin
course finished on [**2200-10-29**]. Patient developed RIGHT dorsal foot
pain and in setting of recent bacteremia MRI was performed that
did not show evidence of osteo. On [**2200-11-1**], patient again
developed tachycardia in the setting of fever and worsening
leukocytosis, and there was concern for septic physiology.
Given his underlying hyponatremia presumed secondary to SIADH,
and concern that fluid boluses for his tachycardia may result in
worsening hyponatremia, he was transferred to ICU for close
monitoring. In ICU, Na noted to have dropped to 120, and he was
started on hypertonic saline. Repeat Na was 127, and hypertonic
saline stopped. Renal was consulted for further management of
his hyponatremia. Patient did have LEFT ankle pain/edema at the
lateral maleoulus, but no warmth, erythema, or significant pain
on range of motion to suggest septic arthritis. Patient already
on Zosyn, and antibiotic coverage broaded to include vancomycin
to provide empiric gram positive coverage. He remained
hemodynamically stable, and HR improved to 90s-110s. WBC down
from 17 to 16. Given stability, was transferred back to
Oncology floor the following day on [**2200-11-2**].
ACTIVE ISSUES
# SCC OF ESOPHAGUS: Stage 3. Pt with persistent odynophagia and
dysphagia had been limiting PO intake, resulting in weight loss.
Plan for feeding tube as esophageal tumor causing high grade
obstruction of esophagus. Pt started concurrent chemoradiation
as an inpatient since he has no insurance. Pt underwent EBUS
[**10-6**] which showed no evidence of endobronchial lesions. Pt had
open G tube placement [**10-6**]. Pt started XRT and chemo
(cisplatin/5FU) [**10-7**]. Tube Feeds started [**10-6**]. He was variously
able to tolerate tube feeds initially with initial feeding rate
titrated to level of distension. By the time of discharge, he
was meeting his goal tube feeds and was sent home on continuous
feeds from caregroup and managed by his daughter and [**Name (NI) 269**]. He
will continue with radiation therapy for the next 2 weeks and
follow-up with Dr. [**Last Name (STitle) **] for further chemotherapy planning as an
outpatient.
Brief Hospital Course:
# SCC of the esophagus: In addition to the management outlined
above, he remained in the hospital until [**11-15**] and completed
another round of chemotherapy with cisplatin and 5-FU without
complications. He also completed an additional week of radiation
therapy. By the time of discharge, he has only 3 radiation
sessions remaining.
# Urinary retention: By the time of discharge, he had
successfully passed a voiding trial on tamsulosin and no longer
required a foley catheter.
# Hyponatremia: His sodium levels stabilized in the 130s by the
time of discharge.
# G-tube site: On [**11-14**], minor white-yellow thin drainage was
noted around the G-tube site associated with 2-3mm of erythema
and induration. Non-tender on exam. The drainage did not appear
to be tube feeds given differences in color and consistency.
Wound culture was performed.
TRANSITIONAL ISSUES:
# G-tube site drainage: Stable.
# BACTEREMIA/ENDOCARDITIS: Found on bl cx during admission in
early 8/[**2200**]. Plan for 4wk of ABX to stop [**2200-10-12**] because unable
to get TEE to r/o IE because of esophageal mass. Continued daily
ceftriaxone until [**2200-10-12**]. On [**10-11**] pt grew out GPCs later
speciated as Abiotrophia, a nutrient deficient Enterococcus.
Initially started on Vancomycin, then switched to Augmentin.
Repeat TEE showed tricuspid leaflet thickening so this was
switched to Amp/Gent. Surveillance culture subsequently grew a
GNR later speciated as Capnocytophagia and so antibiotics were
broadened to Gentamycin/Zosyn. Unclear source for these
bacteria, but ID suspects it may have to do with translocation
of oropharyngeal flora across esophageal tumor. There was some
concern for osteomyelitis as well given left and right ankle
swelling and pain on separate occasions. These were negative on
MRI, so vancomycin was discontinued. Additionally, while on
vanco he had developed some additional renal insufficiency and
worsening anterior chest rash - these improved after
discontinuing the vanco and liberalizing his fluids.
# STRONGYLOIDES: IgG was positive. Treated with Ivermectin.
# HEMATEMESIS: At baseline patient had normocytic anemia with
iron studies c/w anemia of chronic disease. On [**10-20**] patient
developed hematemesis of bright red blood and clots also with
blood found on G-tube draws during residual checks. Hematocrit
dropped and so pt was transfused several units of blood. He was
transfered to ICU for endoscopy on [**10-21**] which revealed clot
above a malignant stricture. The clot was removed and revealed a
malignant stricture that could not be traversed along with what
appeared to be a necrotic central lumen that had some associated
red blood (likely source of bleeding). This was not intervened
upon because did not have significant active bleeding and any
intervention would have likely been short lived with re-bleeding
to follow. He remained stable without any episodes of
hematemesis for the 5-6 days prior to discharge.
# HYPOTENSION-->SEPSIS: Patient's baseline is SBP 140s but over
course of admission ran mostly in 100-110s. The cause of this is
likely due to fluid restriction for treatment of his SIADH. He
had 3 trigger events for SBP to the 90s. During these events he
responded appropriately to small boluses. After his endoscopy on
[**10-21**] it was found that his sodium was recovering so fluid
restriction was removed. On [**10-23**] became tachycardic to the 140s
with fever spiking to 102 and continuing relative hypotension
with SBP in the 100s. In context of ongoing bacteremia this was
treated as sepsis. His sepsis physiology improved with hydration
at the expense of another drop in sodium, as discussed below. He
remained borderline tachycardic in the high 90s and low 100s,
though without any drop in his blood pressure.
# HYPONATREMIA: Patient developed hyponatremia that trended down
to nadir of 128 a few days after cisplatin dosage on [**10-7**]. Urine
lytes showed high osmolality and salt wasting and this was
eventually attributed to SIADH from cisplatin effect. Pt was
placed on fluid restriction. Due to this patient developed low
level of [**Last Name (un) **] with creatinine as high as 1.5 on [**10-21**]. Patient was
taken off fluid restriction and hydrated which subsequent
recovery in creatinine and Na. Throughout this admission there
was a balancing act between hydration to treat sepsis physiology
and fluid restriction for SIADH. Tube feeds were eventually
switched to TwoCal HN to further restrict free water. On [**11-1**] pt
recieved hypertonic saline in the ICU and then was transfered
back to the floor. His medications were also concentrated to
restrict free water. By the time of discharge, his sodium had
stabilized around 129-130s, asymptomatic. His water restriction
remained at 2L instead of 1.5 in order to flush his kidneys more
to better tolerate anticipated chemotherapy.
# Urinary Retention: 2 days prior to discharge, he developed
urinary retention > 900ccs in the setting of having discontinued
his doxazosin for his blood pressure. Foley was then placed with
good output. He failed a trial of removing the Foley the day
prior to discharge, retaining > 800ccs. Foley was re-inserted
for plans to manage as an outpatient. He was also started on
tamsulosin, with less blood pressure effects per pharmacy.
INACTIVE ISSUES:
# MVP/MVR: per [**9-11**] TTE Myxomatous mitral valve leaflets,
moderate/severe MVP. eccentric MR jet, moderate (2+) MR.
Recently seen by cardiology and felt there is no indication for
medications at this time given normal LV function. He is
considered to be stable for surgery and chemo as needed.
# BPH: chronic, stable. Doxazosin held in setting of low BP.
Tamsulosin started. Urinary retention managed with Foley as
above.
# H/o CAD: continued daily aspirin
Transitional Issues:
# Radiation therapy: Will receive for the next 2 weeks.
# IV Antibiotics: PICC line in place for anticipate 4 weeks of
IV Zosyn. Will be seen as outpatient in [**Hospital **] clinic.
# Tube feeds: Arranged for continuous tube feeds at home.
# Foley [**Last Name (un) **]: Will be managed by daughter and at upcoming
outpatients appointments. Anticipate improvement in urinary
retention now that he has started on tamsulosin.
The patient was originally scheduled for discharge [**11-8**]. This
purpose of this addendum is to document updates of his hospital
course between [**11-8**] and [**11-15**].
Brief Hospital Course:
# SCC of the esophagus: In addition to the management outlined
above, he remained in the hospital until [**11-15**] and completed
another round of chemotherapy with cisplatin and 5-FU without
complications. He also completed an additional week of radiation
therapy. By the time of discharge, he has only 3 radiation
sessions remaining.
# Urinary retention: By the time of discharge, he had
successfully passed a voiding trial on tamsulosin and no longer
required a foley catheter.
# Hyponatremia: His sodium levels stabilized in the 130s by the
time of discharge.
# G-tube site: On [**11-14**], minor white-yellow thin drainage was
noted around the G-tube site associated with 2-3mm of erythema
and induration. Non-tender on exam. The drainage did not appear
to be tube feeds given differences in color and consistency.
Wound culture was performed.
TRANSITIONAL ISSUES:
# G-tube site drainage: Stable.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver[**Name (NI) 581**].
1. CeftriaXONE 2 gm IV Q24H Duration: 4 Weeks
Four weeks total duration (therapy started [**2200-9-14**], day#1), to
continue through [**2200-10-12**].
2. Aspirin 81 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Doxazosin 4 mg PO HS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN fever
may crush up to put through G-tube.
2. Aquaphor Ointment 1 Appl TP TID:PRN skin rash
3. Cepacol (Menthol) 1 LOZ PO PRN throat dryness
4. DiphenhydrAMINE 25-50 mg PO Q8H:PRN pruritis or insomnia
RX *diphenhydramine HCl [Allergy (diphenhydramine)] 25 mg 1
tablet(s) by mouth every eight (8) hours Disp #*90 Tablet
Refills:*0
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
through G-tube.
RX *lansoprazole 30 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
6. Nystatin Oral Suspension 10 mL PO QID:PRN mucositis
RX *nystatin 100,000 unit/mL 10 mL by mouth four times a day
Disp #*1 Bottle Refills:*0
7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg [**2-10**] tablet(s) by mouth every four
(4) hours Disp #*120 Tablet Refills:*0
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
9. Piperacillin-Tazobactam 4.5 g IV Q8H
End [**12-7**]
RX *piperacillin-tazobactam 4.5 gram every eight (8) hours Disp
#*57 Vial Refills:*0
10. Sodium Chloride 2 gm PO BID
may take with or without food. take with food if upset stomach
with these salt tabs.
RX *sodium chloride 1 gram 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
11. Senna 1 TAB PO BID:PRN constipation
12. Temazepam 15 mg PO HS
patient may refuse
RX *temazepam [Restoril] 15 mg 1 capsule(s) by mouth at bedtime
Disp #*30 Capsule Refills:*0
13. 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.
14. Tamsulosin 0.4 mg PO HS
hold for sbp<90
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime
Disp #*30 Capsule Refills:*0
15. Outpatient Lab Work
Please check CBC with differential, Chem 7 and LFT's qweekly
([**11-21**], [**11-28**]).
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed.
16. Metoclopramide 20 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 2 tabs by mouth Before each meal
and before bedtime. Disp #*120 Tablet Refills:*3
17. Filgrastim 300 mcg SC Q24H
RX *filgrastim [Neupogen] 300 mcg/mL subcutaneously daily Disp
#*10 Syringe Refills:*0
18. multivitamin *NF* Oral daily
RX *multivitamin 1 by mouth daily Disp #*1 Bottle Refills:*0
19. Maalox/Diphenhydramine/Lidocaine
15-30 mL PO QID:PRN mouth/throat pain
Disp: 1 Bottle
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Esophageal SCC complicated by bleeding and hematemesis
Abiotrophia and Capnocytophagia bacteremia
SIADH from cisplatin
Urinary retention
Strongyloides
Primary Diagnosis
Esophageal SCC complicated by bleeding and hematemesis
Secondary Diagnosis
Abiotrophia and Capnocytophagia bacteremia
SIADH from cisplatin
Urinary retention
Strongyloides
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 112389**],
Thank you for choosing us for your care. You were admitted to
start your chemotherapy (cisplatin/flourouracil) and radiation
therapy. In preparation for the side effects of treatment, you
recieved a tube leading to your stomach through which you could
recieve nutrition. After treatment, you reported throat
pain--likely a side effect of the radiation. We controlled this
with pain medication and numbing mouthwashes.
About one month before your admission, one of your blood
cultures grew the bacteria Streptococcus viridans. You had been
treated with a month of the antibiotic ceftriaxone. Towards the
end of this treatment you developed a fever and a repeat blood
culture showed two new bacteria in your blood stream. We
switched your antibiotic several times and ended up with a
regimen covering a broad spectrum of bacteria. Due to there
being bacteria in your bloodstream, we kept a high suspicion for
infections elsewhere in your body. Due to pain in your feet, we
did MRIs of to make sure there were no infections in the bone.
At the same time we found that you had been infected with the
parasite Strongyloides and so we started treatment for this with
the anti-parasite medication Ivermectin. You were also found to
be infected with bacteria in your bloodstream. You will continue
on IV antibiotics for approximately 1 month after your discharge
from the hospital.
During your admission, we noticed that your blood sodium level
was low. We felt that this was due to either a condition called
SIADH or as a side effect of your chemotherapy (the cisplatin
component). The treatment for this condition is to restrict the
amount of water you take in. You went to the ICU several times
due to fear of infection in conjunction with this low sodium.
About two weeks into your radiation treatments you started
vomiting blood and blood clots. We performed an endoscopy to
look at the site of bleeding and found that it was associated
with your tumor. We also found that your esophagus was very
narrow from compression by your tumor. We stented you esophagus
open to allow you to eat more.
You also developed difficulty urinating since you are off of
your prostate medication due to low blood pressure. You will
have a Foley catheter in your bladder until it is safe to be
taken out. You have also been started on a different prostate
medication called tamsulosin in place of doxazosin. Studies can
be done by your doctor to determine when this can be done.
You will be receiving IV antibiotics for approximately 3 weeks
through your IV. These are important to continue taking so that
an infection does not develop or become serious.
Serious symptoms to return to call your doctor and/or go to the
Emergency Department:
Fever 100.4 or above
Vomiting blood
Severe throat or chest pain
Fast heart rate
See below for additional symptoms to look for.
Followup Instructions:
[**Known lastname 269**] Services.
Radiation-oncology treatments Tuesday through Thursday ([**11-18**]
through [**11-20**]) at 7:45am: [**Telephone/Fax (1) 30840**].
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2200-11-18**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 831**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2200-11-19**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**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: INFECTIOUS DISEASE
When: MONDAY [**2200-11-24**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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20,678
| 125,030
|
4863
|
Discharge summary
|
report
|
Admission Date: [**2168-11-7**] Discharge Date: [**2168-11-17**]
Date of Birth: [**2103-5-21**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 65 year-old
woman with a history of end stage renal disease on
hemodialysis who presents with hypotension while she was at
radiology today. The patient had been in her usual state of
health until three days ago when she developed fevers or
chills at hemodialysis. Her old AV graft site was noted to
be red with questionable question of infection. She was
started on Kefzol after hemodialysis. She developed
occipital headache and neck pain, which she states often
happens after hemodialysis, but it has been constant since
then. It usually goes away after twelve hours. She has had
low grade temperatures to 100 degrees over the weekend. She
denies nausea, vomiting, decreased appetite, diarrhea,
abdominal pain, chest pain or shortness of breath. She has
orthopnea and dyspnea on exertion at baseline that has not
significantly changed today. She was at the X-ray Department
today and developed buzzing in her head. Her systolic blood
pressure was in the 70s. She was sent to the Emergency
Department and given intravenous fluids with increase in her
blood pressure to the 90s.
PAST MEDICAL HISTORY:
1. Type 1 diabetes with triopathy.
2. End stage renal disease on hemodialysis times five years.
Current AV graft revision with infections most recently [**5-31**].
3. Coronary artery disease status post coronary artery
bypass graft in [**2161**].
4. Atrial fibrillation.
5. Peripheral vascular disease status post right femoral
popliteal and left femoral distal bypass.
6. Carotid stenosis.
7. Right arm deep venous thrombosis in [**2162**].
8. Gastritis.
9. Depression.
10. Disc herniation L3-L4 [**5-31**].
ALLERGIES: Penicillin causes a rash.
MEDICATIONS:
1. NPH 32.
2. Regular insulin sliding scale.
3. Coumadin 7.5.
4. Captopril 12.5 t.i.d.
5. Digoxin 0.125 three times per week predialysis.
6. Imdur 30 mg q.d.
7. Celexa 20 mg q.h.s.
8. Alprazolam 0.25 mg q.h.s.
9. Nephrocaps one tab q.d.
10. Renagel 1200 mg t.i.d.
11. Quinine one tab three times per week.
12. Neurontin 100 mg q.d.
13. Prilosec 20 mg q.d.
SOCIAL HISTORY: She was a former assembly line worker, 25
pack year tobacco history.
PHYSICAL EXAMINATION: Temperature 97.5. Blood pressure
91/25. Pulse 84. Respirations 26. Sating 99% on room air.
She is a chronically ill appearing female. Pupils are equal,
round and reactive to light. Extraocular movements intact.
Mucous membranes are dry. Neck supple. Right carotid thrill
with loud bruit, left carotid soft bruit. Lungs crackles at
bases. Dullness at right base. Cardiac examination regular
rate and rhythm. S1 and S2. 3 out of 6 systolic murmur
loudest at the left upper sternal border. Abdomen soft,
nontender, nondistended. Normoactive bowel sounds.
Extremities no edema. Right wrist nonpalpable pulse. Ulcers
on the right hand. No surrounding erythema. Left dorsalis
pedis pulse palpable. Right dorsalis pedis pulse
nonpalpable. Neurological alert and oriented times three.
Decreased sensation in lower extremities. Vision markedly
decreased. Moves all four extremities.
LABORATORIES ON ADMISSION: White blood cell count 18.4, 87%
neutrophils, 6% lymphocytes, 1% monocytes, 6% eosinophils,
hematocrit 40.9, platelets 302. Chemistries sodium 124,
potassium 7.7 grossly hemolyzed. Repeat potassium was 2.4,
chloride 89, bicarb 21, BUN 64, creatinine 8.5, glucose 373.
Arterial blood gas 7.32, 37, 63. The patient was given
potassium. Her repeat K was 5.1. Chest x-ray showed
cardiomegaly with mild interstitial edema, mild increase of
right lower lobe and fusion. Head CT was negative with no
shift. Electrocardiogram normal sinus rhythm at 83 beats per
minute, T wave inversions in 1, AVL, V5-V6, ST depressions in
1, AVL, normal axis. No T waves. No significant change
compared with 7/02.
HOSPITAL COURSE: The patient was admitted to the MICU where
she continued to remain hypotensive. She was initially
started on Levophed as a pressor and given intravenous
fluids. She was started on Levofloxacin and Vancomycin for
possible pulmonary versus graft source for infection. The
patient was then switched from Levophed to Neo. She was seen
by transplant surgery who felt that her old right AV fistula
graft may be infected. The patient went to the Operating
Room and had AV graft removed. During surgery purulent
discharge was noted. culture ended up growing out coag
negative staph. The patient had an echocardiogram done,
which showed an EF of 25 to 30%, global left ventricular
hypokinesis, moderate mitral regurgitation, moderate
tricuspid regurgitation. While in the MICU the patient went
into atrial fibrillation with RVR to 150s. Her blood
pressure remained difficult to control. The patient was
started on a Diltiazem drip. She was then loaded with
Amiodarone. A trial of chemical conversion with Ibutilide
was attempted, but was unsuccessful. The patient continued
to be treated with Levo/Vanc. Gradually her blood pressure
became better controlled. The patient was transferred to the
floor. While on the floor it was noted that her right hand
had poor pulses and multiple ulcerations on her hand. This
was felt secondary to likely steel syndrome from her right AV
fistula. The patient had a dialysis catheter placed and the
patient was taken back to the Operating Room at which time
her right AV graft was ligated. During this time the patient
initially was unable to have significant dialysis due to
hypotension, however, as her blood pressure improved she was
able to tolerate longer times at dialysis. The patient
continued to improve clinically and was felt safe for
discharge on [**2168-11-17**]. The patient will continue Vancomycin
for a total of four to six weeks for likely intravascular
infection.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Infected AV graft.
2. Atrial fibrillation.
3. Hypotension secondary to sepsis.
4. Steel syndrome status post AV fistula ligation.
5. End stage renal disease.
6. Diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Quinine sulfate 325 po q Monday, Wednesday and Friday
before dialysis.
2. Neurontin 100 mg po q Monday, Wednesday and Friday after
dialysis.
3. Sevelamer 1200 mg po t.i.d.
4. Nephrocaps one tab q.d.
5. Protonix 40 mg q.d.
6. Aspirin 325 mg q.d.
7. Digoxin 0.125 mg po q Monday, Wednesday and Friday.
8. Xanax 0.5 mg po q.h.s.
9. Vancomycin dosed after dialysis for four more weeks.
10. Celexa 10 mg po q.d.
11. Amiodarone 400 mg po q.d.
12. Coumadin 1 mg po q.d. aiming for an INR between 2 and 3.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 284**]
for evaluation of her atrial fibrillation and possibility of
cardioversion. She is to follow up with her vascular surgeon
Dr. [**First Name (STitle) **] in two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**MD Number(1) 20316**]
Dictated By:[**Name8 (MD) 20317**]
MEDQUIST36
D: [**2169-7-12**] 09:14
T: [**2169-7-12**] 09:33
JOB#: [**Job Number 20318**]
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20,822
| 140,589
|
45915+58869
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-11-11**] Discharge Date: [**2173-11-30**]
Service: MED
Allergies:
Food Extracts
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Atrial fibrillation with rapid ventricular response.
Acute renal Failure
Major Surgical or Invasive Procedure:
Cardioversion times two ([**2173-11-12**] and [**2173-11-16**])
AV node ablation ([**2173-11-19**])
Pacemaker placement ([**2173-11-19**])
History of Present Illness:
[**Age over 90 **] year old man with a history of prostate cancer, stroke,
paroxysmal atrial fibrillation who was recently discharged to
[**Hospital 100**] rehab after an admission for frequent falls. He had a
history of atrial fibrillation during that recent admission;
however, he was not continued on anticoagulation due to frequent
falls. He was initially on digitalis, which was stopped due to
a question of MAT. While at [**Hospital 100**] rehab, he had an elevation
in his BUN and creatine. He was transfered to the [**Hospital1 **] emergency
department for evaluation of acute renal failure. In the ED, he
was found to be in atrial fibrillation with a heart rate to the
130s. The patient was assymptomatic without chest pain,
shortness of breath, or palpitations. In the ED, he was given 5
mg IV lasix times four, 10 mg IV labatelol times one, and 25 mg
PO lasix times one without any response in his heart rate. He
was admitted for rate control. On review of systems, the
patients notes a productive cough for one week but denies fever,
chills, nausea, or vomiting.
Past Medical History:
1. Embolic CVA: 10 years ago with resultant gait ataxia
2. Macular degeneration
3. Gout and pseudogout
4. Paroxysmal atrial fibrillation
5. History of prostate cancer
6. Questionable history of parkinsonism
7. Multiple falls
8. Right renal mass.
9. Depression
10. Dementia
11. Left cerebral subdural hemorrhage.
12. Multifocal Atrial Tachycardia
13. Sick Sinus Syndrome: Dr. [**First Name (STitle) **] cardiology
14. Left third toe cellulits: [**8-15**]
15. ?CAD: based on anterior wall motion abnormality on TTE
16. CHF: severely depressed EF
17. AR [**2-12**]+
18. MR 1+
Social History:
He is a retired endocrinologist. He lives with his wife in
[**Name (NI) 745**], but has been at the [**Hospital 100**] Rehab since his last
admission. They typically spend the [**Doctor Last Name 6165**] in [**State 108**]. He is
a non-smoker.
Family History:
Non-contributory
Physical Exam:
In the ED, his vital signs were temperature 96.5, heart rate
126, blood pressure 90/70, respiratory rate 20, and oxygen
saturation 99% 2 L nasal cannula. He was alert to person and to
place with an expressive aphasia. He had dry mucous membranes.
His cardiac exam had an irregular rate, tachycardic, with a
clear S1 and S2, no murmurs, rubs or gallops. He had a JVD of 7
cm. On pulmonary exam, he had left mid-lung crackles without
wheezes. His abdomen was soft, non-tender, nondistended, with
bowel sounds present. His extremeties were warm without
cyanosis, 2+ pitting edema bilaterally, and his distal pulses
were 2+ bilaterally.
Pertinent Results:
[**2173-11-11**] 06:40PM CK(CPK)-73
[**2173-11-11**] 06:40PM cTropnT-0.10*
[**2173-11-11**] 06:40PM GLUCOSE-253* UREA N-75* CREAT-2.5*#
SODIUM-134 POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-20* ANION GAP-23*
[**2173-11-11**] 06:40PM CALCIUM-8.4 MAGNESIUM-2.3
[**2173-11-11**] 06:40PM WBC-9.6# RBC-3.43* HGB-9.9* HCT-31.1* MCV-91
MCH-29.0 MCHC-32.0 RDW-15.8*
[**2173-11-11**] 06:40PM NEUTS-84.6* LYMPHS-9.1* MONOS-5.9 EOS-0.1
BASOS-0.2
[**2173-11-11**] 06:40PM PLT COUNT-230
[**2173-11-11**] 06:40PM PT-15.1* PTT-27.0 INR(PT)-1.4
[**2173-11-30**] 06:30AM BLOOD WBC-3.1* RBC-3.47* Hgb-9.8* Hct-29.8*
MCV-86 MCH-28.3 MCHC-33.0 RDW-15.7* Plt Ct-159
[**2173-11-29**] 06:30AM BLOOD WBC-3.1* RBC-3.51* Hgb-9.8* Hct-30.1*
MCV-86 MCH-28.0 MCHC-32.7 RDW-15.6* Plt Ct-161
[**2173-11-28**] 06:35AM BLOOD WBC-3.7* RBC-2.96* Hgb-8.6* Hct-25.3*
MCV-85 MCH-29.1 MCHC-34.0 RDW-16.1* Plt Ct-141*
[**2173-11-27**] 03:55PM BLOOD Hct-28.7*
[**2173-11-27**] 07:20AM BLOOD WBC-5.6 RBC-3.23* Hgb-9.2* Hct-27.9*
MCV-86 MCH-28.3 MCHC-32.9 RDW-16.2* Plt Ct-127*
[**2173-11-26**] 06:25AM BLOOD WBC-6.6 RBC-2.88* Hgb-8.2* Hct-25.0*
MCV-87 MCH-28.5 MCHC-32.9 RDW-16.5* Plt Ct-113*
[**2173-11-25**] 06:55AM BLOOD WBC-7.4 RBC-3.14* Hgb-8.9* Hct-27.3*
MCV-87 MCH-28.5 MCHC-32.8 RDW-16.4* Plt Ct-123*
[**2173-11-28**] 06:35AM BLOOD Plt Ct-141*
[**2173-11-27**] 03:55PM BLOOD PT-14.0* PTT-30.3 INR(PT)-1.2
[**2173-11-27**] 07:20AM BLOOD Plt Ct-127*
[**2173-11-26**] 06:25AM BLOOD Plt Ct-113*
[**2173-11-26**] 06:25AM BLOOD PT-14.3* PTT-29.7 INR(PT)-1.3
[**2173-11-25**] 06:55AM BLOOD Plt Ct-123*
[**2173-11-25**] 06:55AM BLOOD PT-14.3* PTT-28.3 INR(PT)-1.3
[**2173-11-24**] 08:30AM BLOOD Plt Ct-132*
[**2173-11-23**] 06:10AM BLOOD Plt Ct-143*
[**2173-11-22**] 06:05AM BLOOD Plt Ct-131*
[**2173-11-30**] 06:30AM BLOOD Glucose-112* UreaN-26* Creat-1.1 Na-140
K-3.6 Cl-104 HCO3-26 AnGap-14
[**2173-11-29**] 06:30AM BLOOD Glucose-110* UreaN-28* Creat-1.1 Na-140
K-3.8 Cl-104 HCO3-26 AnGap-14
[**2173-11-28**] 06:35AM BLOOD Glucose-107* UreaN-27* Creat-1.2 Na-139
K-3.7 Cl-102 HCO3-27 AnGap-14
[**2173-11-27**] 03:55PM BLOOD UreaN-28* Creat-1.2 K-4.3 Cl-102
[**2173-11-27**] 07:20AM BLOOD Glucose-111* UreaN-25* Creat-1.1 Na-140
K-3.9 Cl-103 HCO3-25 AnGap-16
[**2173-11-26**] 06:25AM BLOOD Glucose-152* UreaN-22* Creat-1.2 Na-141
K-3.7 Cl-104 HCO3-26 AnGap-15
[**2173-11-25**] 06:55AM BLOOD Glucose-130* UreaN-22* Creat-1.1 Na-141
K-4.2 Cl-102 HCO3-26 AnGap-17
----
[**2173-11-29**] 11:19 am URINE
URINE CULTURE (Pending):
----
[**2173-11-24**] 12:51 pm BLOOD CULTURE
**FINAL REPORT [**2173-11-30**]**
AEROBIC BOTTLE (Final [**2173-11-30**]): NO GROWTH.
[**2173-11-23**] 3:54 pm URINE
**FINAL REPORT [**2173-11-25**]**
URINE CULTURE (Final [**2173-11-25**]): <10,000 organisms/ml.
ANAEROBIC BOTTLE (Final [**2173-11-30**]): NO GROWTH.
----
Time Taken Not Noted Log-In Date/Time: [**2173-11-24**] 12:50 pm
BLOOD CULTURE
**FINAL REPORT [**2173-11-30**]**
AEROBIC BOTTLE (Final [**2173-11-30**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2173-11-30**]): NO GROWTH.
----
Date: [**2173-11-26**]
Signed by [**Last Name (NamePattern4) 57715**] [**Last Name (NamePattern1) 15102**], CCC-SLP on [**2173-11-26**]
Affiliation: [**Hospital1 18**]
Title: REPEAT BEDSIDE SWALLOWING EVALUATION
BEDSIDE SWALLOWING EVALUATION:
HISTORY:
Returned today to reattempt the consult for this [**Age over 90 **] year old man
who was admitted to [**Hospital1 18**] on [**2173-11-22**] for ARF and rapid
ventricular rate a-fib, dehydration and pna. PMH includes: CVA
[**79**]
yrs ago resulting in gait ataxia and dysarthria, PAF, h/o
prostate cancer, frequent falls, a question of Parkinsonism,
w/recent admit ([**2173-11-1**]) for multiple recent falls and for rehab
placement. Pt was d/c'ed to [**Hospital 100**] Rehab and readmitted from
there.
Wife reports that pt's communication at baseline was noted for
word finding deficits in conversation/sentences whereby pt would
become frustrated midsentence when unable to retrieve a word.
EVALUATION:
The examination was performed while the patient was seated
upright in the chair.
Cognition, language, speech, voice: Notably lethargic, only
maintain alertness when provided with tactile or auditory
stimulation routinely during the exam. Pt even falling asleep
with food/liquid in his mouth.
Pt not able to follow commands for oral motor exam, though he
was
able to react appropriately (when awake) to po's.
Pt's language was notable for perseverative jargon with
occasional words interspersed, but not appropriate to context.
Teeth:In fair condition
Secretions:mild dry mouth noted.
ORAL MOTOR EXAM:
Pt was unable to participate in exam. Face appeared symmetrical.
With mouth opening, able to assess gag which was present
bilaterally.
SWALLOWING ASSESSMENT:
PO swallowing assessment was conducted at lunchtime with purees,
thin liquids (tsp, cup, straw), and egg salad, with wife and
caretaker present. Oral transit was significantly prolonged at
times, however this was due to pt's lethargy, as he would fall
asleep with food/liquid in his mouth, and require cueing to
alert
and then continue swallowing.
Pt had prolonged chewing of egg salad, requiring 2-3 minutes to
finally clear it and then only after several straw sips of
liquid. Once swallowed, onliy minimal residue was appreciated in
the oral cavity. No residue noted with purees or with liquids,
again once the pt swallowed them.
Laryngeal elevation appeared to palpation and timely, when the
pt was awake. No overt cough, throat clear or change in vocal
quality noted however.
SUMMARY / IMPRESSION:
Pt is not demonstrating any overt s/s aspiration at b/s, however
the pt is NOTABLY LETHARGIC, and FALLS ASLEEP WITH FOOD/LIQUID
IN HIS MOUTH, placing him at risk for aspiration. Pt already has
1:1 aide present, and recommendations were discussed with both
pt's wife and aide. Pt will require cueing to remain alert
enough for him to swallow po's. However, given effort of
chewing,
this may actually increase fatigue and place him at further risk
for decreased po intake and falling asleep while eating. As
such, recommended ground solids at this time, but also
instructed pt's wife to select some softer/pureed items from
daily menus in the event pt's lethargy may make ground solids
too difficult.
Lastly, left a basic communication board with pt at b/[**Name Initial (MD) **] [**Name8 (MD) **] RN's
request, however the given pt's h/o macular degeneration and
current altered MS, he is not likely to engage in this as
alternate communication means.
RECOMMENDATIONS:
1.PO diet consistency of ground solids, thin liquids.
2.PO meds as tolerated, with purees or liquids.
3.1:1 assistance with meals.
4.Monitor pt closely to ensure that he is REMAINING AWAKE
while eating!!
5.Maintain basic aspiration precautions.
These recommendations were shared with the patient, nurse and
medical team.
----
Neurophysiology Report EEG Study Date of [**2173-11-27**]
OBJECT: [**Age over 90 **]-YEAR-OLD MAN WITH ATRIAL FIBRILLATION AND A PACEMAKER
WITH
A HISTORY OF APHASIA NOW WITH WORSENING APHASIA. EVALUATE FOR
SEIZURES.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Doctor Last Name **]
FINDINGS:
ABNORMALITY #1: There is mild to moderate amplitude,
intermittent mixed
theta and delta frequency slowing seen independently in the
fronto-central regions, more so on the right.
ABNORMALITY #2: There is occasional low amplitude generalized
delta
frequency slowing.
BACKGROUND: Is a [**8-19**] Hz frequency rhythm.
HYPERVENTILATION: Was not performed due to the patient's
clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Was not performed because the
study
was a portable study.
SLEEP: Normal transitions of the sleep architecture were not
seen.
CARDIAC MONITOR: Shows a wide complex rhythm with a rate of 90
bpm and
frequent ectopy.
IMPRESSION: This is a mildly abnormal portable EEG due to the
presence
of independent mixed delta and theta frequency slowing seen over
the
fronto-cental regions, more so on the right. This finding
suggests
subcortical dysfunction in the these regions and it is a
relatively non-specific finding with regard to an evaluation for
seizures. In addition, occasional low amplitude generalized
delta
frequency slowing was seen, which suggests deep midline
subcortical
dysfunction. No epileptiform abnormalities were seen. Note was
made of
a wide complex rhythm with ectopy on the cardiac monitor.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] W.
----
Brief Hospital Course:
Assessment and Plan:
[**Age over 90 **] year old former physician with [**Name Initial (PRE) **] history of prostate cancer,
stroke, paroxysmal atrial fibrillation who was recently
discharged to [**Hospital1 100**] REhabilition Center for the Aged after an
admission ofr frequent falls admitted with atrial fibrillation
in the setting of pneumonia. Atrial fibrillation was not
controlled with medical medical management and the improvement
of the patient's pneumonia, so the patient had AV nodal ablation
and placement of a dual chamber pacemaker. He was [**Hospital 35261**]
transferred from the cardiac care unit to the medicine service
for a change in mental status involving somnolence and worsened
aphasia which resolved after continuation of the medication
abilify.
*
1. Atrial Fibrillation: He had been documented to have been in
normal sinus rhythm at [**Hospital 100**] rehab within 48 hours prior to his
presentation to the [**Hospital1 **]. Therefore, he was deamed to be a
candidate for DC cardioversion. He was cardioverted on [**2173-11-12**]
and required 2 shocks at 300 J and 360 J to revert to sinus
rhythm. He was loaded with IV amiodarone at the time of
cardioversion. At that time, he became hypotensive and required
a dopamine drip for less than a day to maintain a MAP of 60. The
morning of [**11-13**], he reverted to atrial fibrillation. He was
continued on amiodarone at 400 mg twice a day with the goal on
re-trying a cardioversion once he was loaded with amiodarone. A
second cardioversion was performed on [**2173-11-16**]. He required two
shocks at 360 J to revert to sinus rhythm. He remained in sinus
rhythm until the morning of [**11-18**] when he reverted to atrial
fibrillation. At that time, his beta blocker was increased for
rate control. In order to improve quality of life and to
decrease the number of medications, an AV node ablation was
perfomed and a dual chamber pacemaker was placed on [**2173-11-19**].
Amiodarone and heparin were stopped at this time. His pacemaker
was programmed to pace at 80 bpm for the first month and he was
given 48 hours of vancomycin post-procedure.
*
2. Acute Renal Failure: On admission, he appeared
intravascularly dry on physical exam. His FENa was less than 1;
therefore, his ARF was thought to be pre-renal. He was gently
hydrated with 800 cc of IV fluids even though he had known poor
left ventricular function. His BUN and creatinine did not
significantly respond to the IV fluids. He was subsequently
started on a nesiritide drip due to an increase in CHF. His
acute renal failure improved with the nesiritide treatment over
the course of 3 days.
*
3. Heart Failure: On admission, he had evidence of mild
pulmonary edema on chest x-ray. The next day, he had evidence
of increased pulmonary edema. He was diuresed with a nesirite
drip and added IV lasix to reach a goal fluid balance of net
negative 1L each day. His CHF improved over the course of his
hospital stay. Once his pacemaker was placed, he was
transitioned from the nesiritide drip to an oral regimen of
lisinopril, furosemide, and aldactone.
*
4. Change in mental status: Later in his hospitalization, the
patient experienced mental status changes including excessive
somnolence, worsening Wernicke's aphasia and worsening
paraphasia and neologisms. Care was then transferred to the
general medicine team supervised by the gerontology service,
which felt that may have been related to the use of neuroleptic
medication, particularly Abilify. The mental status changes
were reminiscent of the patients recent stroke months prior to
admission and were thought to represent recrudescence of prior
stroke symptoms in the setting of illness. These mental status
changes resolved with discontinuation of Abilify. The neurology
service was consulted. Head CT documented stable, old left
lentiform nucleus lacunar infarction, no new acute stroke, and
no further change in a chronic bifrontal subdural hematoma that
had previously demonstrated small interval increase. Portable
EEG documented a mildly abnormal EEG likely suggestive of
subcortical dysfunction in the right fronto-central and deep
midline subcortical regions but was non-specific for an
evaluation of seizure. No epileptiform abnormalities were seen
on EEG. The patient had no signs or symptoms of meningismus and
an LP was not thought to be of clinical utility. It was also
considered that the patient might have a neuroleptic
hypersensitivity disorder, but this finding is often seen in the
context of [**Last Name (un) 309**] body dementia and the patient did not have
hallucinations, altered sleep-wake cycle, or other findings that
would support this diagnosis. Urine culture was only positive
for the presence of <10,000 organsims likely representing
colonization from prolonged Foley catheter placement. The foley
catheter was removed and replaced with a condom catheter to
assure appropriate quantification of urine.
*
6. Coronary Artery Disease: He has no history of coronary artery
disease. He ruled out with 3 sets of negative cardiac enzymes
on admission. He was continued on his outpatient dose of
aspirin.
*
7. Pneumonia: On initial presentation, he had focal rhonchi in
the left mid lung field with a productive cough. Although an
infiltrate was not present on the initial chest x-ray, he was
treated with a 10 day course of levofloxacin for a probable
pneumonia.
*
6. Hematuria: On [**2173-11-16**], he had gross hematuria without clots.
The foley was discontinued. A urine culture grew between 10,000
and 100,000 enterococcus that was sensitive to ampicillin and
vancomycin but resistent to levofloxacin. This was likely
secondary to colonization of the foley catheter; therefore, he
was not treated with antibiotics. However, after pacemaker
placement, he did receive 48 hours of vancomycin, which would
also have covered this asymptomatic bacturia.
*
7. Elevated Glucose: His finger-stick glucose ranged from
100-180 during his stay. He was maintained on an insulin
sliding scale to control his blood glucose levels. He was
started on a low dose of glucotrol XL and will require blood
sugar monitoring during the week following discharge to avoid
any hypoglycemia.
*
8. Left hand thrombophlebitis: Treated with a 2-day course of
vancomycin and later iwth a 5-day course of keflex, due to
finish [**2173-12-3**] after discharge to prevent any ascending
infection of an ipsilaterally place pacemaker.
*
9. Anemia: The patient was seen to have an equivocally positive
guiaic study of the stool but subsequent guiaic testing was
negative. KUB was ordered secondary to abdominal distention,
which later improved on an increased bowel regimen. The patient
was transfused twice to maintain a stable hematocrit of 27. He
was also started on an oral proton pump inhibitor to prevent
adverse effects of daily aspirin on the gastrointestinal mucosa.
His hematocrit stabilized thereafter. Hemolysis labs were
negative.
*
10. Right hand swelling. The patient developed right hand
swelling and hand radiography documented scapholunate advance
collapse (SLAC) fracture in the hand. Warm compress, elevation,
and pain management improved the condition which was considered
to be post-traumatic but chronic in nature.
*
11.Prostate Cancer: He was continued on his outpatient dose of
finasteride during this hospital admission.
*
12.Fluid, electrolytes, and nutrition: He was initially hydrated
since he was thought to be pre-renal. Subsequenlty, he was
found to be in CHF and was diuresed daily to a goal of -1L. He
required lowering of his phosphorous and repletion of potassium
and magnesium during this admission. He was kept on a diabetic
cardiac diet. Speech and swallow consultation documented that
the patient was safe to swallow ground solids and nectar
thickened liquids but needed frequent arousal often to prevent
falling asleep before swallowing. They also recommended
alternation between drinking and eating to prevent pocketing of
solids.
*
13.Prophylaxis: He had colace and senna as a bowel regimen. He
was on IV heparin for anticoagulation. He was on a PPI.
Aspiration precautions were maintained after the patient was
seen by speech and swallow consultation (see #11 above). The
patient was continued on heparin sc for venothromboembolism
considering that he was not ambulating and that this had a low
risk to worsen the patient's chronic subdural hematoma. Chronic
anticoagulation with warfarin or heparin was considered to not
be in the patient's long-term interest because of his fall risk
and because of the increased risk of these medications worsening
a chronic subdural hematoma.
.
During his admission, he was continued on he was continued on
his outpatient aripiprazole as well as a multivitamin.
*
14.Disposition: Physical therapy and occupational therapy
recommended acute inpatient rehabilitation and the patient was
discharged in improved and stable condition to [**Hospital **]
[**Hospital **] Hospital after whcih he may return to the [**Hospital1 100**]
Rehabilitaiton Center for the Aged. He has follow-up
appointments scheduled and will, however require glucose
monitoring in the week following discharge to monitor for
hypoglycemia following institution of glucotorl XL as above.
Medications on Admission:
1. Finasteride 5 mg PO QD (once a day).
2. Docusate Sodium 100 mg Capsule PO BID (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Pantoprazole 40 mg Tablet, Sig: One (1) Tablet, PO Q24H
(every 24 hours).
5. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
7. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO QD (once a
day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day.
9. Glipizide 2.5 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO QD (once a day): Please
monitor finger stick blood glucose four times daily for one week
starting [**2173-11-30**] to monitor for hypoglycemia.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing. neb
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for recent L hand cellulitis: last day is on
[**2173-12-3**]. D/C cephalexin afterwards.
14. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Atrial Fibrillation
Acute Renal Failure
Congestive Heart Failure
Pneumonia
Chronic subdural hematoma
Discharge Condition:
Stable and improved.
Discharge Instructions:
Please take all medications as prescribed.
Please check you weight daily. If your weight increases by more
than 3 pounds, contact your primary care physician.
Please monitor your blood sugars frequently within the first
week of discharge as you were recently started on an oral drug
to lower your blood sugars (glucotrol XL 2.5mg po daily).
Followup Instructions:
You are scheduled for the following appointment in the device
clinic ([**Telephone/Fax (1) 21817**]) to check you functioning of your
pacemaker:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2174-1-3**] 11:00
*
*
*
At the same time, you are also scheduled for follow-up in
cardiology clinic with Dr. [**Last Name (STitle) 284**]:
Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2174-1-3**] 11:00
*
*
*
You will need to make an appointment with your primary care
provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 713**] for 2 weeks after your discharge from the
rehabilitation hospital. Please call Dr.[**Name (NI) 1602**] office at
[**Telephone/Fax (1) 719**] to schedule this appointment.
*
*
Finallly, please be aware of the following appointment
previously scheduled for [**2174-8-12**]:
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 9486**] Date/Time:[**2174-8-19**] 11:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Name: [**Known lastname **],[**Known firstname **] B Unit No: [**Numeric Identifier 15606**]
Admission Date: [**2173-11-11**] Discharge Date: [**2173-11-30**]
Date of Birth: [**2079-3-4**] Sex: M
Service: MED
Allergies:
Food Extracts
Attending:[**First Name3 (LF) 11969**]
Chief Complaint:
as above
Major Surgical or Invasive Procedure:
Cardioversion times two ([**2173-11-12**] and [**2173-11-16**])
AV node ablation ([**2173-11-19**])
Pacemaker placement ([**2173-11-19**])
Brief Hospital Course:
influenza vaccine was administered to the patient prior to
discharge.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
Discharge Diagnosis:
Atrial Fibrillation
Acute Renal Failure
Congestive Heart Failure
Pneumonia
Chronic subdural hematoma
Discharge Condition:
Stable and improved.
Discharge Instructions:
Please take all medications as prescribed.
Please check you weight daily. If your weight increases by more
than 3 pounds, contact your primary care physician.
Please monitor your blood sugars frequently within the first
week of discharge as you were recently started on an oral drug
to lower your blood sugars (glucotrol XL 2.5mg po daily).
Please take all medications as prescribed.
Please check you weight daily. If your weight increases by more
than 3 pounds, contact your primary care physician.
Please monitor your blood sugars frequently within the first
week of discharge as you were recently started on an oral drug
to lower your blood sugars (glucotrol XL 2.5mg po daily).
Influenza vaccination was administered to the patient prior to
discharge.
Followup Instructions:
You are scheduled for the following appointment in the device
clinic ([**Telephone/Fax (1) 4004**]) to check you functioning of your
pacemaker:
Provider: [**Name10 (NameIs) 1727**] CLINIC Where: [**Hospital6 189**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 1728**] Date/Time:[**2174-1-3**] 11:00
At the same time, you are also scheduled for follow-up in
cardiology clinic with Dr. [**Last Name (STitle) 998**]:
Provider: [**First Name11 (Name Pattern1) 1197**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 189**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5898**] Date/Time:[**2174-1-3**] 11:00
You will need to make an appointment with your primary care
provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for 2 weeks after your discharge from the
rehabilitation hospital. Please call Dr.[**Name (NI) 15607**] office at
[**Telephone/Fax (1) 7151**] to schedule this appointment.
Finallly, please be aware of the following appointment
previously scheduled for [**2174-8-12**]:
Provider: [**First Name8 (NamePattern2) 1500**] [**Last Name (NamePattern1) 2197**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 189**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 15608**] Date/Time:[**2174-8-19**] 11:30
[**Name6 (MD) 73**] [**Name8 (MD) 72**] MD [**MD Number(2) 11970**]
Completed by:[**2173-11-30**]
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27122, 28530
|
2421, 2439
|
21620, 23375
|
26165, 26268
|
21072, 21597
|
26335, 27099
|
2454, 3095
|
25752, 25762
|
459, 1544
|
14909, 21046
|
1566, 2141
|
2157, 2405
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,898
| 198,009
|
41105
|
Discharge summary
|
report
|
Admission Date: [**2163-12-8**] Discharge Date: [**2163-12-26**]
Date of Birth: [**2098-1-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents / cefepime / vancomycin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hyopxia
Major Surgical or Invasive Procedure:
Tracheostomy placement [**12-16**]
History of Present Illness:
65-year-old male with a history of AAA repair with multiple
complications (operated in [**Month (only) 404**] by Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]),
including spinal ischemia with LE paralysis, bowel perforation
with colostomy, and right pleural effusion and perihepatic fluid
coming in with acute onset shortness of breath and hypoxia.
Patient developed acute onset of shortness of breath this
morning accompanied by pleuritic chest pain. No hemoptysis. No
history of blood clots, and he is on fondaparinox for
prophylaxis. He denies any fevers or chills.
.
The patient was admitted from [**10-26**] to [**11-1**] with a pleural
effusion and perihepatic fluid collection. He had a perihepatic
[**Month/Year (2) 19843**] placed by IR, with cultures growing clostridium species,
and the decision was to treat him with cipro, metronidazole and
fluconazole until the [**Month/Year (2) 19843**] was removed. He went to [**Hospital1 1872**]
rehab to continue the antibiotics.
.
In the ED, initial vs were: 98.7 114 124/59 22 96%
non-rebreather. UA suggested an infection, so he was given
ciprofloxacin. A CTA chest showed no PE, but tracheal secretions
causing plugging and possible infection, so the patient got
ceftriaxone and metronidazole. Transplant surgery requested a CT
abd/pelvis to see if his [**Hospital1 19843**] could be removed. He got [**4-1**]
liters of fluid. He was requiring a lot of suctioning for oral
secretions, so he was triaged to the MICU instead of the floor.
Prior to transfer he had 18g and 22g PIVs, vitals were 76 128/48
26 satting 98% on 50% O2 moistened air.
.
On the floor, patient tachypneic and uncomfortable.
Intermittently hypoxic down to the low 80s, requiring increasing
amounts of oxygen. He has no feeling below T8, so does not know
if he has dysuria, but does note his foley was changed 3-4 days
ago. His ostomy output is unchanged. Other ROS negative.
Past Medical History:
- AAA repair ([**1-/2163**]) c/b T8 paraplegia, bowel perforation with
graft infection and bacteremia/fungemia (bacteriodes, strep
pneumo and [**Female First Name (un) **]). On chronic suppressive medications with
suppressive antibiotics with ciprofloxacin, Flagyl and
fluconazole.
- complete heart block, now status post pacemaker placement
- Hypertension
- Hyperlipidemia
- COPD
- Osteoarthritis
- Increased PSA for which the patient underwent a biopsy prior
to [**2163-1-29**], which was complicated by an E. coli bacteremia
- s/p Trach for inability to clear secretions. Trach removed
about 3 weeks ago.
Social History:
Has 50 pack-year smoking history who stopped smoking prior to
his admission in [**Month (only) 404**]. He has a pet dog. He is married with a
very supportive wife and children. He works as a wine
distributor but is currently on disability and also retired a
year ago. Currently living at [**Hospital1 **] Rehabilitation
Center. No drugs or EtOH
Family History:
non-contributory
Physical Exam:
VS: 98.7 114 124/59 22 96% non-rebreather
General: Alert, oriented, anxious, moderate resp distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: course central breath sounds
CV: distant, regular, no audible murmurs
Abdomen: large, well-healed scars. G-tube in place, colostomy
with greenish discharge. Perihepatic [**Hospital1 19843**] in place with small
amt white fluid. Non-tender, non-distended, bowel sounds
present.
GU: foley in place
Ext: atrophied LE that are warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: A&Ox3, CNII-XII intact, no movement or sensation in the
LEs. Sensation and movement of UEs intact. Wound-vac in place
over left hip and sacrum.
Discharge:
VS 96.8, P: 61, BP: 126/60, RR: 16, 96% on trach mask
General: Alert, oriented, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD , trach in place
Lungs: scattered rhonchi
CV: distant, regular, no audible murmurs
Abdomen: large, well-healed scars. G-tube in place. Non-tender,
non-distended, bowel sounds present.
GU: chronic foley in place
Ext: atrophied LE that are warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema. Lateral L hip wound with clean
borders, wound vac currently off.
Neuro: A&Ox3, CNIII-XII intact, no movement or sensation in the
LEs. Sensation and movement of UEs intact.
Pertinent Results:
Admission labs:
[**2163-12-8**] 03:45PM GLUCOSE-115* UREA N-24* CREAT-0.4* SODIUM-137
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13
[**2163-12-8**] 03:45PM cTropnT-0.02*
[**2163-12-8**] 03:45PM WBC-17.5*# RBC-4.30* HGB-11.8* HCT-36.7*
MCV-85 MCH-27.4 MCHC-32.2 RDW-16.7*
[**2163-12-8**] 03:45PM NEUTS-86.0* LYMPHS-4.9* MONOS-6.9 EOS-1.8
BASOS-0.3
[**2163-12-8**] 03:45PM PLT COUNT-433
[**2163-12-8**] 03:45PM PT-13.2 PTT-33.8 INR(PT)-1.1
[**2163-12-8**] 03:59PM LACTATE-1.6
[**2163-12-8**] 06:13PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2163-12-8**] 06:13PM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2163-12-8**] 06:13PM URINE RBC-17* WBC-20* BACTERIA-FEW YEAST-NONE
EPI-0
[**2163-12-8**] 06:13PM URINE CA OXAL-RARE
Imaging:
[**2163-12-8**] AP Chest: FINDINGS: AP upright portable view of the
chest were obtained. No definite evidence of pneumothorax is
seen. There are right greater than left bibasilar opacities that
may be due to atelectasis, although consolidation is not
excluded. Blunting of the bilateral costophrenic angle suggests
trace bilateral pleural effusions. The cardiac and mediastinal
silhouettes are stable. A single-lead right-sided pacemaker is
unchanged in position.
CTA chest: IMPRESSION:
1. Large amount of secretions throughout the trachea and main
stem bronchi
with impaction of bronchi of the lower lobes and right middle
lobe. Increased atelectasis at both bases with small pleural
effusions. Given the elevated white blood cell count, there may
be a developing aspiration pneumonia, although the lower lobe
opacification is felt primarily due to atelectasis and volume
loss.
2. No evidence of pulmonary embolism.
CT Abd/Pelvis: IMPRESSION:
1. Interval near complete resolution of subphrenic perihepatic
collection
with residual tiny foci of air noted within.
2. Unchanged appearance to aortic graft without evidence of
infection.
3. Left greater than right bibasilar atelectasis. Cannot exclude
superimposed aspiration.
4. Status post left colectomy with colostomy.
5. Large anterior abdominal wall defect as before.
[**2163-12-23**] AP CXR: FINDINGS: In comparison with the study of
[**12-21**], the monitoring and support devices remain in place. Areas
of opacification are seen at both bases, similar to the previous
study on the right and probably decreased on the left.
Although this most likely represents atelectasis and effusion,
the possibility of supervening pneumonia would have to be
considered in the appropriate clinical setting.
Micro:
Multiple blood cultures all negative
[**2163-12-11**] Urine culture: SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- =>512 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Bronchoalveolar lavage:
GRAM STAIN (Final [**2163-12-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2163-12-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final [**2163-12-22**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2163-12-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
65-year-old male with a history of AAA repair with multiple
complications (operated in [**Month (only) 404**] by Dr. [**Last Name (STitle) **]), including
spinal ischemia with LE paralysis, bowel perforation with
colostomy, and right pleural effusion and perihepatic fluid
coming in with acute onset shortness of breath and hypoxia.
.
#. Secretions and hypoxia: Prior to admission, patient had had
increased secretions for the 3 days, exacerbating his chronic
difficulty clearing secretions. His tracheostomy had been
decannulated [**2163-11-18**]. The increase in secretions was likely the
result of infection, either bacterial or viral. He was afebrile,
but with an increased WBC count. Decision was made to cover
broadly with meropenem and linezolid for 10 days. He was treated
with maximal management of his secretions, including chest PT,
oral suctioning, adequate hydration, cough-assist device. He was
seen by speech and swallow, who felt that he did not have overt
aspiration. Blood and sputum cultures were all negative. Despite
treatment of a likely pneumonia, the patient continued to have
difficulty clearing his secretions. [**12-16**] the decision was made
to replace his tracheostomy tube, which was done by the
interventional pulmonary service without complications.
Afterwards, the patient continued to have hypoxia episodes
requiring intermittent mechanical ventilation. He required
frequent suctioning. Overall, his respiratory status slowly
improved, and by the time of discharge, he was requiring
suctioning every four hours, and was intermittently using the
Acapella cough assist device.
.
#. UTI: Patient had a positive UA on admission, and his culture
grew out enterobacter cloacae. His foley catheter was replaced.
He was initially treated with linezolid given a history of VRE,
but was covered with meropenem (along with his lung infection)
for 10 days.
.
# Perihepatic fluid collection: [**Month/Year (2) 19843**] had minimal drainage. On
admission, CT abdomen and pelvis showed resolution of the
perihepatic fluid collection, so the [**Month/Year (2) 19843**] was pulled. The
patient should follow-up with Dr. [**First Name (STitle) **], his surgeon, in one
month.
.
# Chronic aortic graft infection: Patient was continued on
fluconazole throughout the admission. His ciprofloxacin and
metronidazole were held while on meropenem, and afterwards
restarted. He has follow-up with Dr. [**Last Name (STitle) 6137**] in [**Hospital **] clinic
[**1-26**].
.
#. Nutrition: in the setting of intermittent respiratory
distress, the patient was not getting adequate POs, so his tube
feeds were increased to 85ccs/hr cycling from 6pm to 10am.
However, after his respiratory status improved, he passed his
speech and swallow test and again was taking a diet during the
day. His tube feeds were put back to 70cc/hr from 10pm to 6am.
.
# Chronic pain: continued gabapentin.
TRANSITIONAL ISSUES:
-trach sutures should be removed on [**12-30**]
-He has f/u outpt with surgery for perihepatic fluid
collection-[**1-8**]
Medications on Admission:
- Tylenol 650mg Q6hrs
- Ascorbic acid 500mg [**Hospital1 **]
- Cipro 500mg Q12hrs (suppressive dose)
- Vitamin D 50,000 units QTU
- ferrous sulfate 300mg [**Hospital1 **]
- fluconazole 200mg QHS
- fondaparinux 2.5mg daily
- gabapentin 200mg [**Hospital1 **]
- hydroxyzine 25mg Q6hrs PRN
- lisinopril 5mg daily
- lorazepam 0.5mg Q4hrs
- Mag Oxide 400mg daily
- metronidazole 500mg TID
- miconazole 2% powder TID
- MVI 1 tablet daily
- Zofran 4mg Q8hrs prn
- Percocet 1-2 tabs Q6hrs PRN
- Zinc 220mg daily
- paroxetine 20mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-4**]
hours as needed for fever or pain.
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
4. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five (5)
mL PO twice a day.
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
14. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. paroxetine HCl 10 mg/5 mL Suspension Sig: Twenty (20) mg PO
DAILY (Daily).
16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Health-care associated pneumonia
Inability to clear secretions requiring tracheostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure caring for you in the intensive care unit Mr.
[**Known lastname 1924**]. You were admitted with increased secretions, likely from
pneumonia. You were treated with 10 days of broad-spectrum
antibiotics. Because you continued to have frequent episodes
with low oxygen, your tracheostomy was replaced [**12-16**].
Your respiratory secretions have slowly improved and we think
you are ready to return to [**Hospital1 **] to work on getting
stronger.
While here you had your liver [**Hospital1 19843**] removed. You should follow
up with Dr.[**Name (NI) 670**] office within the next three or four
weeks.
Some changes were made to your medications. Your antibiotics are
back at the doses for chronic suppression of your aortic graft
infection. Your blood pressures have been normal, so we did not
restart your lisinopril. You did not require hydroxyzine or
Ativan while you were in the Hospital. You were started on
chlorhexidine to help with care of your tracheostomy. You can
get albuterol and ipratropium to help with your breathing.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: THURSDAY [**2164-1-26**] at 1:30 PM
With: URGENT CARE ID [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2164-2-23**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2164-2-23**] at 1:30 PM
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.**
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2164-2-23**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2164-2-23**] at 1:30 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2164-2-23**] at 1:30 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
-f/u outpt with surgery for perihepatic fluid collection-[**1-8**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"707.03",
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"996.62",
"707.24",
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
13762, 13834
|
8728, 11617
|
328, 365
|
13964, 13964
|
4775, 4775
|
15216, 17004
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3328, 3346
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13855, 13943
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3361, 4756
|
8650, 8650
|
8683, 8705
|
11638, 11761
|
281, 290
|
393, 2318
|
4791, 8613
|
13979, 14116
|
2340, 2949
|
2965, 3312
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,342
| 140,750
|
30429
|
Discharge summary
|
report
|
Admission Date: [**2113-5-14**] Discharge Date: [**2113-6-5**]
Date of Birth: [**2056-5-11**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Ancef
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
Laryngeal cancer
Major Surgical or Invasive Procedure:
Bronchoscopy, tracheal biopsy ([**5-15**])
Total Laryngectomy ([**5-23**])
History of Present Illness:
Patient is a 56 year old male who presented to [**Hospital 1727**] Medical
Center on [**5-8**] with stridor and respiratory distress. Prior to
presentation he had complained of 5 weeks of cough, shortness of
breath, and a sore throat for which he had been treated with
steroids and antibiotics without improvement. A laryngoscopy at
the OSH showed severe narrowing of the subglottic area and CT
scan showed a large laryngeal mass concerning for neoplasm. An
emergent trachestomy/bronchoscopy was done by the thoracic
surgery team and biopsy of the mass were sent. These biopsies
were suspicious for adenoid cystic carcinoma. Of note,
bronchial washings were sent which were positive for MSSA. He
was therefore started at cefazolin and transferred to [**Hospital1 18**] for
further care.
Past Medical History:
1. h/o sinus surgery
2. Chest tube placed [**2076**], unknown reason
3. LLE fracture after MVC [**2081**]
Social History:
Denies alcohol use
Smoked 1ppd tobacco for 30 years but quit 1 month prior to
presentation
Works as an electrician
Family History:
noncontributory
Physical Exam:
AVSS, 98% on 35% TM
NAD
OC/OP wnl, no obvious masses, symmetric palate elevation,
midline uvula, FOM soft
Normal anterior rhinoscopy. Nasopharynx with slight fullness on
right side. Patent ET bilaterally.
FOE: BOT appears symmetric, normal vallecula, crisp epiglottis.
Supraglottis appears slightly erythematous, no obvious mass
lesions are seen. Vocal cords have a small amount of abduction
bilaterally, but to a maximum of 2mm opening. No true vocal fold
lesions are seen but cannot rule out a submucosal thickening of
the posterior glottis. FOE via tracheotomy tube reveals
circumferential narrowing below tracheotomy tip, but patent
trachea and clear view to carina with no obvious massess.
Neck: supple, no LAD, 8 portex in place
CV: RRR
Lungs: CTA b/l
ABD: soft, NT, ND
Pertinent Results:
.......RADIOLOGY STUDIES:
...[**5-14**] CT TRACHEA
FINDINGS: A tracheostomy tube is present, with tip terminating
within the anterior tracheal lumen above the level of the aortic
arch.
The glottic, subglottic and proximal trachea appear diffusely
abnormal. Within the glottic and subglottic airway, diffuse soft
tissue thickening is present with narrowing of the airway lumen.
The thickening is most pronounced posteriorly and laterally and
results in luminal narrowing to approximately 4 mm in transverse
dimension by about 7-9 mm in the anterior dimension.
Additionally, in the proximal trachea at the level of the
thyroid gland, there is a more discrete 12 mm x 11 mm diameter
rounded intraluminal opacity. This is contiguous more inferiorly
with circumferential wall thickening. The tracheal walls remain
mildly thickened to approximately the level of the aortic arch.
Diffuse stranding is present throughout the adjacent
paratracheal fat, most prominent above the level of the aortic
arch, but continues in a milder degree below this level to the
subcarinal region. Increased number of mediastinal nodes are
present, but there are no individual nodes measuring greater
than 1 cm in diameter. Air is identified within the tracheal
soft tissues adjacent to the tracheostomy tube, as well as
within the adjacent subcutaneous tissues adjacent to the
pectoralis muscles, probably reflecting recent placement of the
tube. A small amount of pneumomediastinum is also present.
Multiple pulmonary emboli are present throughout the right
pulmonary arterial system, involving the origin of the right
middle lobe bronchus and extending into segmental branches, and
also involving the intralobar and proximal right lower lobe
pulmonary artery extending into segmental and subsegmental
arteries.
Within the lungs, extensive upper lobe predominant centrilobular
emphysema is present. Multiple peribronchiolar ground glass
nodular opacities are present in the superior segment of the
right lower lobe and a small solid 3-mm diameter left lower lobe
nodule (image 48, series 3) is also present, as well as an
additional 3 mm left lower lobe nodule laterally (imaged 220,
series 4).
Images obtained during dynamic expiration are suboptimal as the
patient did not appear to be able to cooperate with the
breathing instructions.
Trace right pleural effusion is present.
No suspicious lytic or blastic skeletal lesions are identified.
Multiplanar and 3D images confirm the presence of an
intraluminal mass and adjacent luminal narrowing as well as
circumferential thickening of the airway.
Additionally, on review of thin section axial images, there is
apparent partial destruction of the cricoid cartilage.
IMPRESSION:
1. Proximal tracheal intraluminal mass with contiguous
circumferential thickening of the airway extending proximal to
the level of the vocal cords. Apparent cricoid cartilage
destruction. Less prominent wall thickening below the mass
extending at least to the level of the aortic arch with
extensive stranding of the adjacent paratracheal fat. Findings
are concerning for circumferential involvement of adenoid cystic
carcinoma with associated extensive submucosal spread.
Correlation with bronchoscopy findings recommended.
2. Increased number of mediastinal nodes, without individual
nodes meeting size criteria for enlargement. Malignant
involvement is not excluded.
3. Acute pulmonary emboli in the right pulmonary arterial system
as described.
4. Two solid left lower lobe lung nodules, measuring less than 5
mm in diameter. Although potentially benign, early foci of
metastatic disease cannot be excluded. Attention to these on a
three-month followup CT may be helpful.
5. Peribronchiolar ground glass nodules superior segment of
right lower lobe, likely due to aspiration or early infection.
6. Small right pleural effusion.
.
...[**5-15**] CHEST PA/LAT:
The patient is diagnosed with adenoid cystic carcinoma of the
trachea. Tracheostomy is in place with its tip projecting 8.4 cm
above the carina. The heart size and the mediastinal contours
are unremarkable. The lungs are clear. There is no pleural
effusion. The sub 5-mm left lower lobe nodules diagnosed on the
chest CT are below the resolution of this chest radiograph.
IMPRESSION: No evidence of pneumonia. Tracheostomy in place.
Known adenoid cystic carcinoma of upper trachea.
.
...[**5-15**] BRONCHOSCOPY
DESCRIPTION OF PROCEDURE: The patient was consented and
topical lidocaine was given in the oropharynx in the usual
fashion. The bronchoscope was inserted via the mouth. On
inspection of the posterior pharynx there was diffuse tissue
infiltration throughout with crowding of the airway. The
vocal cords were visible only on deep inspiration. Their
movement through the inspiratory cycle could not be well
visualized. The scope was not inserted past the vocal cords
via that approach. The bronchoscope was removed and then
reinserted via the tracheostomy. The airways were normal in
appearance grossly distal to the tracheostomy. On
endotracheal ultrasound immediately distal to the
tracheostomy there was diffuse tracheal infiltration. An
endobronchial biopsy was taken x2 at the carina as well as on
the right and on the left just distal to the trach. There was
some mild oozing after the biopsy which spontaneously
resolved. The patient did well throughout the procedure.
OVERALL IMPRESSION:
1. Diffuse posterior pharyngeal tissue infiltration.
2. Diffuse tracheal thickening by ultrasound.
.
...[**5-17**] BILATERAL LOWER EXTREMITY ULTRASOUND:
No prior studies for comparison. Bilateral [**Doctor Last Name 352**]-scale and
Doppler son[**Name (NI) 867**] were performed of the common femoral,
superficial femoral, and popliteal veins. On the right, there is
noncompressible thrombus within the right popliteal vein, which
is only partially occlusive. There appears to be a small amount
of flow traversing flow on the sagittal images. The right common
femoral and superficial veins compress normally with normal
flow, waveforms, and augmentation. On the left, there is no
evidence of noncompressible veins and all veins demonstrate
normal flow, waveforms, and augmentation.
IMPRESSION:
1) Near occlusive right popliteal thrombus.
2) No DVT in the left lower extremity.
.
...[**5-18**] IVC FILTER PLACEMENT:
PROCEDURE: Doctors [**Name5 (PTitle) **] and [**Name5 (PTitle) 380**] performed the procedure.
Prior to the procedure, informed consent was obtained. A
preprocedure timeout was performed. The patient was prepped and
draped in standard sterile fashion. After multiple attempts, the
right common femoral vein was entered under ultrasonographic
guidance with a micropuncture needle. Prior to cannulation of
the femoral vein, the femoral artery was entered with hemostasis
achieved by manual compression. A 0.035 [**Last Name (un) 7648**] guide2wire was
advanced into the inferior vena cava under fluoroscopic
guidance. The micropuncture needle was exchanged for a sheath,
and contrast run was performed which showed a prominent draining
vein in the lower IVC. The renal veins were shown to drain at
the level of the inferior endplate of L2. There was no evidence
of duplication of the inferior vena cava. The large draining
vein in the left lower IVC was later cannulated with a C1 Cobra
catheter with contrast injection demonstrating this to be a
prominent lumbar vein. Thus, there was no evidence of
circumaortic or duplicated renal vein. Decision was then made to
place the IVC filter at the level of the draining renal vein, at
the inferior endplate of L2. Under fluoroscopic guidance, a Bard
recovery IVC filter was placed at this level. Hemostasis was
achieved by manual compression.
ANESTHESIA: Moderate sedation was achieved via the
administration of 50 mcg of fentanyl and 2 mg of Versed given in
divided doses throughout the intraservice time of 55 minutes.
The patient's hemodynamic parameters were monitored throughout.
IMPRESSION:
1. Normal IVC-gram
2. Successful placement of a Bard recovery filter in an
infrarenal vein location.
.
...[**5-30**] ECHOCARDIOGRAM:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Overall left ventricular systolic function is normal (LVEF>55%).
Tissue
Doppler imaging suggests a normal left ventricular filling
pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal.
The aortic root is moderately dilated athe sinus level. The
ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
...[**5-31**] BARIUM SWALLOW STUDY:
BARIUM ESOPHAGRAM: Optiray contrast passes freely through the
esophagus. There is no aspiration into the airway, and no
significant retention in the valleculae or pyriform sinuses is
seen. There is no evidence of active extravasation to suggest a
leak in the area of surgery. Once this was determined, thin
barium was also administered to the patient in AP and lateral
views and again no aspiration or leak at the area of surgery was
identified.
IMPRESSION: No evidence of esophageal leak in the region of
recent surgery.
.
.
.......PATHOLOGY
SPECIMEN SUBMITTED: CERVICAL ENDOBRONCHIAL AND PROXIMAL TRACHEA
ENDOBRONCHIAL BXS (2).
Procedure date Tissue received Report Date Diagnosed
by
[**2113-5-15**] [**2113-5-15**] [**2113-5-18**] DR. [**Last Name (STitle) **]. BROWN/lfb
DIAGNOSIS:
A. Carina, endobronchial biopsy: Respiratory mucosa with acute
and chronic inflammation and focal squamous metaplasia with mild
to moderate atypia. No carcinoma seen.
B Proximal trachea, endobronchial biopsy: Respiratory mucosa
with acute and chronic inflammation and focal squamous
metaplasia with mild to moderate atypia. No carcinoma seen.
.
SPECIMEN SUBMITTED: Consult slides from [**Hospital 1727**] Medical Center
Procedure date Tissue received Report Date Diagnosed
by
[**2113-5-19**] [**2113-5-19**] [**2113-5-22**] DR. [**Last Name (STitle) **]. BROWN/lfb
Previous biopsies: [**Numeric Identifier 72343**] CERVICAL ENDOBRONCHIAL AND
PROXIMAL TRACHEA ENDOBRONCHIAL
DIAGNOSIS:
Tracheal biopsy: Low grade carcinoma with adenoid cystic
features. See note.
Note: Although the overall architectural and cytologic features
are most suggestive of adenoid cystic carcinoma, the tumor shows
very focal squamous differentiation which is not typical of
adenoid cystic carcinoma. Another tumor which can occur in this
area and mimic adenoid cystic carcinoma on a small biopsy
specimen is a basaloid squamous cell carcinoma, although they
usually show more atypia, mitotic activity and necrosis than we
see in this case. Biopsy slides were reviewed with Drs. [**Last Name (STitle) 9885**],
[**Name5 (PTitle) **], [**Name5 (PTitle) 10165**], [**Doctor Last Name **] and [**Doctor Last Name **]. Cytology was reviewed by Dr.
[**Last Name (STitle) 10165**], who felt the findings were consistent with adenoid
cystic carcinoma.
.
SPECIMEN SUBMITTED: SUBGLOTTIC LARYNX FS, LEVEL 3 LYMPH
NODE-NECK, LARYNX FS, LEVEL 2 LYMPH NODE NECK LEFT.
Procedure date Tissue received Report Date Diagnosed
by
[**2113-5-23**] [**2113-5-23**] [**2113-6-4**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/nbh
Previous biopsies: [**Numeric Identifier 72344**] Consult slides.
[**Numeric Identifier 72343**] CERVICAL ENDOBRONCHIAL AND PROXIMAL TRACHEA
ENDOBRONCHIAL
DIAGNOSIS:
1. Larynx, subglottic, biopsy (A):
Carcinoma, most consistent with adenoid cystic carcinoma.
2. Lymph nodes, left neck level 3, dissection (B-C):
No carcinoma identified in nine lymph nodes (0/9).
3. Lymph nodes, left neck level 2, dissection (D):
No carcinoma identified in two lymph nodes (0/2).
4. Larynx, laryngectomy (E-AG):
A. Carcinoma, most consistent with adenoid cystic carcinoma
with focal squamous differentiation, larynx. See note.
B. No carcinoma identified in two lymph nodes (0/2).
C. Larynx with extensive squamous metaplasia and chronic
inflammation.
D. Skin and trachea with changes consistent with
tracheostomy site.
E. Unremarkable thyroid gland (left lobe).
F. Parathyroid tissue.
Note:
The tumor is subglottic in location and measures 3.4 x 1.4 cm;
the microscopic depth of invasion is 1.1 cm. The tumor invades
into the cricoid cartilage. There is ossification of this
cartilage and tumor involves the bone at this site. There is a
focus suspicious for lymphovascular invasion. No definitive
perineural invasion is identified. The resection margins are
free of tumor; the tumor is within 1 mm of the posterior soft
tissue margin. The pathologic stage for this subglottic tumor
is T4a.
The main differential diagnosis of this tumor is an adenoid
cystic carcinoma with squamous differentiation versus a basaloid
squamous cell carcinoma. The larynx shows extensive squamous
metaplasia and chronic inflammation, however, no squamous
dysplasia/carcinoma in situ is identified.
Immunohistochemical stains performed on a section of tumor show
the tumor cells are positive for cytokeratin cocktail
(AE1:AE3/CAM 5.2), smooth muscle actin, calponin, and p63. CEA
(unabsorbed) shows rare positivity of some squamous cells as
well as rare ductal-type structures. S-100 protein is
non-contributory due to high background staining.
Based on the tumor morphology and results of the
immunohistochemical studies (particularly cytokeratin and actin
positivity), this tumor is interpreted to be an adenoid cystic
carcinoma with squamous differentiation. In the absence of a
similar tumor elsewhere, this tumor is compatible with a
laryngeal primary, as adenoid cystic carcinoma may occur in the
larynx/trachea.
Sections of the tumor (H&E slides) have been reviewed by Dr. [**Last Name (STitle) **].
[**Doctor Last Name 10165**].
Brief Hospital Course:
Mr. [**Known lastname 72345**] was transferred from [**Hospital 1727**] Medical Center to [**Hospital1 18**]
on [**5-14**] to the Interventional Pulmonology service. On arrival he
was continued on the cefazolin for presumed pneumonia based on
MSSA in a BAL. A CT trachea was done which confirmed a 4mm x
8mm proximal tracheal intraluminal mass. In addition, multiple
pulmonary emboli on the right were noted as well as two solid
LLL lung nodule, benign in appearance. For details, please see
the CT report. He was immediately started on a heparin drip
with a goal PTT between 60 and 80 for the pulmonary embolus. A
bronchoscopy was one by the IP service showing diffuse posterior
pharyngeal tissue infiltration and diffuse tracheal thickening
by ultrasound. For details, please see the operative report.
An ENT consult was obtained and a total laryngectomy was
recommended for T4Nx laryngeal cancer, suspiscious for adenoid
cystic carcinoma.
In preperation for the procedure, b/l lower extremetiy
ultrasounds were done to search for a cause for the pulmonary
embolus. No DVT was noted in the left leg, but a near occlusive
popliteal dvt was noted in the right. Therefore, an IVC filter
was placed by interventional radiology in anticipation of being
off anticoagulation for several days during the immediate
postoperative period. The heparin drip was stopped 6 hours
prior to the procedure and restarted afterwards. He tolerated
this procedure well, for details please see the operative
report. In addition a medicine consult was obtained for
preoperative risk assessment. No further testing was
recommended, however they recommended restarted the heparin drip
postoperatively once surgically safe and to discharge him on
lovenox. Perioperative beta-blockers were not recommended.
Prior to the surgery, the patients pathology, including the
biopsies from [**Hospital 1727**] Medical Center, were reviewed at our
institution. The tracheal biopsies taken during the
bronchoscopy at sites distal to the mass were consistent with
respiratory mucosa with acute and chronic inflammation, and
focal squamous metaplasia. No cancer was seen in these
biopsies. The biopsies of the mass taken at the OSH were
reviewed as well and were felt to show features most consistent
with adenoid cystic carcinoma, although basaloid squamous cell
carcinoma could not be ruled out. Regardless, a total
laryngectomy was felt to be the necessary treatment.
He was therefore transferred to the ENT service and on [**5-23**]
he underwent a total laryngectomy with modified left neck
dissection. His heparin drip was stopped 6 hours prior to the
procedure. He tolerated the procedure well and was extubated,
for details please see the operative report. Post-operatively
he was initially transferred to the ICU for close monitoring.
He was kept NPO with a dilaudid pca for pain, and clindamycin
and levofloxacin for perioperative prophylaxis. He was
transferred out of the ICU on POD2 and started on tube feeds
through a dobhoff tube placed intraoperatively. In addition he
was evaluated by speech therapy who began teaching him how to
use an electrolarynx. On POD3 the heparin drip was restarted
and the pain service was consulted for continuing pain not
controlled by the PCA. They intially recommended adding
neurontin and later recommended adding a fentanyl patch for
continued pain.
On POD6 Mr. [**Known lastname 72345**] began complaining of worsening dyspnea and
faintness. He then developed atrial fibrillation with RVR, with
a rate of 150-200. He was given IV lopressor x 2 with no effect
and a cardiology consult was obtained. He was then given IV
diltiazem and became hypotensive with a SBP of 70. He was
transferred to the ICU where he was started on an amiodarone gtt
and given several fluid boluses with good blood pressure
response. That evening he returned to sinus rhythm and became
normotensive. He continue to do well until POD8 when developed
nausea and emesis, possibly related to the amiodarone which was
therefore stopped. In discussion with cardiology, it was felt
that the episode of atrial fibrillation was a one time event and
was unlikely to happen again. However, they did recommend [**5-19**]
weeks of treatment with a beta-blocker. He was started on 25mg
lopressor [**Hospital1 **] which he tolerated well without any signs of
hypotension.
He continued to remain in sinus rhythm and was transferred
out of the ICU on POD 9. Potassium, magnesium, and calcium
levels were checked daily after the episode of atrial
fibrillation. His potassium level ranged from 3.6-3.8 requiring
potassium supplementation daily. He will therefore be
discharged home with potassium supplements. A barium swallow
study was obtained at this time which did not show an esophageal
leak or tracheoesophageal fistula. He was therefore started on
a clear liquid diet which was slowly advanced. At the time of
discharge, POD 13, he was tolerating a regular diet without
difficulty.
Prior to discharge he was transitioned from IV heparin to
lovenox 80mg subcutaneous injections [**Hospital1 **]. These will need to be
continued indefinetly. He was seen by physical therapy prior to
discharge and cleared to go home. He will be visited at home by
a VNA for respiratory care and assistance with tracheal stoma
care. In addition, a suction device was arranged to be
delivered to his home. He will follow up with Dr. [**First Name (STitle) **] from
ENT 1 week after discharge. The laryngectomy tube will be left
in place for 1 month postoperatively to prevent narrowing of the
stoma. The stoma stitches and staples were removed prior to
discharge. In addition, he will follow up with his primary care
physician for management of the lopressor and lovenox. Finally,
he will follow up with Dr. [**Last Name (STitle) 3929**] from radiation oncology
regarding future radiation therapy.
Medications on Admission:
At Home: None
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringes* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*400 ML(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab PO once a day.
Disp:*30 tabs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**] SACO
Discharge Diagnosis:
Laryngeal Cancer s/p total laryngectomy
Pulmonary Embolus
Deep Vein Thrombosis
Postoperative atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
Call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101.4F, persistent
nausea, pain not relieved by pain medications, worsening redness
or discharge from incision, shortness of breath, wheezing, chest
pain, or other symptoms concerning to you.
Do not swim or take baths. You may shower. Do not drive while
taking pain medications.
Continue all medications as prescribed. Continue to take the
iron supplements and metoprolol until instructed by your primary
care physician to discontinue their use. Please follow up with
your primary care physician soon after discharge in order to
determine the need for continuation of the lopressor.
A visiting nurse will visit you home and a suction setup will be
delivered to your home.
Completed by:[**2113-6-5**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,592
| 177,031
|
33974
|
Discharge summary
|
report
|
Admission Date: [**2201-6-26**] Discharge Date: [**2201-7-2**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
no neurosurgical procedures were done
History of Present Illness:
HPI: The pt is an 85 year-old gentleman with a history of
Parkinson's disease who presented to the ED after a fall.
The pt was not able to give a history at the time of my
encounter. Therefore, the following is per the ED staff.
Apparently, the pt was last seen well around 11pm. His wife
found
him at approximately 3am in the bathroom lying on the floor with
a laceration above the left eye. EMS was called and he was
brought to the [**Hospital1 18**] ED for evaluation. No EMS trip sheet was
left in the ED.
Past Medical History:
PMHx:
Parkinson's disease
colon cancer
prostate ca
malignant melenoma
lung cancer
Social History:
Social Hx: Lives with wife. Otherwise unknown.
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM:
O: T: 98.5F BP: 185/66 HR: 86 R 12 O2Sat 98% 2L
Gen: WD/WN, comfortable.
HEENT: Laceration over left eye. MM slightly dry.
Neck: In hard collar.
Lungs: Transmitted upper airway sounds bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert. Regards examiner inconsistently.
Does not speak nor attempt to answer questions. Does not follow
commands. Says "ouch" to pain.
Cranial Nerves:
I: Not tested
II: Left pupil 3mm to 2mm and reactive. Right pupil 2.5mm to 2mm
and reactive. Blinks to treat bilaterally.
III, IV, VI: Extraocular movements appear intact bilaterally.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Unable to test.
XII: Tongue midline.
Motor: Normal bulk throughout. Relatively high amplitude, low
frequency tremor of upper extremities at rest with cogwheeling
bilaterally. Unable to formally test strength due to mental
status, but moves all extremities spontaneously, though does not
briskly withdraw to pain.
Sensation: Grimaces to pain in all four extremities.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 0
Left 1 1 1 1 0
Plantar response flexor on the left, extensor on the right.
Coordination: Unable to test.
Pertinent Results:
Labs notable for WBC of 15.3 and Hct of 59.4. Chemistry pending.
CT: Bifrontal SAH R >> L. SDH layering on top of the tentorium.
?
of facial fractures (but not ideally imaged)
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2201-6-28**] 2:47 AM
CHEST (PORTABLE AP)
Reason: worsening sputum production
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with SAH
REASON FOR THIS EXAMINATION:
worsening sputum production
ADDENDUM:
Findings were communicated to Dr. [**Last Name (STitle) **] over the phone by Dr.
[**Last Name (STitle) **] at the time of dictation.
REASON FOR EXAMINATION: Increased sputum production in a patient
with subarachnoid hemorrhage.
PORTABLE AP CHEST RADIOGRAPH WAS COMPARED TO [**2201-6-26**], AND
CHEST CT FROM [**2201-6-26**].
The heart size is normal. There is no change in mediastinal
contour. There is also unchanged appearance/mild improvement of
lingular consolidation, but new opacity in the right lower lobe
is demonstrated, which might be consistent with developing
infection/aspiration. The known right upper lobe spiculated
lesion is again demonstrated suspicious for pneumonia as well as
the right apical lesion, which was described on the recent CT
torso but not optimally visualized on the current radiograph.
The retrocardiac atelectasis is again noted.
The ET tube tip is 8 cm above the carina. The NG tube tip is in
the proximal stomach.
IMPRESSION:
New right lower lobe opacity, which might be consistent with
developing pneumonia/aspiration.
Unchanged lingular consolidation.
Known right upper lobe lesions concerning for neoplasm.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: MON [**2201-6-29**] 9:29 PM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2201-6-27**] 11:08 AM
CT HEAD W/O CONTRAST
Reason: assess for interval change.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with SAH, SDH.
REASON FOR THIS EXAMINATION:
assess for interval change.
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 85-year-old male with subarachnoid hemorrhage, subdural
hemorrhage. Assess for interval change.
COMPARISON: [**2201-6-26**].
TECHNIQUE: Contiguous axial images of the head were obtained
without IV contrast.
FINDINGS: There has been no significant interval change in the
diffuse subarachnoid hemorrhage seen within the cortical sulci
as well as a layering hemorrhage within the lateral ventricles
bilaterally. No new foci of hemorrhage are identified. The
ventricular system is unchanged in size from the prior study.
There is no edema, shift of normally midline structures, or
acute major vascular territorial infarction. Again demonstrated
is a small amount of prominent right extra-axial space, which
could represent a small subdural hygroma on the right, similar
in appearance to [**2201-6-26**]. Visualized paranasal sinuses
demonstrate fluid within the sphenoid sinuses bilaterally, as
well as mucosal thickening of the left maxillary sinus. Osseous
structures are unremarkable. There is soft tissue hematoma
overlying the left frontal region.
IMPRESSION:
1. No significant change in the subarachnoid and
intraventricular hemorrhage compared to [**2201-6-26**] at 2:15
p.m.
2. Stable small right frontal extra-axial fluid collection,
likely reflecting a hygroma.
3. Left soft tissue hematoma overlying the left frontal region.
4. Mild sinus disease as noted above.
Cardiology Report ECG Study Date of [**2201-6-26**] 3:44:54 AM
Sinus rhythm. Right bundle-branch block with left anterior
fascicular
block. Baseline artifact makes interpretation difficult. No
previous tracing
available for comparison.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 158 134 366/418 80 -80 69
([**-8/3121**])
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2201-6-26**] 3:46 AM
CT HEAD W/O CONTRAST
Reason: FOUND DOWN, LAC ON FOREHEAD. ? BLEED.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with found down in bathroom with lac on
forehead, increasingly unresponsive.
REASON FOR THIS EXAMINATION:
bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 85-year-old male found down with laceration on
forehead.
COMPARISONS: None.
TECHNIQUE: MDCT axial images were obtained through the brain
without intravenous contrast. Multiplanar reconstructions were
performed.
FINDINGS: Rounded hyperdense material is seen along the right
frontal falx, and right tentorium consistent with subdural
hematoma. There is linear high- attenuation material tracking
within sulci in the bilateral frontal lobes and right sylvian
fissure consistent with subarachnoid hemorrhage. There is
prominence of the ventricles and sulci consistent with
age-related involutional change. There is no shift of the
normally midline structures, or major vascular territorial
infarct. Periventricular and subcortical white matter
hypodensities consistent with sequela from chronic microvascular
ischemia. There is a moderate soft tissue hematoma along the
superior margin of the left orbit. No radiopaque foreign bodies
are seen. Multiple hyperdense fluid levels are seen within the
sphenoid, ethmoid and left maxillary sinus likely representing
blood products. Small amount of fluid is also noted within the
frontal sinus. Findings are concerning for underlying fractures
and a facial bone CT is recommended for further
characterization.
IMPRESSION:
1. Subdural and subarachnoid hemorrhage as above. No evidence
for shift of midline structures or hydrocephalus.
2. Moderate left frontal soft tissue hematoma and multiple fluid
levels in the paranasal sinuses, concerning for underlying
fractures. A facial bone CT is recommended for further
characterization.
3. Atrophy.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13248**] at 4:00 am on
the date of dictation.
RADIOLOGY Final Report
CT C-SPINE W/O CONTRAST [**2201-6-26**] 3:47 AM
CT C-SPINE W/O CONTRAST
Reason: FOUND DOWN
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with found down in bathroom with lac on
forehead, increasingly unresponsive.
REASON FOR THIS EXAMINATION:
fx?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 85-year-old male found down with laceration on
forehead.
COMPARISON: Noncontrast head CT performed concurrently.
TECHNIQUE: MDCT axial images were obtained through the cervical
spine without intravenous contrast. Multiplanar reconstructions
were performed.
FINDINGS: There is no evidence of fracture or subluxation. No
prevertebral soft tissue abnormality is seen. There are
moderately severe multilevel degenerative changes characterized
by loss of intervertebral disc space height, cystic change and
marginal osteophyte formation most prominent at C5-6, C6-7 and
C7-T1. A 7 mm spiculated nodule is seen in the right lung apex.
Please refer to the accompanying torso CT (clip #[**Clip Number (Radiology) 78462**]) for
additional details.
IMPRESSION: No evidence of fracture or subluxation. Multilevel
degenerative change.
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2201-6-26**] 3:48 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: FOUND DOWN, HX CA. ASSESS FOR INJURY.
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with found down in bathroom with lac on
forehead, increasingly unresponsive. Has CA and may have PE as
cause of syncope.
REASON FOR THIS EXAMINATION:
PE? injury?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 85-year-old male found down with forehead
laceration. The patient has history of cancer and there is
concern for possible pulmonary embolism as cause of syncope.
TECHNIQUE: MDCT axial images were obtained through the chest
prior to and following administration of intravenous Optiray
contrast. Additional delayed images were obtained through the
abdomen and pelvis. Multiplanar reconstructions were performed.
CT CHEST WITHOUT AND WITH IV CONTRAST: No filling defects are
seen within the pulmonary arterial vasculature to indicate an
underlying pulmonary embolus. The thoracic aorta is normal in
caliber without evidence for dissection or aneurysmal
dilatation. There are coronary artery calcifications and
moderate calcified atheroma throughout the aortic arch. A right
paratracheal lymph node measures 1.1 cm in short axis. A
subcarinal node measures up to 2 cm in short axis. There is no
mediastinal or hilar lymphadenopathy. The proximal esophagus
appears dilated and air-filled, measuring up to 3 cm tapering
distally. The lungs demonstrate moderate changes of
centrilobular emphysema with upper lobe predominance. A large
spiculated mass is present in the right lung apex measuring
approximately 6.0 x 2.2 cm concerning for underlying carcinoma.
A 1.0 cm pulmonary nodule is present in the right apex. Nodular
soft tissue is also seen adjacent to surgical chain sutures in
the left upper lobe which could reflect tumor recurrence at a
site of prior wedge resection (series 2A image 43). There is
moderate nodular ground-glass opacity in the lingula and at the
left base representing an inflammatory or infectious etiology
such as aspiration. There is no pericardial or pleural effusion.
CT ABDOMEN WITH IV CONTRAST: There are multiple subcentimeter
hypodensities throughout the liver parenchyma, which are too
small to characterize. Layering sludge is seen within the
gallbladder. There is no evidence for gallbladder wall edema or
pericholecystic fluid to indicate acute cholecystitis. The
pancreas is atrophic. The spleen, adrenal glands, and
unopacified loops of bowel are grossly unremarkable. The kidneys
enhance symmetrically and excrete contrast normally. A low
attenuation 3 cm lesion in the upper pole of the right kidney is
compatible with a cyst. A 1-cm and 1.5 cm cystic lesion in the
mid right and lower left kidney respectively do not meet CT
criteria for a simple cyst and are incompletely characterized.
The ureters are not dilated. There is no free intraperitoneal
fluid or air. Small mesenteric and retroperitoneal lymph nodes
not not meet criteria for pathologic enlargement.
Atherosclerotic plaque is seen throughout the aorta. The celiac
axis, SMA, [**Female First Name (un) 899**], and renal arteries are opacified normally. There
is a right- sided aorto- fem bypass graft.
CT PELVIS WITH IV CONTRAST: Multiple surgical clips are seen in
the pelvis from previous prostatectomy. The bladder is
moderately distended. A large amount of stool is present
throughout the rectum and sigmoid colon. No inguinal or pelvic
lymphadenopathy is evident. No free fluid is seen in the cul-
de- sac.
BONE WINDOWS: No fractures are seen. There is a destructive
lytic lesion involving the left iliac [**Doctor First Name 362**] with cortical
disruption concerning for a metastatic focus. A lucent area is
also seen in the greater trochanter of the right femur. There
are moderate degenerative changes throughout the thoracic and
lower lumbar spine.
IMPRESSION:
1. No evidence of pulmonary embolus, aortic dissection or
traumatic injury within the chest, abdomen and pelvis.
2. 1.0 cm right upper lobe nodule, spiculated mass in the right
upper lobe and nodular thickening along chain sutures in the
posterior superior left lung concerning for carcinoma.
Correlation with outside studies and medical history is
recommended.
3. Nodular ground-glass opacity in the lingula and left lower
lobe, which could reflect an evolving infectious inflammatory
process or aspiration.
4. 1.5 cm cystic lesions in the kidneys which do not meet CT
criteria for a simple cyst. If clinically indicated, further
evaluation with renal ultrasound could be performed when the
patient's condition allows.
5. Cholelithiasis without evidence for acute cholecystitis.
6. Destructive lytic lesion in the right femoral greater
trochanter and left iliac [**Doctor First Name 362**] concerning for osseous
metastases. Bone scan could be performed if indicated to assess
for additional foci of osseous metastasis.
RADIOLOGY Final Report
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2201-6-26**] 5:31 AM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: ?fracture
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with fall.
REASON FOR THIS EXAMINATION:
?fracture
CONTRAINDICATIONS for IV CONTRAST: None.
CT SINUS WITHOUT CONTRAST, [**2201-6-26**]
HISTORY: Fall. Question fracture.
Contiguous axial images were obtained through the paranasal
sinuses. No contrast was administered. No prior sinus imaging
studies are available for comparison. Comparison to a head CT
scan of [**2201-6-26**] at 4 a.m.
FINDINGS: Again identified is an air-fluid level in the left
maxillary sinus with air-fluid levels in the sphenoid sinuses
bilaterally. The ethmoid air cells are partially opacified, and
there is minimal mucosal thickening or fluid in the frontal
sinus. No fractures are identified. No other osseous
abnormalities are identified. The middle turbinates are
partially aerated bilaterally. There are [**Last Name (un) 36826**] type II fovea
ethmoidalis bilaterally.
CONCLUSION: Partial opacification of the paranasal sinuses as
described above with an air-fluid level in the left maxillary
sinus and in the sphenoid sinuses.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2201-6-26**] 6:07 AM
CHEST (PORTABLE AP)
Reason: s/p intubation. please check tube placement.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with recent intubation
REASON FOR THIS EXAMINATION:
s/p intubation. please check tube placement.
INDICATION: 85-year-old man with recent intubation, evaluate for
tube placement.
COMPARISON: CT from [**2201-6-26**].
BEDSIDE RADIOGRAPH OF CHEST, SUPINE: ET tube is terminating 5.8
cm above the carina. NG tube is extending into the stomach,
looped on itself with tip within the gastric fundus.
Tiny nodular right upper lobe opacity was better seen on the
recent study. Additionally, 1.7 x 2 cm spiculated right upper
lobe subpleural opacity only partially reflects the larger
subpleural lesion well visualized on the recent CT. There is
mild oligemia consistent with emphysema. There is no pleural
effusion or pneumothorax. Faint left mid lung opacity likely
reflects aspiration/infection. Heart size is normal. There is no
pulmonary edema. There is no pneumothorax.
IMPRESSION:
1. Right upper lobe spiculated nodular foci as described above
only partially visualized on the current study and were better
evaluated on the recent CT torso.
2. ET tube is terminating 5.8 cm above the carina.
3. Faint left mid lung opacity, likely infectious.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2201-6-26**] 6:07 AM
CHEST (PORTABLE AP)
Reason: s/p intubation. please check tube placement.
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with recent intubation
REASON FOR THIS EXAMINATION:
s/p intubation. please check tube placement.
INDICATION: 85-year-old man with recent intubation, evaluate for
tube placement.
COMPARISON: CT from [**2201-6-26**].
BEDSIDE RADIOGRAPH OF CHEST, SUPINE: ET tube is terminating 5.8
cm above the carina. NG tube is extending into the stomach,
looped on itself with tip within the gastric fundus.
Tiny nodular right upper lobe opacity was better seen on the
recent study. Additionally, 1.7 x 2 cm spiculated right upper
lobe subpleural opacity only partially reflects the larger
subpleural lesion well visualized on the recent CT. There is
mild oligemia consistent with emphysema. There is no pleural
effusion or pneumothorax. Faint left mid lung opacity likely
reflects aspiration/infection. Heart size is normal. There is no
pulmonary edema. There is no pneumothorax.
IMPRESSION:
1. Right upper lobe spiculated nodular foci as described above
only partially visualized on the current study and were better
evaluated on the recent CT torso.
2. ET tube is terminating 5.8 cm above the carina.
3. Faint left mid lung opacity, likely infectious.
Brief Hospital Course:
Pt was seen in the emergency room s/p fall for SAH and SDH over
tentorium. Pt admitted to the ICU. He was intubated for airway
protection in the ED for decreased sats to 85% and treated for
pneumonia. He was started on dilantin for sz prophylaxis. He
was supported in the ICU and his serial CT scans of the brain
had improved. CT of chest and pelvis showed: 1.0 cm right upper
lobe nodule, spiculated mass in the right upper lobe and nodular
thickening along chain sutures in the posterior superior left
lung concerning for carcinoma. A Destructive lytic lesion in the
right femoral greater trochanter and left iliac [**Doctor First Name 362**] concerning
for osseous metastases and a renal mass was also noted.
His mental status improved slightly over the course of his
stay. However his overall medical condition is very
deconditioned metastic cancer his family decided to make the pt
[**Name (NI) 3225**] after discussion with the pts PCP and Oncologist. On [**7-1**] a
morphine drip was started and sinamet via NG was continued. The
patient died on [**7-2**] at 1550 surrounded by his family.
Medications on Admission:
Medications prior to admission: Unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid hemorrhage
subdural hematoma
Respiratory Failure
Pneumonia
Lung cancer
Malignant melenoma
prostate cancer
colon cancer
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2201-7-2**]
|
[
"852.00",
"486",
"873.42",
"V66.7",
"V10.05",
"197.0",
"518.81",
"E888.9",
"198.5",
"V10.46",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19559, 19568
|
18334, 19439
|
227, 267
|
19744, 19753
|
2383, 2693
|
19806, 19935
|
996, 1005
|
19530, 19536
|
17150, 17189
|
19589, 19723
|
19465, 19465
|
19777, 19783
|
1035, 1314
|
19497, 19507
|
183, 189
|
17218, 18311
|
295, 809
|
1491, 2364
|
1329, 1475
|
831, 915
|
931, 980
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,926
| 141,128
|
46866
|
Discharge summary
|
report
|
Admission Date: [**2162-8-20**] Discharge Date: [**2162-8-25**]
Date of Birth: [**2102-12-29**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Hydromorphone
Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 59 yo male w/ h/o metastatic pancreatic cancer s/p
partial whipple (aborted due to diffuse disease) w/ open
cholecystectomy and gastrojejunostomy in [**2161-8-14**] s/p 6 cycles
of gemzar/cisplatin
who presented to [**Hospital **] hospital on [**2162-8-19**] w/ melena. Pt
complained of dark, tarry stools for three to four days before
presentation to the hospital. In addition, he described having
epigastric pain. Hct on arrival to the OSH was 21.5, for which
he received 2 units of pRBC's, most recent Hct was 26.2 prior to
transfer. He underwent endoscopy at [**Hospital **] hospital today where
he was found to have a large ulcer with a bleeding artery at
gastro-jejunal junction that was clipped x 4 (one clip fell off)
and injected with epi with good hemostasis. During the EGD, SBP
were in the 70s briefly, returning to baseline following the
procedure.
[**Hospital **] hospital would like the pt transferred to the [**Hospital1 18**] ICU
in the event that he re-bleeds as they have no angio backup.
On arrival at [**Hospital1 18**] the pt is comfortable after having a bowel
movement.
Past Medical History:
metastatic pancreatic Ca s/p partial whipple (aborted due to
diffuse disease), s/p open cholecystectomy and gastrojejunostomy
[**8-14**]
- s/p 6 cycles of gemzar/cisplatin
- GERD
- anxiety/depression
- hernia s/p repair x 2
Social History:
Occasional EtOH, denies smoking or elicit drug use.
Married, lives with wife and daughter.
Family History:
Father - colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 98.8 BP: 142/78 P: 85 R: 24 18 O2: 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, minimal tenderness to palpation throughout the
abdomen, non-distended, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8, 104/73, 67, 18, 99%RA
General: awake, no acute distress, flattened affect
HEENT: Sclera anicteric, oropharynx clear
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, minimal tenderness to palpation throughout the
abdomen, non-distended, bowel sounds present, no organomegaly
Neuro: CNII-XII grossly intact
Pertinent Results:
ADMISSION LABS:
[**2162-8-20**] 09:38PM BLOOD WBC-7.2# RBC-3.92* Hgb-12.6* Hct-36.1*
MCV-92# MCH-32.2* MCHC-35.0 RDW-15.0 Plt Ct-85*#
[**2162-8-20**] 09:38PM BLOOD PT-11.5 PTT-25.0 INR(PT)-1.1
[**2162-8-20**] 09:38PM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-135
K-3.5 Cl-103 HCO3-24 AnGap-12
[**2162-8-20**] 09:38PM BLOOD ALT-37 AST-27 LD(LDH)-157 AlkPhos-79
TotBili-1.6*
[**2162-8-20**] 09:38PM BLOOD Albumin-3.9 Calcium-8.2* Phos-3.1 Mg-1.8
DISCHARGE LABS:
[**2162-8-25**] 06:53AM BLOOD WBC-5.1 RBC-3.44* Hgb-11.0* Hct-33.1*
MCV-96 MCH-32.0 MCHC-33.2 RDW-14.9 Plt Ct-114*
[**2162-8-25**] 06:53AM BLOOD Glucose-96 UreaN-6 Creat-0.8 Na-137 K-4.2
Cl-104 HCO3-30 AnGap-7*
[**2162-8-25**] 06:53AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 99440**] is a 59 yo M w/ metastatic pancreatic cancer s/p
partial whipple (aborted due to diffuse disease) w/ open
cholecystectomy and gastrojejunostomy in [**2161-8-14**] s/p 6 cycles
of gemzar/cisplatin who presented to OSH on [**2162-8-19**] w/ melena
and was transfered to [**Hospital1 18**] for further management and possible
IR intervention.
#GI bleed- Endoscopy at OSH on [**8-19**] showed an arterial bleed at
the site of gastro-jejunal anastomosis. The artery was
successfully clipped/injected with epi. Pt's Hct is now stable
(36 on arrival) s/p 2 units of PRBC's at the OSH. He had no
further episodes of bleeding while in the hospital and did not
require any further transfusions. He was hemodynamically stable
and monitored for 24 hours prior to being transferred to the
floor. He was treated with IV pantoprazole drip, which was
converted to PO pantoprazole after 72 hours. Upon discharge his
hematocrit was stable at 33, and he was having normal bowel
movements. He was able to tolerate a full diet upon discharge.
# Non-Sustained Ventricular Tachycardia: Had two episodes of
NSVT during which time his other vitals were stable and he was
asymptomatic. His lytes were carefully monitored and
aggressively repleted, and his hematocrit was trended.
#Hx of pancreatic cancer: No management changes were made. Creon
was given when the patient took full liquids and regular diet.
#Sundowning: In the ICU he was agitated overnight, however did
not pull on lines and was not violent. The most likely cause of
this was ICU delerium and deliriogenic medications used for
pain control and anxiety.
#Anxiety: Patient was continued on ativan 0.5-1mg PRN for
anxiety
#Pain control: Patient was continued on home regimen for pain
control, as he is allergic to dilaudid.
TRANSITIONAL ISSUES
- Blood cultures pending
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
2. Oxycodone SR (OxyconTIN) 60 mg PO TID
3. Lorazepam 1 mg PO Q4H:PRN anxiety
4. Omeprazole 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Docusate Sodium 100 mg PO BID
3. Pancrelipase 5000 1 CAP PO TID W/MEALS
RX *lipase-protease-amylase [Pancrelipase 5000] 5,000
unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit [**Unit Number **] capsule(s) by mouth three times a
day Disp #*90 Capsule Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 1 TAB PO BID:PRN constipation
6. Lorazepam 1 mg PO Q4H:PRN anxiety
7. Oxycodone SR (OxyconTIN) 60 mg PO TID
8. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
9. Aspirin 81 mg PO DAILY
10. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: GI bleed
Secondary: Pancreatic cancer
Pancreatic insufficiency
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 99440**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were hospitalized here because of your upper
GI bleed. While you were here, you were treated supportively
with IV fluids, pain medications, and anti-nausea medications.
Additionally, while you were here you had a couple of episodes
where your heart rate went very high for a few seconds. This is
called Non-Sustained Ventricular Tachycardia. During these
episodes, your other vital signs were normal, and you were
asymptomatic. This is most likley due to electrolyte
abnormalities and your recent GI bleed. Your electorlytes were
closely monitored and repleted as needed, and your hematocrit
remained stable. Please discuss these episodes with your PCP and
outpatient oncologist.
Additionally, you will need to have a repeat endoscopic
evaluation of your esophagus, stomach, and small intestine in 8
weeks. This will be performed by Dr. [**Last Name (STitle) **] at [**Hospital **] Hospital.
You will need to follow-up with him as directed below. Prior to
your follow-up endoscopy, it is important that you continue to
take omeprazole 40 mg by mouth twice a day. This medication
works to decrease the acid secretion in your stomach, and will
help your ulcer to heal.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S
Address: [**Apartment Address(1) 99441**], [**Location (un) **],[**Numeric Identifier 4770**]
Phone: [**Telephone/Fax (1) 3149**]
Appointment: Tuesday [**2162-8-31**] 3:00pm
Name: [**First Name4 (NamePattern1) 99442**] [**Last Name (NamePattern1) **]
Location: [**Location (un) 1121**] GI
Address: 100 [**Doctor Last Name **] Center [**Apartment Address(1) 99443**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Numeric Identifier 26668**]
Phone: [**Telephone/Fax (1) 88022**]
Appointment: Thursday [**2162-9-2**] 10:45am
*This is a follow up appointment for your hospitalization. You
will reconnect with your Gastroenterologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
after this visit.
Department: SURGICAL SPECIALTIES
When: MONDAY [**2162-11-15**] at 11:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2162-8-25**]
|
[
"427.1",
"300.00",
"534.40",
"197.7",
"577.8",
"287.5",
"197.6",
"157.9",
"198.89",
"799.4",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6535, 6541
|
3733, 5584
|
294, 300
|
6690, 6690
|
2980, 2980
|
8138, 9248
|
1809, 1833
|
5923, 6512
|
6562, 6669
|
5610, 5900
|
6841, 8115
|
3439, 3710
|
1873, 2559
|
248, 256
|
328, 1432
|
2996, 3423
|
6705, 6817
|
1455, 1681
|
1697, 1792
|
2584, 2961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,065
| 135,510
|
9507
|
Discharge summary
|
report
|
Admission Date: [**2200-1-23**] Discharge Date: [**2200-1-31**]
Date of Birth: [**2125-5-11**] Sex: M
Service: SURGERY
Allergies:
Lisinopril / Cozaar / Losartan Potassium
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Descending aortic ulcer
Major Surgical or Invasive Procedure:
Descending aortic ulcer s/p TAG [**2200-1-28**]
History of Present Illness:
74M w/ PVD s/p aorto-bifem by [**Doctor Last Name **] in '[**96**], ESRD on HD,
about a week ago during dialysis mentioned that he had been
having some chest and back pain, not too severe that comes and
goes. IN [**Hospital1 **] they got a CT scan to r/o any acute pathology
and found a descending aortic ulcer, 18mm, around T10-T11. Was
sent
into [**Location (un) 86**] to [**Hospital1 2177**] (their referring center) for further BP and
surgical management, then tx here to [**Hospital1 18**] because is a patient
of Dr[**Name (NI) 5695**]. Currently feels well without any complaints.
Denies any n/v/f/c/d/c/SP or BA pain currently.
Past Medical History:
Diastolic CHF (normal LVEF on TTE in [**12/2198**])
moderate mitral regurgitation
COPD
PVD
L renal artery stenosis
Chronic kidney disease (baseline creatinine [**3-25**])
Anemia of chronic kidney disease
hx H.pylori infection
hx of cellulitis
Gout
Colonic polyps
h/o herpes zoster
Claudication
Carotid Stenosis
Social History:
Lives in [**Hospital1 392**] alone, has meals delivered. Quit smoking 3
months ago, used to smoke +1ppd x 50 yrs, no etoh x many years,
no drugs.
Family History:
Non-contributory
Physical Exam:
T: 99,3 P: 76 BP: 118/42 RR: 13 Spo2 93%
Gen: NAD
Neuro: Alert and oriented x 3
Resp: CTA b/l
CV: RRR
Abd: soft, nt, nd
Pulses: palpable through-out
Left AV fistual +thrill/bruit
Pertinent Results:
[**2200-1-31**] 05:25AM BLOOD WBC-22.5* RBC-3.11* Hgb-10.8* Hct-31.4*
MCV-101* MCH-34.7* MCHC-34.4 RDW-15.6* Plt Ct-421
[**2200-1-31**] 05:25AM BLOOD Plt Ct-421
[**2200-1-31**] 05:25AM BLOOD Glucose-103 UreaN-53* Creat-6.6*# Na-133
K-4.4 Cl-91* HCO3-28 AnGap-18
[**2200-1-31**] 05:25AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.8
[**2200-1-29**] 01:41AM BLOOD calTIBC-185* Ferritn-945* TRF-142*
Name: [**Known lastname 32335**], [**Known firstname 412**]
Unit No: [**Numeric Identifier 32336**]
Service:
Date: [**2200-1-29**]
Date of Birth: [**2125-5-11**]
Sex: M
Surgeon:
CO-SURGEONS: Drs. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 914**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
ASSISTANTS: Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] and [**First Name4 (NamePattern1) 11805**] [**Last Name (NamePattern1) 29316**].
PREOPERATIVE DIAGNOSES:
1. Symptomatic descending thoracic aortic penetrating
ulcer.
2. Hypertension.
3. Chronic renal failure on hemodialysis.
4. Peripheral vascular disease status post an
aortobifemoral bypass graft by Dr. [**Last Name (STitle) **].
PROCEDURES:
1. Repair of descending thoracic aortic penetrating ulcer
with [**Doctor Last Name 4726**] TAG Endo graft 34 x 100 mm. The [**Doctor Last Name 4726**] graft
data is the following; catalog number
[**Serial Number 32337**], lot number [**Serial Number 32338**].
2. Thoracic aortography.
3. Repair of aortobifemoral bypass graft.
The patient is a 77-year-old gentleman with history of back
pain and thoracic CT scan showed a penetrating
atherosclerotic ulcer with no associated intramural hematoma.
The patient had continued back pain despite good medical
management of his hypertension. The patient was referred to
Dr. [**Last Name (STitle) **] for consideration of repair. After evaluating
the patient, Dr. [**Last Name (STitle) **] asked me to consider a combined
approach for an Endo graft repair of the descending thoracic
aortic pathology. The patient understood the risks, benefits
and possible alternatives including but not limited to
bleeding, infection, myocardial infarction, stroke, death,
renal and pulmonary insufficiency as well as the
possibility of paraplegia and blood transfusion and future
operations on his aorta and agreed to proceed. All questions
were answered to his satisfaction prior to proceeding with the
surgery.
OPERATIVE FINDINGS: Thoracic aortography in a cross-table
lateral position showed that there was a fairly large
penetrating ulcer in the mid descending thoracic aorta.
Thoracic aortography performed after deployment of the stent
graft showed that there was initially a type 1 Endo leak, but
after additional balloon profiling a repeat thoracic
aortography showed that there was no type 1 Endo leak and
good positioning of the prosthesis and no filling of the
penetrating ulcer.
DESCRIPTION OF PROCEDURE IN DETAIL: After informed consent
was obtained, the patient brought in the operating room and
placed in supine position. General endotracheal tube
anesthesia was achieved without difficulty as well as full
hemodynamic monitoring. The patient's abdomen, chest and
groins, and upper legs were prepped and draped in the usual
sterile fashion. A 9-French left femoral venous sheath was
placed for anesthesia due to the inability to place a line in
the neck. Once this was done the right femoral dissection
was performed exposing the native circulation (common femoral
artery) as well as the right limb of the aortobifemoral both
proximally and distally. Proximal and distal control was
obtained of the graft in the right groin. The left femoral
artery was then accessed using a micropuncture technique and
a 5-French sheath was placed in the left limb of the
aortobifemoral and a pigtail catheter advanced over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
wire into the descending thoracic aorta under fluoroscopic
guidance. An 8-French sheath was then inserted after
heparinizing the patient with 5000 units of heparin into the
right limb of the aortobifemoral. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] wire was then
advanced into the descending thoracic aorta, Kumpe catheter
was exchanged over the [**Location (un) **] wire and a stiff Lunderquist
wire was then placed over the Kumpe catheter into the proximal
descending thoracic aorta. The Kumpe catheter was withdrawn
and serial dilators were then used to dilate the right limb
of the aortobifemoral up to a 24-French dilator. Initially
we had planned to use a 37 x 100 mm [**Doctor Last Name 4726**] TAG device, however,
the
24-French sheath that was necessary to deliver this would not
advance into the right limb of the aortobifemoral graft and
therefore, we chose to use a 34 x 100 mm graft and the 22-French
sheath was then advanced over the Lunderquist wire into the
right limb of the aortobifemoral bypass graft. Once this was
done the 34 x 10 [**Doctor Last Name 4726**] TAG device was then advanced over the
Lunderquist wire with some difficulty, but ultimately passed
fairly smoothly. The [**Doctor Last Name 4726**] TAG device was positioned in the
descending thoracic aorta and aortography was then performed
in the cross-table lateral orientation to observe the
posteriorly directed penetrating ulcer. Once the ulcer was
identified the TAG device was then positioned so that the
ulcer was in the middle of the device. We then deployed the
TAG graft and profile ballooned the device with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 32339**]
balloon. Once this was done, repeat thoracic aortography was
performed which showed a type 1 Endo leak from the proximal
seal zone, we therefore profile ballooned the proximal
landing zone several times and repeated the thoracic
aortography which revealed that there was no evidence of an
Endo leak at this time. All catheters and sheaths were then
removed from the right limb of the aortobifemoral graft and
the graft was then closed with a running 5-0 Prolene stitch.
The left-sided femoral sheath was then removed. The patient
was then taken to the cardiothoracic surgical intensive care
unit in stable condition.
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 914**] were co-surgeon's on this case
due to the complex nature of the disease process. The new
technology
of stent grafting requires two separate but equally important
skill sets of
both the cardiothoracic surgeon and vascular surgeon to
safely facilitate deployment of these grafts.
Brief Hospital Course:
[**2200-1-23**]
Transferred from OSH for descending aortic ulcer. BP stable.
Repeat CT scan done on transfer. Nephrology consulted for ESRD
on HD.
[**2200-1-24**] Vitals, BP stable. CTA showed aortic ulcer. Underwent HD.
Pre-op'ed for an Endovascular repair.
[**2200-1-25**]
VSS. Cardiac Surgery consulted, recommended echo and pre-op
cardiac clearance. Pt continued on HD MWF. Renal following
[**2200-1-26**]
Vitals stable. No acute events. OR scheduled for Tuesday [**2200-1-28**].
Close monitoring for BP control
[**2200-1-27**]
Pre-op'ed for Endovascular repair of thoracic aneurysm. Pain
management for Left flank pain. HD today. No acute events.
[**2200-1-28**]
To OR (see attached op report). Tolerated procedure well without
complications. Transfer to ICU on nitro gtt.
[**2200-1-29**]
Vitals table. Neo weaned. Lopressor po started. Transferred to
VICU. Lumbar drain intact. Left groin site stable without
hematoma or bleed.
[**2200-1-30**]
Stable on floor status. Cleared by physical therapy. OOB
ambulating. Dispo planning.
[**2200-1-31**]
DC home without need for VNA services.
Medications on Admission:
norvasc 10; Hydralazine 25'"; ASA 81, allopurinol 100',
atorvastatin 20, imdur 30', iron 325', folic acid, (recently on
prednisone 20' for gout flare)
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Methylprednisolone 2 mg Tablet Sig: One (1) Tablet PO once ()
for 1 doses: Take 6mg (three tablets) on [**2200-1-31**], Take 4mg (2
tablets) on [**2200-2-1**], Take 2mg (1tablet) on [**2200-2-2**] take 1mg ([**1-22**]
a tablet). Then stop .
Disp:*8 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): Take as needed at home
.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
hx: Cardiomyopathy (transient EF now normal 60%)
Hypertension
CRF on HD
Gout
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Thoracic Aneurysm Repair Discharge Instructions
Medications:
?????? Take Aspirin 81mg 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 [**2-23**]
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 [**4-27**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2200-2-27**] 8:00
Please call Dr.[**Name (NI) 5695**] office [**Telephone/Fax (1) 3121**] to arrange an
office visit in 2 weeks. You will have a CTA prior to your
office visit.
Completed by:[**2200-1-31**]
|
[
"428.0",
"441.2",
"585.6",
"425.4",
"496",
"428.30",
"274.9",
"285.21",
"443.9",
"V45.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.49",
"39.73",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
11152, 11158
|
8431, 9530
|
325, 375
|
11279, 11288
|
1791, 8408
|
13989, 14339
|
1555, 1573
|
9731, 11129
|
11179, 11258
|
9556, 9708
|
11312, 13290
|
13316, 13966
|
1588, 1772
|
261, 287
|
403, 1041
|
1063, 1375
|
1391, 1539
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,610
| 195,419
|
37792
|
Discharge summary
|
report
|
Admission Date: [**2111-8-30**] Discharge Date: [**2111-9-2**]
Date of Birth: [**2086-5-5**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
APAP overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
25 MTF transgender, admitted on [**2111-8-30**] with APAP overdose. She
took "a whole bottle of tylenol, >100" at 11pm on [**8-29**] because
she was feeling "flu like symptoms." She called EMS post
ingestion and was taken to ED.
.
In the ED, initial vital signs BP:131/73 HR:87 O2%98%. Given
APAP level of 225 patient started on NAC 150mg/hr over 1 hr. She
also received total 3L NS. APAP trended down to 194 over first
four hours. While patient on commode her pressure transiently
dropped to 80's and she became unresponsive to sternal rub. She
was intubated for airway protection. BP came back up to 130's
systolic.
.
In the MICU, NAC continued with appropriate decrease in levels.
Level negative this AM. Transaminases decreasing and coags
normal. Psych following, section 12ed. Patient has code word in
order to pass information due to domestic violence concerns.
Past Medical History:
none
Social History:
Lives in a shelter. Possible history of domestic violence.
Family History:
nc
Physical Exam:
Vitals: T:96.4 BP:120/62 P:75 R: 12 O2: 99% RA*
General: Sedated, intubated, responds to light sternal rub by
moving upper and lower extremities
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
labs on admission:
[**2111-8-30**] 12:10AM BLOOD WBC-6.9 RBC-3.83* Hgb-12.9 Hct-37.7
MCV-99* MCH-33.8* MCHC-34.3 RDW-12.9 Plt Ct-182
[**2111-8-30**] 12:10AM BLOOD Neuts-54.4 Lymphs-31.9 Monos-5.4 Eos-7.3*
Baso-1.0
[**2111-8-30**] 12:10AM BLOOD Glucose-131* UreaN-8 Creat-0.9 Na-137
K-4.0 Cl-105 HCO3-22 AnGap-14
[**2111-8-30**] 12:10AM BLOOD ALT-68* AST-57* AlkPhos-66 TotBili-0.3
[**2111-8-30**] 12:10AM BLOOD Albumin-4.3
[**2111-8-30**] 12:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-225*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
tylenol trend:
[**2111-8-30**] 12:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-225*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2111-8-30**] 03:10AM BLOOD Acetmnp-194.7*
[**2111-8-30**] 05:15AM BLOOD Acetmnp-178.0*
[**2111-8-30**] 10:33AM BLOOD Acetmnp-105*
[**2111-8-30**] 04:36PM BLOOD Acetmnp-17.9
[**2111-8-30**] 10:43PM BLOOD Acetmnp-NEG
[**2111-8-31**] 04:44AM BLOOD Acetmnp-NEG
LFT trend:
[**2111-8-30**] 12:10AM BLOOD ALT-68* AST-57* AlkPhos-66 TotBili-0.3
[**2111-8-30**] 03:10AM BLOOD ALT-83* AST-91* LD(LDH)-103 AlkPhos-55
TotBili-0.3
[**2111-8-30**] 05:15AM BLOOD ALT-166* AST-222* LD(LDH)-150 AlkPhos-61
TotBili-0.8
[**2111-8-30**] 04:36PM BLOOD ALT-136* AST-84* LD(LDH)-112 AlkPhos-50
TotBili-0.4
[**2111-8-30**] 10:43PM BLOOD ALT-133* AST-75* LD(LDH)-126 AlkPhos-54
TotBili-0.5
[**2111-8-31**] 04:44AM BLOOD ALT-123* AST-60* LD(LDH)-112 AlkPhos-53
TotBili-0.5
[**2111-8-31**] 03:58PM BLOOD ALT-115* AST-53* LD(LDH)-163 AlkPhos-55
TotBili-0.4
Brief Hospital Course:
This is a 25 yo female who presents with acetaminophen overdose.
.
# APAP Overdose: Reported that this was not a suicide attempt.
s/p full NAC treatment course (4000mg/4 hours and 8000/16 hours
then 500 mg/hr for another 16 hours). APAP level now negative.
No synthetic dysfunction, and transaminases trending down.
.
# ?Suicidal Ideation: Pt had 1:1 sitter throughout admission.
Psych was consulted and felt that she was safe for discharge
home and was at no psychiatric risk to herself.
.
# Hypotension: Pt hypotensive x1 episode in ED. This was felt to
be vasovagal as pt on commode at time of hypotensive episode.
.
# GPC bacteremia. Pt had one set positive blood cultures for
gram positive cocci in clusters from [**8-30**]. This was initially
felt to likely represent contamination as pt did not have any
indwelling lines and no antibiotics were started. Culture
eventually grew out coag negative staph from one bottle only,
and subsequent blood cultures were negative. No treatment
required.
.
# Domestic violence/concern for safety of pt. Pt reports that
there may be people looking to harm her. Pt has had h/o abuse.
Pt had 1:1 sitter and q1h visits from security. Further, pt's
name was hidden in all public spaces and not written on her
chart or telemetry monitor. Psychiatry and social work were
following, and she was discharged to a safe setting. Her social
worker from a domestic violence program was
helpful to the psychiatry team and was present on the day of
discharge to help get her to a safe shelter.
Medications on Admission:
albuterol MDI
?estrogen therapy
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-12**] Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*
2. Outpatient Lab Work
Please draw LFTs (ALT, AST, Alk Phos, Tbili, Dbili) by [**2111-9-8**].
Discharge Disposition:
Home
Discharge Diagnosis:
Acetaminophen overdose
.
Acute hepatitis, secondary to acetaminophen
Respiratory failure, secondary to encephalopathy
Discharge Condition:
Stable, ALT 104 AST 39
Discharge Instructions:
You were admitted to the hospital after taking too much Tylenol.
This caused injury to your liver which has improved with proper
treatment. Our psychiatrists have also seen you and feel that
you are safe to go home.
.
Please return to the hospital or call your doctor if you
experience any of the following:
- Yellowing of the skin or eyes.
- Nausea, vomiting, abdominal pain, or inability to tolerate
food or liquids.
- Severe sadness or thoughts of hurting yourself or others.
- Any new symptoms that you are concerned about.
.
Since you were admitted, we have made the following medication
changes:
- None.
.
Please have your liver function tests checked and followed up by
a physician within the next week. It is very important that you
see a medical doctor within one week.
Followup Instructions:
Please followup with a physician within one week. As above, you
need to have your liver function tests checked and followed up.
We are providing you with a copy of your tests so you can give
them to your new doctor for reference.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"784.0",
"348.30",
"302.85",
"789.01",
"389.9",
"E980.0",
"965.4",
"V62.84",
"458.9",
"573.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
5337, 5343
|
3428, 4953
|
307, 313
|
5505, 5530
|
1932, 1937
|
6360, 6715
|
1332, 1336
|
5035, 5314
|
5364, 5484
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5554, 6337
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1351, 1913
|
254, 269
|
341, 1211
|
1952, 3405
|
1233, 1240
|
1256, 1316
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,380
| 110,837
|
42705
|
Discharge summary
|
report
|
Admission Date: [**2105-4-6**] Discharge Date: [**2105-4-10**]
Date of Birth: [**2035-9-2**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
[**4-5**] intubation
History of Present Illness:
The pt is a 69 year-old man with PMHx of afib (not on
anticoagulation) s/p pacemaker, HTN, COPD, CAD s/p cardiac
bypass
in [**2104-1-19**], DM2 and adrenal insufficiency (on chronic steroids)
who presents from an OSH after 5 reported seizures. Per pt's
wife, the pt had been c/o "not feeling well" for 3 days, but did
not have any specific sx like runny nose, cough, sore throat
etc.
and did not have any fevers/chills. Then on [**4-5**], pt's wife
reports that he pt was on the phone with their granddaughter,
and
she thought he had hung up the phone (she was in the next room),
but then the phone rang again and he didn't pick it up, so she
went to check on him and found him on the bed with his arms and
legs shaking and her eyes rolled back. This lasted about a
minute
and so his wife called 911. [**Name2 (NI) **] then had 2 more before EMS
showed
up. EMS noted that he had urinated on himself. He was taken to
[**Hospital3 **], but in the ambulance and while in the ED he was
given
6mg of ativan, intubated, sedated (on propofol) and given
fosphenytoin 1200mg x1. He then began bucking the vent so was
given 2mg of additional ativan. As the pt is on chronic
steroids, there was concern for an infectious source of the
seizures, so at the OSH he was given vancomycin and zosyn, as
well as hydrocortisone 100mg IV x1.
He was then sent to [**Hospital1 18**] for further management. In the ED, he
was minimally responsive, not following commands. He had an LP
which showed 0 WBCs and 8 RBCs, with protein of 35 and glucose
of
165. He was noted to be afebrile. He was admitted to the neuro
ICU for further monitoring.
.
Pt is unable to complete the Neuro or General ROS as he is
intubated and sedated.
Past Medical History:
- afib not on anticoagulation
- s/p pacemaker
- HTN
- COPD
- CAD s/p cardiac bypass [**2104-1-19**]
- DM2
- hx of GIB
- LBB
- adrenal insuffiency
Social History:
- smoked 20 yrs 1ppd, quit 25 years ago, drinks 5 beers per day,
but did not suddenly stop recently (however, his ethanol level
was undetectable), no substance abuse, lives
with wife, retired from being a truck driver
Family History:
unknown
Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 97.8 P: 100 R: 18 BP:129/74 SaO2: 100% on ETT
General: intubated, not sedated, unresponsive
HEENT: ETT in place
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Pt unresponsive to voice or sternal rub, did not
follow commands, would occ. spontaneously open eyes and look
straight ahead.
-Cranial Nerves:
I: Olfaction not tested.
II: L pupil 2->1mm, R pupil 1.5->1mm, both reactive. Pt does
not
blink to threat. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages. Pt does not have corneal reflexes
bilaterally
III, IV, VI: Unable to test [**Name (NI) 3899**], pt unable to follow commands
V: Unable to test
VII: No facial droop (although ETT in place, therefore difficult
to assess), facial musculature appears symmetric.
VIII: Unable to test
IX, X: Per nursing, gag intact
[**Doctor First Name 81**]: Unable to test
XII: Unable to test
-Motor: Normal bulk, tone throughout. No asterixis noted. Pt
withdraws briskly in all 4 ext to noxious stim, but is unable to
cooperate more fully with strength testing.
-Sensory: Withdraws to noxious stim as above
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was withdrawal bilaterally.
-Coordination/Gait: Unable to test
------
Pertinent Results:
Admission Labs:
[**2105-4-5**] 11:44PM WBC-13.6* RBC-3.51* HGB-13.3* HCT-42.1
MCV-120* MCH-38.0* MCHC-31.7 RDW-14.7
[**2105-4-5**] 11:44PM PLT COUNT-178
[**2105-4-5**] 11:44PM PT-10.6 PTT-24.8* INR(PT)-1.0
[**2105-4-5**] 11:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
[**2105-4-5**] 11:44PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2105-4-6**] 12:43AM TYPE-ART PO2-175* PCO2-31* PH-7.22* TOTAL
CO2-13* BASE XS--13 INTUBATED-INTUBATED
[**2105-4-6**] 01:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-35
GLUCOSE-162
[**2105-4-6**] 01:30AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-8* POLYS-4
LYMPHS-58 MONOS-38
[**2105-4-6**] 08:24AM PHENYTOIN-2.8*
[**2105-4-6**] 08:24AM %HbA1c-5.8 eAG-120
[**2105-4-6**] 08:24AM ALBUMIN-3.1* CALCIUM-7.4* PHOSPHATE-3.4
MAGNESIUM-2.0
[**2105-4-6**] 08:24AM ALT(SGPT)-22 AST(SGOT)-51* ALK PHOS-85 TOT
BILI-0.4
[**2105-4-6**] 08:24AM GLUCOSE-209* UREA N-10 CREAT-1.0 SODIUM-142
POTASSIUM-3.7 CHLORIDE-117* TOTAL CO2-15* ANION GAP-14
NCHCT [**2105-4-6**]: No acute intracranial process. If there is
ongoing concern of the cause of seizures, then an MR may be far
more helpful than this non contrast CT.
LENIs [**2105-4-6**]: No deep venous thrombosis in right or left
lower extremity.
KUB [**2105-4-7**]: An image of the abdomen centered at the
umbilicus shows a
nasogastric tube coiled in the stomach and may end just below
the
gastroesophageal junction. There is no particular distention of
intestinal
tract in the upper abdomen.
NCHCT [**2105-4-6**]: There is no evidence of hemorrhage, edema,
mass, mass effect, or infarction. The ventricles and sulci are
normal in size and configuration. The basal cisterns appear
patent and there is preservation of [**Doctor Last Name 352**]-white differentiation.
No fracture is identified. Bilateral sclerosis of mastoid air
cells, right greater than left, suggest chronic inflammation.
Bilateral retention cysts are noted in the maxillary sinuses.
The visualized ethmoid and frontal sinuses are clear.
Chest Film [**2105-4-7**]: As compared to the previous radiograph,
the patient has been extubated and the nasogastric tube was
removed. Lung volumes have slightly decreased. The signs
suggesting fluid overload have slightly increased. The size of
the cardiac silhouette is still above the normal range. No
larger pleural effusions. No focal parenchymal opacity
suggesting pneumonia.
Brief Hospital Course:
69M w/ AF (not on AC) s/p PPM, HTN, COPD, CAD (s/p CABG), DM2,
adrenal insufficiency presented s/p five seizures. Intubated for
airway protection/respiratory support initially in ICU. The
patient initially was admitted for control of a cluster of
seizures which did not recur. He was treated with Fosphenytoin
which his liver appeared to metabolize quickly, resulting in
initial subtherapeutic levels. Fosphenytoin was subsequently
bolused and titrated up. He had a 20 min EEG performed to
exclude the possbility of status epilepticus which showed
encephalopathy but no epileptiform discharges or electrographic
seizures. When he was tapered from Propofol and extubated, his
mental status returned to his normal baseline.
In terms of the possible etiologies, he could then report that
he had no prior history of seizures. There were no toxic
metabolic abnormalities on his laboratory studies including on
measures of electrolytes, given his history of adrenal
insufficiency. He does, however, drink ETOH daily (at least five
beers) which although reporting consistent drinking during the
prior three days when he felt ill he also had an ETOH level of 0
upon arrival to our ED. He was treated with an MVI, thiamine,
and folate. He will be maintained on Dilantin mono-therapy (PO)
for 4 weeks after discharge before discontinuation.
In the days prior to his discharge, he remained at times
noncooperative with RN staff and PT staff on the floor. He
refused PT evaluations. At times, he would become tearful, and
at other times, he would make open advances to female nursing
staff. His wife arrived on his discharge day and confirmed his
sedentary lifestyle. He was extensively counseled by myself and
others about the importance reducing or discontinuing his
alcohol intake, and replacing his EtOH with diet and exercise.
He was prescribed thiamine/folate repletion. On discharge, he
had a nonfocal neurological examination.
Medications on Admission:
- ASA 81mg QD
- motrin 800mg Q8H PRN
- omeprazole 40mg QD
- percocet 1tab Q6H PRN
- insulin lispro (75/25) 14 units QAM and 6 units QPM
- hydrocortisone 15mg QAM and 5mg QPM
- florinef 0.1mg QD
- levothyroxine 150mcg QD
- K-Dur 40mEQ TID
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
4. insulin lispro 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous QAM: Take as prior to admission.
5. insulin lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous QPM: Take as prior to admission.
6. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
7. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
8. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. phenytoin sodium extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day): To be taken @ 8AM and 8PM.
Disp:*120 Capsule(s)* Refills:*0*
15. phenytoin sodium extended 100 mg Capsule Sig: 1.5 Capsules
PO once a day for 1 months: Take 1.5 tabs daily at 2 PM in
addition to 2 tabs daily at 8 AM and 8 PM.
Disp:*45 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care
Discharge Diagnosis:
Alcohol withdrawal seizure
Atrial fibrillation
Diabetes mellitus
Coronary artery disease
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 7739**],
It was a pleasure taking care of you during this
hospitalization. You were admitted to the Neuro-Intensive Care
unit and the Neurology wards of the [**Hospital1 827**] following several seizures. These seizures were
likely related to your alcohol use. We started you on a
medication called Phenytoin (dilantin) to decrease the chance of
having another seizure. Please continue this for one month. As
we discussed, it is very important that you stop drinking as
this likely caused your seizure, and could cause further
injuries and health problems if you continue to drink.
.
Physical therapy saw you, and recommended continued physical
therapy within your home after discharge.
.
According to [**State 350**] State law, you cannot drive until you
are seizure-free for six months after your event.
.
Please continue your medications as prescribed. In addition to
your anti-seizure medication, we added a medication (Atenolol)
for your blood pressure and a multivitamin, thiamine, and folate
to take daily with your home medications.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1693**], your primary care physician.
[**Name10 (NameIs) 6**] appointment has been made for you on Tuesday [**2105-4-14**]
at 1:00PM. The phone number is [**Telephone/Fax (1) 75799**], and their address
is 237A [**Street Address(1) **], [**Location **],[**Numeric Identifier 21478**].
Please also follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital1 771**]. An appointment has been scheduled for
you on Tuesday, [**6-16**] at 4 PM. His office can be reached at
[**Telephone/Fax (1) 2574**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2105-4-10**]
|
[
"250.00",
"303.91",
"414.00",
"255.41",
"V58.65",
"V45.81",
"291.81",
"427.31",
"401.9",
"496",
"780.39",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10448, 10509
|
6633, 8559
|
311, 333
|
10647, 10647
|
4160, 4160
|
11929, 12624
|
2497, 2506
|
8849, 10425
|
10530, 10626
|
8585, 8826
|
10830, 11906
|
3175, 4141
|
2546, 3016
|
263, 273
|
361, 2076
|
4176, 6610
|
10662, 10806
|
2098, 2246
|
2262, 2481
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,099
| 192,135
|
467
|
Discharge summary
|
report
|
Admission Date: [**2135-6-15**] Discharge Date: [**2135-7-22**]
Service: Vascular Surgery
CHIEF COMPLAINT: Ruptured, infected right femoral
pseudoaneurysm.
HISTORY OF PRESENT ILLNESS: This 82 year old white female
with coronary artery disease, coronary artery bypass graft,
cerebrovascular accident, diabetes, hypertension, renal
artery stenosis, status post left renal artery stent,
peripheral vascular disease, had undergone a right common
femoral to anterior tibial artery bypass graft with PTFE on
[**2132-11-27**] by Dr. [**Last Name (STitle) **]. After the patient developed
gangrene of her lower saphenectomy site with two ulcers.
The patient did well until she had a catheterization via her
right groin in [**2135-4-28**]. The patient
developed a right groin hematoma which was evacuated in [**2135-4-28**]. At that time there was no graft involvement.
The patient was sent to the [**Hospital6 2018**] Emergency Room from [**Hospital6 310**] on
[**2135-6-15**] with recent history of fevers and development
of a pulsatile mass in her right groin. The right groin
began to bleed and the patient was sent for evaluation. In
the Emergency Room the patient was diagnosed with an infected
pseudoaneurysm and was admitted for emergency surgery.
PAST MEDICAL HISTORY:
1. Coronary artery disease: NWQMI, percutaneous
transluminal coronary angioplasty/stent [**2132-6-23**],
coronary artery bypass graft [**2132-8-24**].
2. Cerebrovascular accident [**2128**], no residual.
3. Right medullary cerebrovascular accident [**2135-3-29**].
4. Seizure disorder, hospitalized [**2129-4-28**] at [**Hospital6 1760**].
5. Diabetes diagnosed in [**2123**].
6. Hypertension.
7. Hypercholesterolemia.
8. Carotid artery stenosis.
9. Renal artery stenosis, stent placement, left renal artery
[**2135-3-29**].
10. Recurrent urinary tract infection.
11. Severe depression, status post electroconvulsive therapy,
[**2123**] and [**2125**].
12. Left femoral neck fracture.
13. Right groin hematoma.
14. Recurrent urinary tract infections.
15. Peripheral vascular disease.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times three with right leg
saphenous vein on [**2132-8-24**] by Dr. [**Last Name (STitle) **] at [**Hospital6 1760**].
2. Right common femoral to anterior tibial artery bypass
graft with PTFE and distal tailor vein patch on [**2132-11-27**] by Dr. [**Last Name (STitle) **].
3. Left closed reduction internal fixation of left hip
fracture and evacuation of right groin hematoma on [**2135-5-2**] at [**Hospital6 256**].
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Aggrenox
2. Aspirin
3. Lisinopril
4. Amlodipine
5. Atorvastatin
6. Lopressor
7. Bupropion
8. Mirtazapine
9. Temazepam
10. Trazodone
11. Dulcolax
12. Tylenol
13. Sublingual Nitroglycerin
14. RISS
15. Vancomycin
FAMILY HISTORY: Non-contributory.
SOCIAL HISTORY: The patient was at [**Hospital6 3953**] prior to admission. She does not drink alcohol. She
does not smoke cigarettes. She has a son, daughter-in-law
and daughter who are very involved in her care.
ADMISSION LABORATORY DATA: White blood count 9.4, hemoglobin
7.8, hematocrit 22.5, platelets 314,000, PT 13.9, PTT 28.8,
INR 1.3. Sodium 143, potassium 4.5, chloride 108,
bicarbonate 26, BUN 54, creatinine 1.1, glucose 124.
HOSPITAL COURSE: The patient was evaluated in the Emergency
Room. She was noted to have a bleeding pulsatile mass in her
right groin. She had a fever to 102. She was taken to the
Operating Room for emergent repair of her infected right
groin pseudoaneurysm. The proximal prosthetic graft was
removed. The distal prosthetic graft could not be separated
from the surrounding tissue and therefore was ligated. A
right common femoral to profunda femoris artery bypass graft
with right superficial femoral artery was done. The patient
received 6
units of packed red blood cells intraoperatively for her
hematocrit of 22. Post transfusion, hematocrit was 33.7.
The patient was kept on heparin infusion. She was started on
Vancomycin, Levofloxacin and Flagyl. At the end of surgery
the patient had a cool right lower extremity from the foot to
the knee. No doppler signals were found at the dorsalis
pedis or posterior tibial. Dr. [**Last Name (STitle) **] felt there was no
possibility of revascularization. He discussed the necessity
of an above the knee amputation in the future with the
family. Postoperatively the patient remained intubated. Her
urine output decreased considerably. She was determined to
be in metabolic acidosis. Tube feedings were started via
oral gastric tube. Blood cultures grew Methicillin-resistant
Staphylococcus aureus. Tissue culture grew
Methicillin-resistant Staphylococcus aureus.
The Renal Service was consulted for the patient's oliguria
and elevated creatinine from 1.5 to 2.2. Because of her
renal artery stenosis and recent left renal artery stent
placement, they felt the patient's right kidney was not
functioning. They therefore recommended that her systolic
blood pressure be kept greater than 140 and less than 180 to
maintain adequate renal perfusion. In the meantime, until
renal function improved all medications were to be dosed for
a creatinine clearance of approximately 25 cc/hr.
The patient failed multiple attempts to wean her to
extubation. She was felt to be fluid overloaded as well as
having extremely thick secretions. She was diuresed with
Lasix prn and then a Lasix drip. She had a bronchoscopy on
[**2135-6-27**] and secretions grew Methicillin-resistant
Staphylococcus aureus. Chest x-ray showed a left lung
collapse and she had a repeat bronchoscopy on [**2135-7-1**].
Secretions again grew Methicillin-resistant Staphylococcus
aureus. On [**2135-7-2**], large pleural effusion was seen and
the patient underwent ultrasound-guided aspiration of the
left pleural effusion. One liter of fluid was drained.
Cultures were negative. Possibility of a tracheotomy was
discussed with the family who refused to consider it at that
time. Following the pleural tap, the patient continued to
improve and was finally extubated [**2135-7-6**].
Postoperatively she did fairly well with Albuterol and
Ipratropium inhalation as well as Albuterol and Ipratropium
nebulizer treatment as needed. Aggressive chest physical
therapy was also used to help clear her secretion.
After extubation, the patient continued to receive total
parenteral nutrition. Bedside speech and swallow evaluation
could not be done. The patient refused all food and refused
to take part in the swallow evaluation. The patient's family
was able to bring in homemade foods which the patient was
able to eat small quantities. A repeat bedside evaluation
done on [**2135-7-12**] showed definite aspiration. Aspiration
precautions were put in place. The patient's family
consented to place a percutaneous endoscopic gastrostomy.
The patient was then NPO except for medications.
The patient's right leg deteriorated significantly. Family
discussed right above the knee amputation and percutaneous
endoscopic gastrostomy placement with the patient on [**2135-7-15**]. A decision was made to go ahead with both procedures
on [**2135-7-18**]. The patient and family requested
Do-Not-Resuscitate/Do-Not-Intubate status.
The patient had developed some redness along her right groin
wound with minimal drainage. Levofloxacin and Flagyl were
added to her Vancomycin. Her abdominal staples had been
removed on [**2135-7-1**].
The patient had urine culture which grew 10,000 to 100,000
yeast. This was treated with three days of intravenous
Fluconazole. A stool culture from [**2135-7-8**] was sent and
was Clostridium difficile positive. The patient was started
on a two week course of Flagyl on [**2135-7-11**].
At the time of dictation, the patient's right groin wound is
almost healed. She will have dry sterile dressing changes
b.i.d. Her abdominal incision is clean, dry and intact. Her
right above the knee amputation incision is clean, dry and
intact. Staples should remain for one month from surgery
before removal. Appointment with Dr. [**Last Name (STitle) **] in the office
should be made for removal. The patient should continue her
Vancomycin through [**2135-7-27**]. She has been dosed per
level less than 15. At the time of dictation she has a
random Vancomycin level pending and should receive 1 gm of
intravenous Vancomycin today. The patient will finish her
Flagyl on [**2135-7-25**] for her Clostridium difficile
treatment.
MEDICATIONS ON DISCHARGE:
1. Vancomycin through [**2135-7-27**] for
Methicillin-resistant Staphylococcus aureus; dose for level
less than 15.
2. Flagyl 500 mg q. 8 hours via percutaneous endoscopic
gastrostomy.
3. NPH insulin 6 units subcutaneously q. AM
4. Insulin NPH 6 units subcutaneously q.h.s.
5. RISS b.i.d.
6. Lansoprazole 30 mg via percutaneous endoscopic
gastrostomy q.d.
7. Aspirin 325 mg q.d. via percutaneous endoscopic
gastrostomy
8. Bupropion 100 mg p.o. t.i.d.
9. Colace liquid 100 mg via percutaneous endoscopic
gastrostomy b.i.d.
10. Lasix 40 mg b.i.d. via percutaneous endoscopic
gastrostomy
11. Lopressor 50 mg t.i.d. via percutaneous endoscopic
gastrostomy
12. Atorvastatin 10 mg q.d. via percutaneous endoscopic
gastrostomy
13. Temazepam 30 mg h.s. prn via percutaneous endoscopic
gastrostomy
14. Dulcolax 10 mg p.o./p.r. q.d. prn
15. Heparin 5000 units subcutaneously q. 8 hours
16. Nystatin oral suspension, 5 mg p.o. q.i.d. prn
17. Promethazine 25 mg intravenously q. 6 hours prn
20. Percocet elixir [**5-7**] Monocryl q. 4-6 hours prn per
percutaneous endoscopic gastrostomy
21. Tylenol 325 to 650 mg q. 4-6 hours prn per percutaneous
endoscopic gastrostomy
22. Artificial tears one to two drops both eyes prn
23. Albuterol/Ipratropium 1 to 2 puffs inhalation q. 6 hours
prn
24. Albuterol nebulizer treatments q. 2 hours prn
25. Ipratropium Bromide nebulizer one inhalation q. 6 hours
DISPOSITION: [**Hospital **] Rehabilitation Facility.
CONDITION ON DISCHARGE: Satisfactory.
PRIMARY DIAGNOSIS:
1. Ruptured infected right groin pseudoaneurysm
2. Removal of proximal PTFE right bypass graft, and ligation
of distal portion of graft; and right femoral to profunda
saphenous vein graft on [**2135-6-15**].
3. Right above the knee amputation by Dr. [**Last Name (STitle) **] and
percutaneous endoscopic gastrostomy by Dr. [**Last Name (STitle) **] on [**2135-7-18**].
SECONDARY DIAGNOSIS:
1. Traumatic blood loss secondary to pseudoaneurysm rupture;
status post multiple transfusions
2. Methicillin-resistant Staphylococcus aureus sepsis
treated with Vancomycin through [**2135-7-27**]
3. Respiratory failure with prolonged intubation, extubated
on postoperative day #21
4. Methicillin-resistant Staphylococcus aureus pneumonia
5. Bronchoscopy [**6-27**] and [**2135-7-1**]
6. Aspiration left pleural effusion on [**2135-7-4**]
7. Oliguric acute renal failure, resolved
8. Aspiration determined by bedside swallow study
9. Postoperative malnutrition, treated with total parenteral
nutrition followed by percutaneous endoscopic gastrostomy
placement on [**2135-7-18**]: Currently at goal rate of 45
ml/hr of Promote with fiber, full strength.
10. Cellulitis, right abdominal incision resolved, right
groin wound, treated
11. Clostridium difficile colitis treated with Flagyl from
[**7-11**] through [**2135-7-25**]
12. Yeast urinary tract infection treated with three day
course of intravenous Fluconazole
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2135-7-22**] 14:51
T: [**2135-7-22**] 15:25
JOB#: [**Job Number 3955**]
|
[
"263.9",
"998.59",
"996.62",
"682.2",
"482.41",
"511.9",
"008.45",
"584.9",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"43.11",
"38.68",
"96.6",
"33.22",
"84.17",
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] |
icd9pcs
|
[
[
[]
]
] |
2867, 2886
|
8562, 10012
|
3350, 8536
|
2627, 2850
|
2110, 2604
|
120, 170
|
199, 1270
|
10465, 11763
|
10071, 10444
|
1292, 2087
|
2903, 3332
|
10037, 10052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,393
| 170,225
|
40783
|
Discharge summary
|
report
|
Admission Date: [**2105-4-22**] Discharge Date: [**2105-4-30**]
Date of Birth: [**2045-6-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
distended abdomen
Major Surgical or Invasive Procedure:
[**2105-4-23**] ultrasound guided paracentesis
[**2105-4-24**] cardiac catheterization with placement for 2 bare metal
stents
to the left anterior descending artery and one bare metal
stent to
the obtuse marginal branch 1
[**2105-4-24**] endotracheal intubation
[**2105-4-24**] bronchoscopy
[**2105-4-29**] central venous line placement (right IJ)
History of Present Illness:
Mr. [**Known lastname **] is a 59 M with NASH-cirrhosis complicated by
ascites and edema who is currently listed on the transplant list
with a MELD of 18, who is being directly admitted from clinic
with weight gain/refractory ascites, and periumbilical redness,
and a possible ventral hernia.
.
He has struggled with ascites and weight gain, though was
recently aggressively diuresed (lasix 40, spironolactone 200mg)
26 pounds to a dry weight of 223, though was afflicted by leg
cramps, [**Last Name (un) **] with creatinine to 1.7 from 1.0, and mild
hyponatremia to 132. Diuretics were held for about a week, and
when followup labs showed some improvement (Cr 1.4) he resumed
spironolactone 100mg and lasix 40mg daily. He unfortunately
gained about 7 pounds during that week, weighing in at 253 from
246 at his scheduled followup appointment today with the liver
clinic. He has been taking his diuretics as prescribed and is
making urine. He denies any salt indiscretions though had 2
slices of pizza over the weekend, which is an occasional
indulgence.
.
He developed a slight redness over his periumbilical area four
days ago that is not painful, warm, or pruritic. He relates it
to recently starting rifaximin for slight asterixis seen on
recent exam. It has spread slowly. He blames symptoms of
fatigue and weakness on this medication.
.
On ROS, he denies, headaches, fevers, chills, nausea, vomiting,
BRBPR, diarrhea, melena, abdominal pain, chest pain, shortness
of breath, or coughing. No dysuria or hematuria.
.
Past Medical History:
-Type 2 diabetes.
-Hypercholesterolemia.
-[**Doctor Last Name 9376**] disease.
-L5/S1 discectomy in [**2095**] and [**2098**].
-NASH cirrhosis, listed for transplant
Social History:
The patient lives in [**Hospital1 392**], [**State 350**] with his wife. [**Name (NI) **] has
three daughters who are in good health. He works as an
electrical
engineer. Denies tobacco, ethanol, or IV drug use.
Family History:
Remarkable for [**Doctor Last Name 9376**] disease and coronary artery disease. No
history of liver disease or liver cancer.
Physical Exam:
Physical Exam on Admission:
VS: T98.0 BP117/66 P80 RR18 Sat100RA
GENERAL: Well appearing male in no acute distress
HEENT: Sclera ANicteric. PERRL, EOMI.
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly.
faintly demarcated area of erythema but no induration over the
periumbilical area, marked with pen.
EXTREMITIES: 2+ [**Location (un) **] bilaterally to knees.
NEURO: AAOx3, CN 2-12 intact bilaterally
Pertinent Results:
Labs on Admission:
[**2105-4-22**] 08:00PM WBC-4.7 RBC-3.21* HGB-11.6* HCT-35.1*
MCV-109* MCH-36.0* MCHC-32.9 RDW-14.4
[**2105-4-22**] 08:00PM NEUTS-60 BANDS-0 LYMPHS-19 MONOS-19* EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2105-4-22**] 08:00PM ALBUMIN-2.9* CALCIUM-8.7 PHOSPHATE-3.4
MAGNESIUM-2.3
[**2105-4-22**] 08:00PM ALT(SGPT)-104* AST(SGOT)-155* LD(LDH)-282*
ALK PHOS-263* TOT BILI-4.3*
[**2105-4-22**] 08:00PM GLUCOSE-165* UREA N-64* CREAT-1.7* SODIUM-133
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-22 ANION GAP-15
Ascitic Fluid:
[**2105-4-23**] 02:44PM ASCITES WBC-425* RBC-175* Polys-22* Lymphs-30*
Monos-48*
[**2105-4-23**] 02:44PM ASCITES TotPro-0.3 LD(LDH)-63 TotBili-0.4
Imaging:
Chest X-ray [**2105-4-23**]:
As compared to the previous radiograph, there is a minimal
increase
in pulmonary fluid content, expressed by an increased diameter
of pulmonary
vasculature and fluid markings of the minor fissure. However,
there is no
evidence of pleural effusions. Borderline size of the cardiac
silhouette withslight tortuosity of the thoracic aorta. No
other relevant changes.
Liver Path [**2-/2104**]:
1. Established cirrhosis with a prominent sinusoidal component,
confirmed by trichrome and reticulin stains (Stage 4 fibrosis).
2. Moderate portal/septal and mild lobular predominantly
mononuclear inflammation.
3. Minimal steatosis without ballooning or intracytoplasmic
hyalin.
4. Iron stain shows no significant stainable iron; controls are
adequate.
cardiac cath [**2105-4-24**]: Findings
ESTIMATED blood loss: <50 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No angiographically apparent CAD
LAD: Diffuse disease. 20% proximal 80% hazy mid vessel, mild
luminal irregularities mid and distal vessel
LCX: Origin 40-50% and mid vessel 60-70%, hazy into upper pole.
RCA: Mild luminal irregularities with serial 10-30% stenosis.
Distal 40-50%. Focal mid PDA 80%.
Interventional details
Change for 6 French XBLAD3.5 guide. Crossed with Prowater wire
into the LAD and predilated with a 2.5 mm balloon. Deployed a
3.0 x 18 mm Integriti stent in the LAD and a more proximal
overlapping 3.5 x 12 mm Integriti stent. The SDS was used to
postdilate the overlap. The patient complained of [**7-3**] chest
pain after predilation that was unremitting despite normal flow
in the artery, no evidence of dissection. Transient slow flow
in
the diagonal was reversed with IC Diltiazem. As the patient was
continuing to have chest pain, the decision was made to
intervene
upon the OM lesion. A Prowater wire was advanced into the OM
distally. A 2.0 mm balloon was used to predilate. A 2.5 x 22
mm
Integriti stent was then deployed. Final angiography revealed
normal flow, no dissection and 0% residual stenosis in the
stents. The patient was stable throughout the procedure, but
because he was still having 8/10 chest pain and during a
coughing
spell, he was noted to have hemoptysis vs. hematemesis, he was
transferred to the CCU for consultation with the liver service
and ICU service to help determine whether he is having a
gastrointestinal vs. pulmonary bleed.
[**4-26**] CXR
FINDINGS: There is a new dual-lumen endotracheal tube in the
left main stem
bronchus. The tip is likely terminating beyond the takeoff of
the left upper
lobe bronchus. Minimal proximal repositioning is recommended.
There is a new relatively homogeneous left upper lobe opacity,
with a
coma-shaped lucency at the level of the aortic arch. This is
likely to
represent a left upper lobe collapse, following the distal tube
position.
The other lung parenchymal opacities are unchanged. Unchanged
size and shape
of the cardiac silhouette. Unchanged course of the nasogastric
tube.
.
[**4-29**] CXR
Slight increase over the past hour in caliber of mediastinum and
haziness
increasing in the perihilar regions of both lungs suggest
component of
pulmonary edema has developed, in the setting of severe and
persistent
bibasilar consolidation due to hemorrhage or pneumonia. The
dual channel ET
tube unchanged in position, one lumen in the left main bronchus,
the other in
the mid trachea, unchanged. Nasogastric tube passes below the
diaphragm and
out of view. Heart size normal. No pneumothorax.
[**4-29**] EKG
Sinus tachycardia. Poor R wave progression in leads VI-V3 of
unclear
significance. ST segment depressions in leads II, V4-V6 raise
the possibility
of infero-apical ischemia or injury. Compared to the previous
tracing of [**2105-4-25**]
the heart rate has increased. ST-T wave changes are new at a
faster heart rate.
Clinical correlation and repeat tracing are suggested after
slowing the heart
rate.
[**4-29**] TTE
Overall left ventricular systolic function is hyperdynamic (EF
75%). However, the apex appears hypokinetic. Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are mildly thickened. Mitral regurgitation is present
but cannot be quantified. Tricuspid regurgitation is present but
cannot be quantified. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion. There
is an anterior space which most likely represents a fat pad.
Compared with the findings of the prior study (images reviewed)
of [**2105-4-26**], the apex now appears hypokinetic, and may have
been hypokinetic during the prior study, but the technically
suboptimal nature of both studies precludes definitive
comparison.
[**4-30**] CXR
The elective endotracheal intubation with the tip in the left
main bronchus is
present. NG tube tip is out of view below the diaphragm. Right
IJ catheter
tip is in the lower SVC. Extensive bilateral right greater than
left lung
opacities are unchanged.
[**4-30**] renal u/s
Normal-sized kidneys with no evidence of hydronephrosis.
[**4-30**] EKG
Sinus tachycardia.. Non-specific ST-T wave changes. Compared to
the previous
tracing the heart rate has decreased. Previously noted ST
segment depressions
in leads II and V4-V6 have markedly improved and resolved at a
slower heart
rate.
Brief Hospital Course:
Mr. [**Known lastname **] is a 59 year old male with non-alcoholic
steatohepatitis (NASH) cirrhosis listed for transplant who was
admitted for increasing abdominal distention and weight gain,
and possible cellulitis. He developed NSTEMI in the setting of
a paracentesis and underwent cardiac catheterization with
placement of bare metal stent (BMS) to the LAD and OM1 and
developed pulmonary hemorrhage requiring intubation for airway
protection and respiratory compromise. His course was further
complicated by respiratory failure with inability to wean off
the ventilator, acute renal failure, and decompensated liver
disease. He ultimately succumbed to multiorgan system
dysfunction, and on the night of [**2105-4-30**] the family decided to
withdraw aggressive care and provide comfort care. The patient
passed shortly after extubation.
CCU [**Date range (1) 47943**]
MICU [**Date range (1) 16463**]
.
# Non-ST elevation myocardial infarction (NSTEMI): Overnight on
[**2105-4-23**] he started having [**4-2**] pain in his bilateral posterior
shoulder blades, radiating to the jaw. He got up to go to the
bathroom and it worsened, and he had the onset of pain in the
right chest as well. No assoc N/V/diaphoresis/SOB. EKG was
done, and showed new elevation in AVR with new depressions in I,
II, V2-V6, concerning for left main disease/3VD. His troponins
increased to peak of 0.33. He was given nitroglycerin tabs x3
with resolution of his pain and improvement of ST-T segment
changes on EKG. Cardiology was consulted and the decision was
made to medically manage as long as he was chest pain free with
plan for cardiac catheterization in AM. He was started on
aspirin, metoprolol, and atorvastatin and heparin drip. Because
he was still symptomatic it was decided to take him to the cath
lab. Hepatology was involved in the decision to start statin
and they agreed that the cardiovascular benefit was greater than
additional potential liver toxicity.
He was taken to the cath lab on [**2105-4-24**] with radial approach
which showed diffuse Disease to the LAD w/ 20% proximal and 80%
hazy mid vessel and two BMS were deployed to the LAD and one BMS
was deployed to the OM1 after the patient continued to have [**7-3**]
chest pain while in the cath lab. He initially had slow flow in
the diag branches post intervention so bivalirudin was started.
Bivalirudin drip was used for anticoagulation in the cath lab in
addition to ASA 325mg and a supratherapeutic heparin drip given
earlier in the day. Lasix bolus was given for perceived
pulmonary edema. Shortly thereafter, he developed a coughing
spell with frank hemoptysis and was transferred to the CCU for
further monitoring (see below). He was loaded with plavix 300
mg the following day when his bleeding was improved and remained
thereafter on 75mg daily. A few days later he developed new ST
depressions in V4-V6 with echocardiogram evidence of hypokinetic
apex. He was continued on ASA and plavix. However, in the
setting of hypotension and fevers, metoprolol was discontinued
as patient was hypotensive and ultimately required vasopressors.
.
# Hemoptysis and respiratory failure: He developed hemoptysis in
the setting of several hours of supratherapeutic heparin gtt,
bivalirudin given for stents as above, and thrombocytopenia from
liver disease. He was transferred from the cath lab to the CCU
for close monitoring given his hemoptysis. When he arrived, he
was in respiratory failure and was intubated emergently on
[**2105-4-24**]. Pulmonary was consulted and they performed a
bronchoscopy on [**2105-4-24**] with visualization of fresh blood in the
right lung. They were unable to see a source for the bleeding
but injected epinephrine into the bronchus. After this, his
hematocrit stablized at 29 (baseline 35 on admission) and his
chest xrays showed improvement. Later, he continued to bleed on
[**5-11**] and multiple PRBC and platelet transfusions. He
continued bleeding and therefore had a double lumen ETT placed.
Bleeding gradually decreased and HCT remained stable, however
developed progressive difficulty ventilating patient. CXR was
significant for persistent extensive bilateral infiltrates
concerning for superimposed pneumonia, especially in setting of
fevers and hypotension.
.
# Nash cirrhosis: Patient's with abdominal distention, rapid
weight fluctuations despite dietary stability likely reflect
ascites accumulation, and a positive shifting dullness. Denied
abdominal pain. Per previous notes, in the weeks preceeding his
admission, he was aggressively diuresed with lasix 40,
spironolactone 200mg to a dry weight of 223, but then developed
renal insufficiency (Cr 1.7 from 1.0), and hyponatremia to 132.
As aggressive diuresis led to renal failure, had therapeutic and
diagnostic paracentesis on [**2105-4-23**] with removal of 1.9 L. Ruled
out spontaneous bacterial peritonitis with ascitic fluid
studies. Infection was not a cause of kidney injury and ascites
reaccumulation. The patient's liver function continued to
decompensate with increasing bilirubin and INR, reaccumulation
of ascites, hypotension, and likely encephalopathy with later
development of anuric renal failure unresponsive to trial of
albumin.
.
# Fevers
Patient developed fevers during his MICU course. Given h/o
pulmonary hemorrhage and extensive persistent bilateral
infiltrates on CXR, there was concern for VAP. He was continued
on Vancomycin (for improving cellulitis) and cefepime was
started, with later addition of levofloxacin. No definitive
infectious etiology found, with negative blood, urine, sputum
and peritoneal fluid cultures.
.
# Hypotension
Patient's BP gradually downtrending since [**4-27**]. Initially related
to sedatives and liver disease, but increasing concern for
sepsis given development of fevers. Initially volume responsive,
however, ultimately required up to three pressors
(norepinephrine, neosynephrine, and vasopressin).
.
# Acute renal failure
Patient with progressively worsening creatinine from 1.3 on [**4-26**]
to 4.5 on [**4-30**], with significantly reduced urine output starting
on [**4-28**]. No structural abnormalities identified on ultrasound.
Given liver disease, concern for hepatorenal syndrome, however,
patient failed to improve with fluid challenge and albumin.
Other contributing insults included nephrotoxic medications,
contrast dye, and hypotension. A renal consult was obtained,
however, found to indication for dialysis at the time of
assessment. It was also unclear whether the patient would be a
candidate for CVVH as he was requiring multiple vasopressors for
hemodynamic support.
.
# Cellulitis: Periumbilical erythema and warmth with demarcation
suggestive of cellulitis. Patient was treated with Vancomycin
with improvement in appearance.
.
# Abdominal hernia: Small hernia appreciated on exam,
nontender. No concern for incarceration.
.
# Diabetes Mellitus II: Held oral meds in favor of insulin
sliding scale.
.
Medications on Admission:
FUROSEMIDE - (Dose adjustment - no new Rx) - 40 mg Tablet - 1.5
Tablet(s) by mouth once a day
LIRAGLUTIDE [VICTOZA] - (Prescribed by Other Provider) - 0.6
mg/0.1 mL (18 mg/3 mL) Pen Injector - inject 1.2 mg once daily
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
1 Tablet(s) by mouth twice a day
RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth twice
a day
SPIRONOLACTONE - (Dose adjustment - no new Rx) - 100 mg Tablet
- 1 Tablet(s) by mouth a day
.
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
2,000 unit Capsule - 1 Capsule(s) by mouth once a day
MAGNESIUM OXIDE - 400 mg Capsule - 1 Capsule(s) by mouth twice a
day
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY DIAGNOSIS
cirrhosis, non-alcoholic steatohepatitis
non-ST elevation myocardial infarction
pulmonary hemorrhage, respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"E879.8",
"518.0",
"573.5",
"414.01",
"518.81",
"038.9",
"E934.2",
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"997.31",
"571.8",
"785.52",
"571.5",
"250.00",
"277.4",
"682.2",
"V17.3",
"786.39",
"572.2",
"995.92",
"518.4",
"287.49",
"553.20",
"V49.83",
"272.0",
"410.71",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"96.72",
"33.23",
"00.47",
"88.56",
"36.06",
"54.91",
"00.66",
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] |
icd9pcs
|
[
[
[]
]
] |
17228, 17237
|
9488, 16461
|
290, 643
|
17421, 17430
|
3428, 3433
|
17482, 17580
|
2631, 2757
|
17200, 17205
|
17258, 17400
|
16487, 17177
|
17454, 17459
|
2772, 2786
|
233, 252
|
671, 2198
|
3447, 9465
|
2220, 2387
|
2403, 2615
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,916
| 145,323
|
30320
|
Discharge summary
|
report
|
Admission Date: [**2184-2-20**] [**Year/Month/Day **] Date: [**2184-2-27**]
Date of Birth: [**2109-11-29**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
intra-abdominal abscess
Major Surgical or Invasive Procedure:
IR placement of intra-abdominal drain ( 8.0 French Meditech
catheter )
History of Present Illness:
74F with [**Doctor First Name **] history of perforated sigmoid
diverticulitis s/p ex lap sigmoid resection and [**Doctor Last Name **]
procedure
in [**2-21**]. [**Doctor Last Name **] takedown [**10-15**] was c/b leak requiring ex lap,
transverse loop colostomy, and repair of the anastomosis [**10-29**].
Thought was given to reduction of the current ostomy but due to
patients age and dementia the ostomy was left.
She is a nursing home resident and has had a week of LLQ pain.
She reports no fevers/chills. However a CT scan demonstrates a
large abd multiloculated fluid collection.
Past Medical History:
PMH: DMII, CAD, dementia, HTN, hypercholesterolemia, perforated
sigmoid diverticulitis, ?endometrial hyperplasia
PSH: 1. CABG, 2. L TKR, 3. exploratory laparotomy, sigmoid
resection, Hartmann procedure [**2182-3-13**], 4. left colectomy,
colostomy closure [**2182-10-15**]
Social History:
Currently lives in rehab facility following relocation from
[**State 108**] due to illness. No recent history of alcohol, tobacco,
or recreational drug use.
Family History:
Non-contributory
Physical Exam:
Upon Admission:
PE: 98.4 104 127/77 12 98%RA
A&Ox3, NAD
Tachy, regular
CTAB
Abd soft, tender left abdomen
Ext no edema
Upon [**State **]:
VS: 97.5, 96.9, 70, 130/80, 16, 94% RA
NAD, disoriented at times.
NCAT
RRR, S1S2
CTAB
ABD: soft, NTND. Ostomy in RLQ C/D/I. Drain in place at LLQ.
There is minor erythema near the drain site which is vastly
improved since admission. Several old scars noted.
Ext: wnl
Pertinent Results:
[**2184-2-20**] 05:00PM BLOOD WBC-17.7*# RBC-4.27# Hgb-12.3# Hct-37.5#
MCV-88 MCH-28.8 MCHC-32.8 RDW-14.6 Plt Ct-654*
[**2184-2-21**] 12:03AM BLOOD WBC-15.6* RBC-3.92* Hgb-11.3* Hct-34.7*
MCV-89 MCH-28.7 MCHC-32.4 RDW-14.3 Plt Ct-541*
[**2184-2-21**] 03:55AM BLOOD WBC-14.5* RBC-3.56* Hgb-10.5* Hct-31.1*
MCV-87 MCH-29.5 MCHC-33.8 RDW-14.7 Plt Ct-551*
[**2184-2-22**] 03:57AM BLOOD WBC-10.1 RBC-3.21* Hgb-9.1* Hct-28.1*
MCV-88 MCH-28.4 MCHC-32.5 RDW-14.7 Plt Ct-449*
[**2184-2-23**] 06:20AM BLOOD WBC-8.8 RBC-3.27* Hgb-9.3* Hct-28.3*
MCV-87 MCH-28.5 MCHC-32.9 RDW-15.0 Plt Ct-492*
[**2184-2-24**] 05:45AM BLOOD WBC-10.8 RBC-3.61* Hgb-10.5* Hct-31.1*
MCV-86 MCH-29.2 MCHC-33.8 RDW-14.8 Plt Ct-595*
[**2184-2-25**] 07:05AM BLOOD WBC-10.9 RBC-3.68* Hgb-10.3* Hct-31.8*
MCV-87 MCH-28.0 MCHC-32.4 RDW-14.8 Plt Ct-521*
[**2184-2-26**] 05:25AM BLOOD WBC-11.9* RBC-3.72* Hgb-10.9* Hct-32.1*
MCV-86 MCH-29.3 MCHC-34.0 RDW-15.0 Plt Ct-563*
[**2184-2-27**] 05:35AM BLOOD WBC-12.6* RBC-3.72* Hgb-11.0* Hct-32.3*
MCV-87 MCH-29.7 MCHC-34.2 RDW-15.3 Plt Ct-572*
[**2184-2-20**] 05:00PM BLOOD Neuts-81.1* Lymphs-7.6* Monos-3.4
Eos-7.8* Baso-0.1
[**2184-2-21**] 12:03AM BLOOD Neuts-84.0* Lymphs-6.8* Monos-3.1
Eos-6.0* Baso-0.1
[**2184-2-23**] 06:20AM BLOOD Neuts-55.8 Lymphs-24.6 Monos-4.8
Eos-14.3* Baso-0.5
[**2184-2-20**] 10:27PM BLOOD PT-16.3* PTT-25.5 INR(PT)-1.5*
[**2184-2-21**] 12:03AM BLOOD PT-16.7* PTT-25.1 INR(PT)-1.5*
[**2184-2-21**] 03:55AM BLOOD PT-17.1* PTT-25.3 INR(PT)-1.5*
[**2184-2-22**] 03:57AM BLOOD PT-16.8* PTT-27.5 INR(PT)-1.5*
[**2184-2-26**] 05:25AM BLOOD PT-14.2* PTT-26.1 INR(PT)-1.2*
[**2184-2-20**] 05:00PM BLOOD Glucose-340* UreaN-28* Creat-1.3* Na-136
K-4.4 Cl-96 HCO3-27 AnGap-17
[**2184-2-21**] 12:03AM BLOOD Glucose-241* UreaN-22* Creat-0.9 Na-138
K-4.5 Cl-101 HCO3-26 AnGap-16
[**2184-2-21**] 03:55AM BLOOD Glucose-231* UreaN-17 Creat-0.9 Na-135
K-4.0 Cl-102 HCO3-27 AnGap-10
[**2184-2-22**] 03:57AM BLOOD Glucose-172* UreaN-11 Creat-0.9 Na-136
K-3.5 Cl-101 HCO3-28 AnGap-11
[**2184-2-23**] 06:20AM BLOOD Glucose-155* UreaN-9 Creat-1.0 Na-138
K-3.7 Cl-100 HCO3-30 AnGap-12
[**2184-2-24**] 05:45AM BLOOD Glucose-118* UreaN-8 Creat-1.0 Na-137
K-4.5 Cl-99 HCO3-28 AnGap-15
[**2184-2-25**] 07:05AM BLOOD Glucose-134* UreaN-11 Creat-1.0 Na-139
K-4.3 Cl-100 HCO3-27 AnGap-16
[**2184-2-26**] 05:25AM BLOOD Glucose-135* UreaN-14 Creat-0.9 Na-139
K-4.1 Cl-101 HCO3-26 AnGap-16
[**2184-2-27**] 05:35AM BLOOD Glucose-139* UreaN-13 Creat-0.8 Na-141
K-4.3 Cl-104 HCO3-24 AnGap-17
[**2184-2-27**] 05:35AM BLOOD ALT-8 AST-20 LD(LDH)-181 AlkPhos-73
TotBili-0.2
[**2184-2-21**] 12:03AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.3 Mg-1.6
[**2184-2-21**] 03:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.5*
[**2184-2-21**] 03:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.5*
[**2184-2-22**] 03:57AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.1
[**2184-2-23**] 06:20AM BLOOD Albumin-2.8* Calcium-8.6 Phos-3.0 Mg-1.8
[**2184-2-24**] 05:45AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.6
[**2184-2-25**] 07:05AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.9
[**2184-2-26**] 05:25AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.7
[**2184-2-27**] 05:35AM BLOOD Albumin-3.5 Calcium-9.3 Phos-3.3 Mg-2.3
CT Abd/Pelvis [**2184-2-20**]:
IMPRESSION:
1. Large left intraabdominal abscess with adjacent, adherent
loops of small bowel and proximal small- bowel obstruction, with
transition point in the region of the abscess.
2. Mildly dilated fluid filled esophagus.
[**2184-2-21**] 12:00 pm ABSCESS LLQ ABDOMINAL ABSCESS.
GRAM STAIN (Final [**2184-2-21**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
SINGLY AND IN PAIRS.
WOUND CULTURE (Final [**2184-2-25**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE
GROWTH.
SENSITIVITIES REQUESTED BY DR. [**First Name (STitle) 2053**] GROSS [**2184-2-24**]
3-4792.
ESCHERICHIA COLI. SPARSE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G----------<=0.06 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2184-2-25**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
Ms. [**Known lastname 7363**] was admitted to the general surgery service and a CT
scan of the abdomen and pelvis showed a large collection in the
LLQ. IR was consulted for drainage and placement of a drain. GS
and culture were sent which showed resistant E. Coli and strep.
ID was consulted for Abx course and choices. Initially Zosyn was
utilized, but the patient was switched to meropenem on [**2-24**].
A PICC line was placed in IR on [**2-27**] for continued IV abx use.
She was seen and evaluated by PT.
She was tolerating a regular diet throughout her stay. Her pain
was well controlled on PO pain meds.
She was often disoriented to time and place, but was always
pleasant and cooperative.
She was discharged to a rehab facility on [**2184-2-27**] with an ostomy
and a drain in place in her LLQ. A PICC was also in place in her
right arm.
Medications on Admission:
Lantus 17U/d, metformin 500''', ASA 325', colace 100'', Cymbalta
20'', prilosec 20', risperdal 0.5'', simvastatin 40', toprol
100', tramadol 25'', zetia 10'
[**Date Range **] Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 2 weeks.
13. Insulin Regular Human Subcutaneous
[**Date Range **] Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
[**Location (un) **] Diagnosis:
Intra-abdominal abscess
[**Location (un) **] Condition:
Stable. Drain in place. Tolerating a regular diet.
[**Location (un) **] 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.
* 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.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-20**] weeks. Please call his
office to make your appointment ([**Telephone/Fax (1) 2537**].
You will need weekly labs to monitor: LFTs, Chem-7, CBC while
you are on your current antibiotics. Please arrange this at your
rehab facility or with your primary care doctor.
Completed by:[**2184-2-27**]
|
[
"V45.81",
"V58.67",
"567.22",
"272.0",
"V43.65",
"294.0",
"E878.2",
"562.10",
"V12.51",
"997.4",
"401.9",
"V44.3",
"041.4",
"250.00",
"560.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
7386, 8238
|
351, 424
|
1992, 7308
|
11004, 11365
|
1532, 1550
|
8264, 9655
|
1565, 1567
|
7341, 7363
|
9687, 9713
|
288, 313
|
9745, 9798
|
9833, 10981
|
452, 1043
|
1581, 1973
|
1065, 1340
|
1356, 1516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,137
| 169,704
|
3641
|
Discharge summary
|
report
|
Admission Date: [**2120-7-2**] Discharge Date: [**2120-7-12**]
Date of Birth: [**2085-11-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Hypokalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
34F Hx bulemia difficult to treat x several years referred to ED
after outpatient workup revealed lab abnormalities. She has
noted that she has had increased lethargy, weakness, slight
nausea and lightheadedness over the past fews days Admitted to
floor for electrolyte correction. No complaints of
numbness/tingling, muscle pain. She had stopped taking her
potassium pills for an unclear amount of time. In addition, she
stopped her psychiatric medications a few months ago.
.
In the ED:
EKG: NSR @ rate of 66. Axis wnl. Intervals wnls. U waves present
- hence computer may be misreading the QT interval. No ST
changes.
Past Medical History:
* s/p breast implants ([**7-/2109**])
* s/p liposuction ([**2-/2110**])
* s/p rhinoplasty
* PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1355**] @ [**Hospital 8**] Hospital
.
PSYCHIATRIC HISTORY:
* Diagnoses: polysubstance abuse, PTSD, depression, bulemia
* Multiple past psychiatric hospitalizations mostly at [**Hospital 8**]
Hospital. Last hospitalization at [**Last Name (un) 3671**] Behavioral in the fall
of [**2119**].
* At least one past suicide attempt via significant overdose on
Tylenol #3, Percocet, and alcohol in [**2110**]. Hospitalized at
[**Hospital1 18**] at that time and had outpatient followup at [**Hospital1 18**] as well.
* Past med trials include Zoloft which the patient did find
helpful.
* Psychiatrist Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **] at [**Hospital 8**] Hospital ([**Telephone/Fax (1) 16539**]
* Therapist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] at [**Hospital 8**] Hospital ([**Telephone/Fax (1) 16540**]
Social History:
Ms. [**Known lastname **] was born in [**Country 3992**] and the youngest of 5 children. Her
family moved to [**Location (un) 86**] 24 years ago due to political pressures.
She was placed in several [**Doctor Last Name **] homes and there are allegations
of sexual abuse. As of [**2110**], notes indicate that her famliy
lives in CA, and that she has no contact with them. She attended
high school through the 11th grade, obtained a GED and attended
some college. She now lives in a house in [**Location (un) 16541**] in [**Location (un) 583**]
with her boyfriend. She was working as a barrista at Starbucks
until a couple of weeks ago.
SUBSTANCE ABUSE HISTORY:
The patient reports daily marijuana use and she also abuses
Suboxone which she gets from her boyfriend. She also has a
history of alcohol abuse though would not state exactly how much
she drinks. She smokes cigarettes.
Family History:
noncontributory
Physical Exam:
VS: T: 96.8BP 110/80 HR 66
GEN: Very thin woman in NAD, well groomed answering questions
appropriately.
HEENT: Swelling at base of neck bilaterally. Nontender.
RESP: CTA-BL
CV: Reg Nml S1, S2, no M/R/G
ABD: Thin, ND/NT +BS, no rebound/guarding
EXT: No peripheral edema
SKIN: No lanugo or rashes
Pertinent Results:
Admission Labs:
[**2120-7-2**] 05:00PM GLUCOSE-87 UREA N-17 CREAT-0.7 SODIUM-135
POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-33* ANION GAP-7*
[**2120-7-2**] 05:00PM CALCIUM-8.7 PHOSPHATE-2.9 MAGNESIUM-2.2
[**2120-7-2**] 11:32AM TYPE-ART PO2-84* PCO2-53* PH-7.41 TOTAL
CO2-35* BASE XS-6
[**2120-7-2**] 11:32AM NA+-134* K+-3.5
[**2120-7-2**] 11:32AM O2 SAT-94
[**2120-7-2**] 11:30AM GLUCOSE-79 UREA N-14 CREAT-0.7 SODIUM-135
POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-35* ANION GAP-10
[**2120-7-2**] 11:30AM CALCIUM-9.0 PHOSPHATE-2.7# MAGNESIUM-2.2
[**2120-7-2**] 02:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2120-7-2**] 02:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2120-7-2**] 02:30AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-RARE
EPI-[**12-31**]
[**2120-7-2**] 02:30AM URINE HYALINE-<1
[**2120-7-2**] 02:10AM GLUCOSE-100 UREA N-21* CREAT-1.2* SODIUM-137
POTASSIUM-2.7* CHLORIDE-78* TOTAL CO2-49* ANION GAP-13
[**2120-7-2**] 02:10AM ALT(SGPT)-27 AST(SGOT)-39 ALK PHOS-80
AMYLASE-327* TOT BILI-0.6
[**2120-7-2**] 02:10AM LIPASE-39
[**2120-7-2**] 02:10AM ALBUMIN-5.0* CALCIUM-10.2 PHOSPHATE-4.3
MAGNESIUM-2.5
[**2120-7-2**] 02:10AM COMMENTS-GREEN TOP
[**2120-7-2**] 02:10AM GLUCOSE-92 NA+-140 K+-2.3* CL--74* TCO2-50*
[**2120-7-2**] 02:10AM WBC-6.7 RBC-5.04 HGB-15.2 HCT-42.9 MCV-85
MCH-30.1 MCHC-35.4* RDW-13.1
[**2120-7-2**] 02:10AM NEUTS-56.4 LYMPHS-36.9 MONOS-4.5 EOS-1.6
BASOS-0.6
[**2120-7-2**] 02:10AM PLT COUNT-470*
[**2120-7-1**] 03:00PM GLUCOSE-102
[**2120-7-1**] 03:00PM UREA N-23* CREAT-1.0 SODIUM-135
POTASSIUM-2.2* CHLORIDE-79* TOTAL CO2-48* ANION GAP-10
[**2120-7-1**] 03:00PM estGFR-Using this
[**2120-7-1**] 03:00PM CALCIUM-10.2 PHOSPHATE-4.4 MAGNESIUM-2.6
[**2120-7-1**] 03:00PM TSH-1.24
.
Discharge Labs:
[**2120-7-9**] 05:20AM BLOOD WBC-4.7 RBC-4.29 Hgb-13.2 Hct-36.8 MCV-86
MCH-30.7 MCHC-35.8* RDW-13.2 Plt Ct-313
.
MICRO:
[**2120-7-2**] 2:30 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2120-7-4**]**
URINE CULTURE (Final [**2120-7-4**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Brief Hospital Course:
34 yo female with hx of bulemia presents after findings of
hypokalemia and alkalosis on routine lab testing. On admission,
pt was started on the eating disorder protocol. She had
aggressive repletion of electrolytes. She was given IV fluid
200-250 cc boluses with resolution of ARF and alkalosis on HD 2.
Nutrition followed giving recommendations for repletion of
phosphate to avoid refeeding syndrome. Pt was evaluated by
psychiatry on HD1. They felt that the pt had very poor insight
into her illness. She was deemed to be medically incompetent.
She failed solid diet on HD2 and was changed to a liquid diet.
She failed the liquid diet on HD3 and NGT was place with
difficulty. Pt was fighting and saying "you can't feed me." She
was restrained with soft restraints and given ativan as
tolerated- avoiding hypotension, Pt was felt to be too much
work for a regular medical floor and was transferred to the
MICU.
.
In the Micu, the patient was originally hypotensive which was
attributed to orthostatic hypotension, as she fell when she
stood up. She had no evidence for sepsis, bleeding, or
cardiogenic causes. The patient's pressure improved with IVF.
In terms of her eating disorder she was originally allowed to
eat what she wanted, but as she continued to vomit, she was
reinstated on the strict eating disorder protocol. She had her
electrolytes closely followed and did not develop signs of
refeeding. She was closely followed by nutrition and psych, and
the patient continued to try to leave but was not deemed to have
capacity per psych. She was given haldol prn and ativan prn to
keep her calm and had a 1:1 sitter to monitor her behavior.
Finally, the patient was noted to have a UTI (e.coli) sensitive
to cipro and she remained afebrile and completed a 3 day course
of antibiotics.
.
The patient was transferred back to the medical floor. She
initially continued to vomit her food, including an Ensure
protocol. Her ativan was stopped due to patient agitation. She
was continued on Haldol with good effect. Serial EKGs were
taken and her QTc was stable. On [**7-11**] she was able to hold down
3 consecutive meals. Though her ideal body weight was at about
73% of normal, she was accepted to the in-patient psychiatry
unit. On discharge her electrolytes were stable, except for a
minimal increase in her calcium for which her calcium carbonate
was stopped.
.
To Do:
1. Continue nutrition protocol
2. Continue psychiatric evaluation
3. Continue haldol as needed for agitation. Serial EKGs will
need to be taken to monitor her QTc
4. Continue to monitor her electrolytes periodically
Medications on Admission:
1. Citalopram 20 mg daily
2. Potassium chloride 40 mEq TID
3. Quetiapine 25 mg qHS
4. Topiramate 25 mg TID
* Patient was not taking any of these medications due to poor
non-adherence
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Haloperidol 1 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day) as needed for agitation.
6. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal [**Hospital1 **] PRN ().
Discharge Disposition:
Extended Care
Discharge Diagnosis:
eating disorder
hypokalemia
alkalosis
Discharge Condition:
stable
Discharge Instructions:
You were admitted with sever electrolyte abnormalities from your
eating disorder. This is a serious illness that requires long
term treatment. You were put on a strict eating protocol while
on the medical floor. Moreover, your electrolytes and heart
rhythm were monitored. You will be discharged to an in-patient
psychiatric facility to further treat your illness. You are
unable to leave under your own [**Location (un) **].
.
It is very important that you follow up with all of your
appointments.
.
Please present to the hospital or call your primary care
provider if you have fever/chills, chest pain/shortness of
breath, headache/dizzyness.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 3707**] within the next week once
you are formally discharged. She is an eating disorder
specialist. Her phone number is ([**Telephone/Fax (1) 15205**].
|
[
"307.51",
"300.3",
"584.9",
"261",
"276.52",
"041.4",
"276.3",
"300.00",
"309.81",
"305.21",
"599.0",
"V62.84",
"276.1",
"458.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9794, 9809
|
6426, 9039
|
327, 334
|
9891, 9900
|
3338, 3338
|
10597, 10801
|
2991, 3008
|
9273, 9771
|
9830, 9870
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9065, 9250
|
9924, 10574
|
5193, 6403
|
3023, 3319
|
276, 289
|
362, 984
|
3354, 5177
|
1006, 2072
|
2088, 2975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,037
| 192,662
|
9200
|
Discharge summary
|
report
|
Admission Date: [**2186-10-17**] Discharge Date: [**2186-10-23**]
Date of Birth: [**2111-5-16**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Vicodin / Ambien
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
IVC filter
History of Present Illness:
Mr. [**Known lastname 31611**] is a 75 year old male with a history of hemorrhagic
stroke 2 months ago admitted for shortness of breath. He was
noted by VNA to have labored breathing and was found to be
hypoxic at home to 70s on RA.
.
He was initially taken to [**Location (un) 620**], where CTA showed massive
bilateral PEs. He was also found to be in A. fib with RVR which
resolved with oxygen, but no nodal agents. He was started on a
nitropaste and transferred to [**Hospital1 18**] for further management.
.
Patient reports that that he has had 2-3 weeks of RLE edema, but
was without SOB, CP, nausea, vomiting, diarrhea, melena,
hematemasis. Reports he is up to date on colonoscopy and PSA
and carries no cancer diagnosis. Patient reports he was highly
mobile over the summer, but over the past 2-3 months has been
primarily bedbound due to sciatica symptoms and deconditioning
after recent stroke. Was prescribed lasix for LE edema by PCP [**Name Initial (PRE) **]
few weeks ago. Also of note, patient underwent dental
extraction of 7 teeth last week.
.
In the ED, his vitals were 82, 108/92, 24, 96% on NRB. He got a
CXR which showed no acute process. He got LENIs with showed LLE
DVT.
Past Medical History:
Left internal capsule lacunar infarct [**2180**]
Hemmoragic stroke [**2185**]
Hypertension
Lumbar disc disease
Hypercholesterolemia
BPH- s/p TURP
.
Social History:
Patient previously work for Schering Plough in sales. Currently
with limited activity, bedbound secondary to sciatica and recent
stroke, but was very active until 4 months ago. Rare tobacco
use in his youth but currently non-smoker. Rare wine use.
Family History:
Mother with stroke at age 77. Father with CAD. Sister with
dementia.
Physical Exam:
VS:T 97.5 BP 120/60 HR 91 RR24 95%4L NC O2
Gen: Pleasant, conversive, interactive elderly gentleman in NAD
HEENT: nc/at PERRL. EOMI.
Neck: Supple. FROM. No carotid bruits. JVP approx. 7-8cm
CV: Regularly irreg. Distant. No murmurs heard.
Pulm: Diminished BS. CTAB
Abd: Soft. NT/Nd. +BS. No HSM
Ext: No c/c. Left foot edematous with trace pitting edema. CP/PT
2+ BL
Neuro: AAO x 3. CN 2-12 intact. [**4-17**] strenth UE, prox LE BL. [**1-17**]
strength left plantar and dorsiflexor. Gross sensation intact.
Pertinent Results:
[**2186-10-17**] 07:27PM BLOOD WBC-10.0 RBC-4.68 Hgb-13.7* Hct-39.5*
MCV-85 MCH-29.2 MCHC-34.6 RDW-13.9 Plt Ct-213
[**2186-10-20**] 06:10AM BLOOD WBC-9.3 RBC-4.56* Hgb-13.3* Hct-39.4*
MCV-86 MCH-29.2 MCHC-33.9 RDW-13.8 Plt Ct-245
[**2186-10-23**] 07:10AM BLOOD WBC-7.4 RBC-4.27* Hgb-12.3* Hct-35.9*
MCV-84 MCH-28.8 MCHC-34.4 RDW-14.3 Plt Ct-299
[**2186-10-21**] 06:18AM BLOOD PT-16.8* PTT-91.6* INR(PT)-1.5*
[**2186-10-22**] 07:15AM BLOOD PT-21.6* PTT-104.6* INR(PT)-2.0*
[**2186-10-23**] 07:10AM BLOOD PT-25.6* PTT-96.7* INR(PT)-2.5*
[**2186-10-17**] 07:27PM BLOOD Glucose-107* UreaN-16 Creat-1.1 Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2186-10-23**] 07:10AM BLOOD Glucose-101 UreaN-6 Creat-0.8 Na-143
K-3.8 Cl-110* HCO3-26 AnGap-11
[**2186-10-18**] 03:22AM BLOOD ALT-9 AST-15 LD(LDH)-299* AlkPhos-56
TotBili-0.8
[**2186-10-17**] 07:27PM BLOOD CK-MB-4 cTropnT-0.02* proBNP-6974*
[**2186-10-18**] 11:24AM BLOOD CK-MB-NotDone cTropnT-0.01
[**10-17**] CXR: IMPRESSION: No acute cardiopulmonary abnormality.
[**10-17**] LENIS: IMPRESSION: Acute deep venous thrombosis within the
left distal superficial
femoral vein and extending into the popliteal and posterior
tibial veins as
described. No deep venous thrombosis of the right lower
extremity.
[**10-18**] ECHO: The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is markedly
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Right ventricular dilation and hypokinesis. Moderate
pulmonary artery systolic hypertension. Mild left ventricular
hypertrophy with normal systolic function. Findings consistent
with pulmonary emboli. No ASD or PFO identified.
[**10-17**] ECG: Sinus rhythm with frequent premature beats, probably
atrial premature beats
with aberrant conduction. Non-specific ST-T wave abnormalities.
Compared to
the previous tracing of [**2186-8-21**] rhythm is similar, T wave
inversions in
leads V1-V3 are now present. Cannot exclude ischemia.
[**10-18**] Head CT: IMPRESSION: No evidence of recent hemorrhage.
Subtle hyperattenuation in
region of prior left basal ganglia/internal capsule parenchymal
hemorrhage.
Foot XRay: IMPRESSION: Soft tissue swelling. No fracture
identified.
Brief Hospital Course:
In summary, Mr. [**Known lastname 31611**] is a 75 year old male with recent
hemorrhagic stroke, HTN, BPH, HL, admitted for bilateral PE and
LLE DVT.
.
Pulmonary Embolism. Patient found to have bilateral central PEs
and LLE DVT. IVC filter placed and anticoagulation with heparin
initiated in spite of recent hemorrhagic stroke (2 months ago)
after discussion with neurology who recommended anticoagulation.
Patient remained hemodyamically stable and was weaned off
supplemental oxygen during hospital stay. Echo showed evidence
of RV strain and he was found to have elevated BNP on admission.
Etiology of PE likely secondary to prolonged immobility; no
history of malignancy or prior clots. He was bridged to Coumadin
prior to discharge and had therapeutic INR for 2 days prior to
discontinuation of heparin drip.
.
H/o CVA. History of hemorrhagic and ischemic CVA with minimal
residual deficits. He was followed by neurology during hospital
stay. Head CT on admission showed no acute event.
.
HTN. Patient continue on lisinopril and felodipine.
.
BPH. S/p turp. He was continued on finasteride.
.
Hyperlipidemia. He was continued on ezetemibe and simvastatin.
.
Left foot/toe pain: Pt c/o pain over dorsum of left foot/toes.
He did not have any focal tenderness or erythema. XR only showed
soft tissue swelling and no fracture. He had edema in left foot,
likely [**1-14**] DVT. He was given 0.5 tab Vicodin with good effect as
needed for toe pain in hospital which was improved at time of
discharge.
Communication: Wife [**Name (NI) 382**] [**Name (NI) 4115**] [**Telephone/Fax (1) 31612**]. Daughter [**Name (NI) 5036**].
[**Telephone/Fax (1) 31613**]
DNR/DNI, confirmed with patient, wife [**Name (NI) 382**]
Medications on Admission:
Finasteride 5 mg daily
Ezetemibe 10 mg daily
Simvastatin 20 mg daily
Felodipine 5 mg daily
Lisinopril 20 mg daily
Lasix 40 daily
K-dur
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day:
Your blood levels will be checked on Wednesday and your dose of
this medication may be adjusted by your primary care physician.
[**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please check INR and Chem 7 on Wednesday [**2186-10-25**] and fax
results to Dr.[**Name (NI) 31614**] office at ([**Telephone/Fax (1) 31615**].
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. K-Dur 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis
1. Pulmonary Embolism
2. Left lower extremity DVT
Secondary Diagnosis
1. Left internal capsule lacunar infarct [**2180**]
2. Hemorrhagic basal ganglia stroke [**8-/2186**]
3. HTN
4. Lumbar disc disease
5. Hypercholesterolemia
6. BPH s/p TURP
Discharge Condition:
Hemodynamically stable, afebrile, oxygenating mid 90s on room
air
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
low oxygen saturations. You were found to have blood clots in
your lungs and one in your left leg which were causing these
symptoms. You had a filter placed in your blood vessels to
prevent clots from going from your legs to your lungs. We also
started you on a blood thinning medication called Coumadin. Your
blood levels of this medication need to be followed very
closely.
We made the following changes to your medications
1. We added Coumadin 7.5 mg by mouth daily. The dose of this
medications may be adjusted based on blood work.
Please return to the ER or call your primary care physician if
you develop any chest pain, shortness of breath, leg swelling,
changes in your vision or speech, numbness, weakness, if you
notice any blood in your stools or if you have any falls or any
other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**]. He
is aware of your recent hospital course. You should call ([**Telephone/Fax (1) 31616**] to make an appointment within the next two weeks.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"453.41",
"V58.61",
"722.52",
"438.89",
"272.0",
"401.9",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
8543, 8601
|
5497, 7225
|
309, 321
|
8905, 8973
|
2621, 5244
|
9900, 10254
|
2008, 2080
|
7410, 8520
|
8622, 8884
|
7251, 7387
|
8997, 9877
|
2095, 2602
|
250, 271
|
349, 1553
|
5253, 5474
|
1575, 1724
|
1740, 1992
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,668
| 132,476
|
4174
|
Discharge summary
|
report
|
Unit No:[**Unit Number 18177**]
Admission Date: [**2142-6-24**]
Discharge Date: [**2142-6-30**]
Date of Birth:
Sex:
Service:
HISTORY OF PRESENT ILLNESS: A 73 year old female with
diastolic dysfunction, chronic prednisone for rheumatoid
arthritis, who presents with four weeks of loose, watery
diarrhea. She was found to be febrile to 100.5 and was also
found to be confused and lethargic at home by family members.
She was then brought to the ED, where initial evaluation
reveals a temperature of 100.1 and hypotension with systolic
blood pressure in the 60s. She received 5 liters of IV fluid
which improved the blood pressure to the 90s. Subsequent to
this the patient desaturated to 89 percent on room air and
was placed on 100 percent non-rebreather, which improved
saturation to 98 percent. Initial laboratory results
revealed a lactate of 4, white blood cell count of 22. She
was, therefore, enrolled in the sepsis protocol. She had a
central line placed and aggressive IV hydration was
initiated. The patient was then transferred to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Lupus.
2. A-fib.
3. Anemia.
4. Osteoporosis.
5. Diastolic CHF.
6. Rheumatoid arthritis.
MEDICATIONS ON ADMISSION: Coumadin 5, prednisone 10,
fentanyl, Lasix 40, Toprol-XL 25.
ALLERGIES: Aspirin, Valium, Demerol, penicillin, codeine,
Percocet and Percodan.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She lives with her husband. She had distant
tobacco smoking.
PHYSICAL EXAMINATION: 100.6, 86/53, pulse 76, 99 percent on
non-rebreather. General, lying flat. Neck, no JVD. No
lymphadenopathy. Lung exam there are crackles one third of
the way up bilaterally. Cardiovascular exam irregularly
irregular. No murmurs appreciated. Abdomen is soft and
nontender, nondistended, normoactive bowel sounds.
Extremities reveal chronic venous stasis changes.
Pertinent laboratories reveal a white count of 24 with 5
bands. Lactate of 4. Initial chest x-ray revealed
cardiomegaly, but otherwise normal.
BRIEF HOSPITAL COURSE:
1. Sepsis. The patient enrolled in the MUST protocol. She
received empiric antibiotic therapy, as well as stress
dose steroids. The eventual source of infection was found
out to be C.difficile colitis. She received p.o. Flagyl
for this with significant improvement in her symptoms. No
other positive cultures came back, excluding the
possibility of disseminated sepsis.
1. Hypoxia. This was believed likely to be due to diastolic
CHF and hyperdynamic state following her sepsis. She was
managed with a non-rebreather in the ICU. As her
hemodynamics improved with the treatment of the sepsis, so
did her shortness of breath.
1. Atrial fibrillation. This remained relatively stable
during the hospital course.
1. Acute renal failure. The patient experienced acute renal
failure most likely secondary to pre-renal azotemia. This
significantly improved with hydration.
1. Rheumatoid arthritis and lupus. She was on stress dose
steroids during the acute illness.
CONDITION ON DISCHARGE: The patient was ambulatory and able
to return home.
DISCHARGE DIAGNOSES:
1. C.difficile colitis.
2. Sepsis.
3. Diastolic congestive heart failure.
4. Atrial fibrillation.
5. Rheumatoid arthritis.
6. Systemic lupus erythematosus.
7. Acute renal failure.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg p.o. daily.
2. Prednisone taper.
3. Fentanyl 50 mcg TP.
4. Vitamin D and calcium.
5. Lasix 40 mg p.o. daily.
6. Protonix 40 mg p.o. daily.
7. Toprol-XL 25 mg p.o. daily.
8. Flagyl 500 mg p.o. t.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**]
Dictated By:[**Doctor Last Name 18178**]
MEDQUIST36
D: [**2143-3-21**] 14:07:17
T: [**2143-3-21**] 14:37:50
Job#: [**Job Number 18179**]
|
[
"710.0",
"428.32",
"355.8",
"428.0",
"427.31",
"038.9",
"584.9",
"008.45",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2048, 3066
|
1388, 1406
|
3165, 3347
|
3370, 3850
|
1226, 1371
|
1509, 2025
|
156, 1084
|
1106, 1199
|
1423, 1486
|
3091, 3144
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,996
| 107,074
|
5681
|
Discharge summary
|
report
|
Admission Date: [**2200-3-18**] Discharge Date: [**2200-3-25**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
woman with complaints of incontinence and difficulty
ambulating and headaches. The patient reported recent falls
including [**2200-3-18**], and a month prior to admission.
The patient per EMS attempted to ambulate on the morning of
discharged from rehabilitation recovering from a fall and
admitted on [**2-1**] with head CT. On the day of admission
she complained of left-sided weakness.
PAST MEDICAL HISTORY: Coronary artery disease. Status post
coronary artery bypass grafting in [**2190**]. Congestive heart
failure with an ejection fraction of 30%. Atrial
Glaucoma. Hypertension. Tachy-brady syndrome. Status post
pacer in [**2191**].
PAST SURGICAL HISTORY: Coronary artery bypass grafting in
[**2190**]. Cataract surgery.
MEDICATIONS: Zestril 10 mg p.o. q.d., Coumadin 2.5 mg q.d.,
Lipitor 10 mg q.d., Levoxyl 15 mg q.d., Lasix 20 mg q.d.,
Glipizide 5 mg b.i.d., Atenolol 75 mg q.d., Aspirin 81 mg
p.o. q.d.
ALLERGIES: BACTRIM.
PHYSICAL EXAMINATION: General: The patient was awake and
alert, oriented to self only. Speech was clear but slow.
HEENT: She had a surgical pupils bilaterally. Extraocular
movements full. She had a decreased nasolabial fold.
Extremities: Her strength in the upper extremity was good on
the right. No antigravity strength on left. She had 2 out
of 5 leg strength, 5 out of 5 on the right, 4 out of 5 in the
left IP,. [**Last Name (un) 938**]. Sensation was grossly intact. Toes
were up on the left, down on the right. Her reflexes were 2+
at the knees, absent at the ankles.
LABORATORY DATA: Head CT showed bilateral subacute large
subdural hematomas with increased layering on the left
greater than right with no midline shift or change in
ventricle.
Her white count was 6.3, hematocrit 34.9, platelet count 237;
INR 2.6, PT 14.3, PTT 31.3.
HOSPITAL COURSE: The patient was admitted into the Surgical
Intensive Care Unit. Her INR was corrected down to less than
1.3. The patient was brought to the OR for surgical
drainage. Once her INR was corrected, she did deteriorate
neurologically becoming more somnolent prior to surgery.
On [**2200-3-20**], she underwent bilateral twist drill
drainage of the right subdural hematoma without
intraoperative complication. Postoperatively the patient was
awake and alert, and oriented times three. She continued to
have a left facial with left upper extremity weakness, but
she was 5 out of 5 in bilateral IPs. She put out 180 cc of
bloody drainage from her subdural drain postoperatively.
Repeat head CT postoperatively showed good evacuation of the
right subdural hematoma. The patient's drain was
discontinued on [**2200-3-21**], and the patient was
transferred to the regular floor. She was seen by Physical
Therapy and Occupational Therapy and found to require
rehabilitation prior to discharge to home.
DISCHARGE MEDICATIONS: Lisinopril 10 mg p.o. q.d.,
Atorvastatin 10 mg p.o. q.d., Levoxyl 15 mcg p.o. q.d., Lasix
20 mg q.d., Glipizide 5 mg p.o. b.i.d., Atenolol 75 mg p.o.
q.d., Zantac 150 mg p.o. q.d.
CONDITION ON DISCHARGE: The patient was stable at the time
of discharge.
FOLLOW-UP: She will follow-up with Dr. [**First Name (STitle) **] in [**2-3**] weeks with
repeat head CT prior to the appointment.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2200-3-25**] 12:03
T: [**2200-3-25**] 12:12
JOB#: [**Job Number 22704**]
|
[
"401.9",
"E878.8",
"428.0",
"427.31",
"432.1",
"998.12",
"427.81",
"365.9",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.24"
] |
icd9pcs
|
[
[
[]
]
] |
2995, 3176
|
1970, 2971
|
818, 1095
|
1118, 1952
|
112, 534
|
557, 793
|
3201, 3665
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,605
| 141,515
|
34628
|
Discharge summary
|
report
|
Admission Date: [**2137-1-10**] Discharge Date: [**2137-1-19**]
Date of Birth: [**2083-9-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Aztreonam / Meropenem / Ace
Inhibitors
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
53M history of morbid obesity, achondroplasia, obstructive
sleep apnea, quadriplegia short stature, with a a history of
acute hypercarbic respiratory failure in [**2133**], [**2134**] requiring
tracheostomy, as well as several episodes of pnemonia, cames to
the ED with shortness of breath today.
Per ED report, he came in today having worsening SOB, trouble
breathing, but no cough or fever.
.
Per family report, patient has been not himself for the past few
days, occasionally confused, short of breath, and weak.
.
In the ED, initial vs were: 99.1 HR 100 BP 199/104 RR 20 93% on
2L.
.
Came in with mild temp of 99.1, intially on nasal cannula, with
saturations in to low 90s, at which point he was switched to
NRB, and while in ED started getting increasingly somnolent,
tiring out. At this point ED got initial ABG was VBG, repeat
showed hypercarbia, with decreased O2sat. Given this, did a
quick bronchoscopy - was intubated via right nare size 7. while
in ED given Levo, Vanc, CTX - for CXR likely RML PNA, per ED
read.
.
Prior to transfer Satting 99% on Vent - not hard to ventilate.
BP 140/90, Tachy to 110. Then, became hypotensive after
intubation while on propofol into 70s, he was also on high PEEP
(10) at that time. He had a right groin line put in, and was
started on Levo.
Prior to transfer, his vent settings wer TV 450, fI02 48% PEEP
10.
.
.
On arrival to the MICU, patient was intubated, sedated. While
attempting to move him to the right side, he desatted, but
recovered when lying flat on his back. His initial vitals were
HR 86, BP 119/63, 97%. He was not on pressors, but was sedated.
Past Medical History:
1. Hypertension.
2. Panic attacks.
3. Achondroplasia.
4. History of cervical laminectomies.
5. History of lumbar laminectomies.
6. History of cervical spinal fusion.
7. Status post tracheostomy.
8. Sinusitis.
9. Arthritis.
10. Hypercarbic respiratory distress s/p trach and PEG in [**2134**]
11. ? h/o Seizure Disorder
12. BPH
13. OSA on BiPAP (I: 18/ E: 13) + nocturnal 2 L O2
Social History:
He is a retired camera manufacturer for Kodak. He lives with
his wife. [**Name (NI) 3003**] smoking history when he was much younger.
- Tobacco: quit 40 years ago
- Alcohol: occasional alcohol use
- Illicits: denies any illicit drug use
Family History:
Heart disease in both of his parents (both smokers and heavy
drinkers). Also fam hx of arthritis, glaucoma, and stroke.
Denies fam hx of diabetes or cancer.
Physical Exam:
Admission Physical exam:
GENERAL: Obese, short stature, lying in bed, intubated.
HEENT: Small pupils 3mm, mildly reactive to light sclerae
anicteric and without injection.MMM. Oropharynx could not be
evaluated.
NECK: Thick, JVP could not be assesed.
HEART: tachycardic, S1, S2, no murmurs auscultated, but distant
heart sound.
LUNGS: Not moving air well, quiet expiratory wheeze with some
rhonchi
ABDOMEN: Obese, Soft/NT/ND, no masses or HSM, no
rebound/guarding. Scars, likely appendectomy.
BACK: Areas of irritation along buttocks and gluteal folds,
multiple skin tags on posterior right thigh, with multiple
excoriative, thick lichenification regions.
EXTREMITIES: WWP, diffuse soft tissue swelling without clear
edema of the legs, 2+ peripheral pulses.
Neuro: Not responsive, sedated, no babinski, but minimal
reflexed.
Discharge Physical Exam:
96.8 116/68 71 20 94% on CPAP
GENERAL - NAD, appropriate
NECK: Thick, JVP could not be assesed.
LUNGS - faint rhonchi throughout, unable to assess well given
body habitus, resp unlabored, no accessory muscle use
HEART - distant heart sounds, regular rate, S1, S2, no murmurs
heard
ABDOMEN: Obese, Soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES: WWP, 2+ peripheral pulses (radials, DPs, PTs)
NEURO: awake, alert and interactive. CNII-XII grossly intact,
moving all four extremities, sensation grossly intact
Pertinent Results:
ADMISSION:
[**2137-1-10**] 10:26PM BLOOD WBC-9.9# RBC-4.54* Hgb-12.6* Hct-39.9*
MCV-88 MCH-27.8 MCHC-31.6 RDW-15.2 Plt Ct-184
[**2137-1-13**] 03:46AM BLOOD WBC-8.1 RBC-3.78* Hgb-10.7* Hct-32.6*
MCV-86 MCH-28.3 MCHC-32.8 RDW-15.2 Plt Ct-169
[**2137-1-10**] 10:26PM BLOOD Neuts-83.4* Lymphs-9.7* Monos-3.2 Eos-3.3
Baso-0.4
[**2137-1-11**] 03:48AM BLOOD Neuts-89.7* Lymphs-6.4* Monos-3.2 Eos-0.5
Baso-0.1
[**2137-1-10**] 10:26PM BLOOD Glucose-185* UreaN-20 Creat-0.9 Na-143
K-5.8* Cl-104 HCO3-36* AnGap-9
[**2137-1-13**] 03:46AM BLOOD Glucose-94 UreaN-16 Creat-1.0 Na-140
K-4.4 Cl-96 HCO3-40* AnGap-8
[**2137-1-10**] 10:26PM BLOOD Calcium-8.8 Phos-4.4 Mg-1.9
[**2137-1-10**] CXR: IMPRESSION: Findings consistent with congestive
heart failure and concerning for concurrent infection in the
right upper and lower lobes. Lentiform opacity in the left base
could be further evaluated with dedicated PA and lateral
radiographs when the patient is able; it is suspected to
represent a fat pad but it is difficult to exclude a loculated
pleural effusion based only on this image.
Notable Studies:
[**2137-1-13**] CXR: IMPRESSION: AP chest compared to [**7-1**] through
[**1-12**]:
There is a large right pleural effusion layering posteriorly
obscuring much of the right lung, but there is a suggestion of
some improvement in consolidation today compared to [**1-10**].
The left upper lung, as a measure of pulmonary edema since it is
not obscured by pleural effusion shows some improvement.
Consolidation at the left base is still substantial, and the
heart is chronically very enlarged. No pneumothorax.
[**2137-1-14**] Bilateral LE Venous Ultrasound: IMPRESSION: Limited
examination, but no evidence of DVT in right or left lower
extremity.
[**2137-1-15**] CT Chest: IMPRESSION: As compared to [**2136-7-1**],
bilateral pleural effusions of overall small-to-moderate extent
have newly appeared. As a consequence, there are areas of
atelectasis at both lung bases, right more than left as well as
in the left lung apex. Unchanged triangular mid lobe nodule. No
evidence of empyema or abscess. Extensive respiratory motion
artifacts. Borderline diameter of the pulmonary
artery. No other mediastinal abnormalities. Degenerative bone
disease.
[**1-14**] LENIs: IMPRESSION: Limited examination, but no evidence of
DVT in right or left lower extremity
[**1-17**] Chest CT with contrast: IMPRESSION: As compared to [**2136-7-1**], bilateral pleural effusions of overall small-to-moderate
extent have newly appeared. As a consequence, there are areas of
atelectasis at both lung bases, right more than left as well as
in the left lung apex.
Unchanged triangular mid lobe nodule. No evidence of empyema or
abscess.
Extensive respiratory motion artifacts. Borderline diameter of
the pulmonary artery. No other mediastinal abnormalities.
Degenerative bone disease.
DISCHARGE LABS:
[**2137-1-18**] CBC: 6.4 11.4* 35.7* 187
[**2137-1-18**] Chem: BUN 31 Cr 0.9 Na 135 K 4.8 Cl 98 HCO3 34 AG 8
Studies Pending at Discharge:
None
Brief Hospital Course:
Mr. [**Known lastname 284**] is a 52 year old man with achondroplasia, morbid
obesity, obesity hypoventilation syndrome c/b pulmonary
hypertension and right heart failure, diabetes mellitus and
hypertension admitted with respiratory failure and MSSA
pneumonia.
.
#Respiratory Failure/Methicillin sensitive staph aureus
pneumonia/Fever/Pulmonary Hypertension/Right heart failure:
The patient was found to be in hypercarbic respiratory failure
on presentation to the ED and was intubated via his right nare.
His CXR showed pneumonia and an intubated sputum culture grew
MSSA. He was treated with Vancomycin given his allergies to
cephalosporins and penicillins (including anaphylaxis) and
diuresed for volume overload in the setting of right heart
failure. He was extubated and improved clinically but had
persistent fevers which resolved over 3 days with a downtrending
fever curve each day. Given persistent fever he had lower
extremity dopplers negative for DVT and had Chest CT which
showed no abscess or empyema or pulmonary embolism. His UA was
not consistent with UTI. Therefore, it was felt that fevers were
due to slowly resolving MSSA pneumonia and the decision was made
to continue treatment for 14 day course. He was discharged home
to complete Vancomycin via PICC and will have safety labs
checked by VNA on discharge and sent to PCP [**Name Initial (PRE) 3726**]. He was back
to his home 3L oxygen requirement prior to discharge.
#Obesity hypoventilation syndrome:
Patient was continued on his nighttime BIPAP
.
#Rash: The patient has an extensive wart-like rash on his
buttocks that he says has been unchanged for 2 years. Although
the patient denies anal intercourse, there was concern for HPV
PAP smear of the anal lesion was sent for analysis. However, the
sample inadequate. His PCP will follow up on his rash as an
outpatient.
.
#Hypertension/Hypotension: - The patient was initially
hypotensive and started on pressors and monitored via A-line. He
was weaned off pressors and his A-line was removed in the ICU
and his BP remained stable on the floor and his home
antihypertensives were restarted.
.
#Diabetes mellitus type 2: The patient was put on an insulin
sliding scale while inpatient. Metformin was held during his
admission.
.
#Benign prostatic hypertrophy: Urine output was monitored with
foley initially and then patient was able to void on his own.
Medications were resumed on discharge.
.
Transitional issues:
- complete course of IV vanc as outpatient
- outpatient labs to be followed up by PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] after being
drawn by VNA
# Communication: [**Name (NI) **] wife - ([**Telephone/Fax (1) 79439**] home,
([**Telephone/Fax (1) 79436**]
# Code: Full (discussed with patient's wife)
# Disposition: Patient was discharged home with VNA for labs to
be checked and faxed to PCP and to continue Vancomycin for total
14 day course.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every four (4) hours as needed for shortness of
breath with upper respiratory infection
ECONAZOLE - 1 % Cream - daily prn yeast infection
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol [**Hospital1 **] prn
coughing/wheezing Rinse mouth after use
LOSARTAN - 50 mg Tablet daily
METFORMIN - 750 mg Tablet Extended Release 24 hr daily
METOPROLOL TARTRATE - 25 mg Tablet [**Hospital1 **]
OXYGEN - home portable NC daily if sat <90% at rest or
exertion 2-3L continuous pulse dose for portability Dx 278.03
Obesity hypoventilation syndrome
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr daily
TERAZOSIN - 5 mg Capsule - 1 Capsule(s) by mouth QHS
CETIRIZINE - (OTC) - 10 mg Tablet - 1 Tablet(s) by mouth at
bedtime
Discharge Medications:
1. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
every twelve (12) hours for 6 days: Course will be completed on
[**2137-1-24**].
Disp:*12 doses* Refills:*0*
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
3. econazole 1 % Cream Sig: One (1) Topical once a day as
needed for yeast infection.
4. fluticasone 110 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day as needed for shortness of breath or
wheezing.
5. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metformin 750 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. cetirizine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Outpatient Lab Work
Please obtain Vancomycin trough, CBC, and Chem 7 panel on
[**2137-1-23**] prior to AM Vancomycin dose and fax results to Dr
[**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **] (Phone: [**Telephone/Fax (1) 250**], Fax: [**Telephone/Fax (1) 4004**]).
Discharge Disposition:
Home
Discharge Diagnosis:
Methicillin Sensitive Staph Aureus Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 284**],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You were admitted to the intensive care unit for pneumonia. You
were found to be in respiratory distress when you arrive in the
Emergency Department and you were intubated. You were started
on antibiotics for your pneumonia and gradually improved during
your stay.
You should continue your antibiotics at home through your picc
line. The following changes have been made to your medications:
Add:
- Vancomycin 1g every 12 hours through [**2137-1-24**]
Discontinue:
- TERAZOSIN due to low blood pressure. Please discuss with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**] this at your follow up
appointment.
Followup Instructions:
Please go to the following scheduled appointments.
Department: [**Hospital3 249**]
When: FRIDAY [**2137-1-25**] at 4:30 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**2137-2-14**] 02:00p [**Year/Month/Day 1570**],INTERPRET W/LAB NO CHECK-IN [**Year/Month/Day 1570**]
INTEPRETATION BILLING
[**2137-2-14**] 02:00p GOLD/BEACH COPD,TCC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] PULMONARY UNIT-CC7 (SB
Department: [**Hospital3 249**]
When: TUESDAY [**2137-4-2**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2137-6-4**] at 1:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 1570**]
When: TUESDAY [**2137-6-4**] at 2:00 PM
Completed by:[**2137-1-21**]
|
[
"482.41",
"278.01",
"493.20",
"428.0",
"250.00",
"518.81",
"782.1",
"401.9",
"276.2",
"V46.2",
"428.33",
"V46.3",
"V44.0",
"327.23",
"600.00",
"451.84",
"416.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12332, 12338
|
7303, 9723
|
349, 361
|
12427, 12427
|
4261, 7114
|
13363, 14714
|
2686, 2846
|
11060, 12309
|
12359, 12406
|
10242, 11037
|
12578, 13340
|
7130, 7257
|
2886, 3689
|
7271, 7280
|
9744, 10216
|
290, 311
|
390, 2002
|
12442, 12554
|
2024, 2413
|
2429, 2670
|
3714, 4242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,524
| 123,196
|
37147
|
Discharge summary
|
report
|
Admission Date: [**2167-12-14**] Discharge Date: [**2167-12-19**]
Date of Birth: [**2130-9-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Increasing dyspnea on exertion s/p AVR in [**2160**]. Serial ECHO's
reveal 4+ AR.
Major Surgical or Invasive Procedure:
1. Redo sternotomy and replacement of aortic valve with a 21-mm
Onyx mechanical aortic valve, serial #[**Serial Number 83693**], reference ONX
ACE.
2. Replacement of the ascending aorta and hemi-arch using deep
hypothermic circulatory arrest and a 28-mm
History of Present Illness:
History of Present Illness:37 year old male who is status post
aortic valve replacement with homograft root replacement in [**Month (only) 205**]
[**2155**]. Since that time, serial echocardiograms have shown
progressive aortic regurgitation. He has recently experienced
worsening dyspnea on exertion and decreased exercise tolerance.
Past Medical History:
Hypercholesterolemia
Migraines
Lyme's disease
Sciatica
Aortic insufficiency
eczema
AVR/homograft root replacement in [**2156-6-16**] (B&W)
s/p Appendectomy [**2155**]
Social History:
Race:Caucasian
Last Dental Exam:[**9-24**]
Lives with:wife
Occupation:mechanical engineer
Tobacco:denies
ETOH:2 drinks per week
Enrolled in any clinical/research study? ON-X
Family History:
non contributory
Physical Exam:
Physical Exam
Pulse: Resp: O2 sat:
B/P Right: Left:
Height: 6'2" Weight:225
General:NAD, very fit
Skin: Dry [x] intact [x]multiple eczema patches
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x];well-healed sternotomy
Heart: RRR [x] Irregular [] Murmur: 5/6 SEM radiates to
carotids; [**1-23**] diastolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema:none
Varicosities: None [x]
Neuro: Grossly intact:nonfocal exam
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit: murmur radiates loudly to carotids
Pertinent Results:
[**12-13**] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D
or color Doppler. 2. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. 4. The ascending aorta is moderately dilated. 5. The
aortic valve appears to be a homograft. The prosthetic aortic
valve leaflets are thickened. Severe (4+) aortic regurgitation
is seen. 6. Trivial mitral regurgitation is seen. 7. There is a
small pericardial effusion. POST-BYPASS: For the post-bypass
study, the patient was receiving vasoactive infusions including
phenylephrine and is in sinus rhythm. 1. A well seated
mechanical valve is seen in the Aortic position. Leaflets move
well. Washing jets are seen. A larger than expected valvular AI
jet ( ashing jet?) is noted from the valve near where the native
RCC would have been. This jet appeared to improve with time to
be no more than mild is severity. Mean gradient across the valve
is 20 mm of Hg at a CO of 6 l/min. 2. Biventricular function is
unchanged. 3. Aorta appears to be intact contours. 4. Other
findings are unchanged.
[**2167-12-19**] 06:45AM BLOOD WBC-6.4 RBC-3.27* Hgb-10.4* Hct-30.0*
MCV-92 MCH-31.7 MCHC-34.5 RDW-14.2 Plt Ct-189#
[**2167-12-19**] 06:45AM BLOOD PT-26.6* PTT-37.2* INR(PT)-2.6*
[**2167-12-18**] 07:10AM BLOOD PT-19.7* PTT-32.8 INR(PT)-1.8*
[**2167-12-19**] 06:45AM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-140
K-4.8 Cl-102 HCO3-30 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and taken to the Operating Room on
[**2167-12-14**] for aortic valve replacement (#21mm Onyx) and ascending
aorta and hemiarch replacement. See operative note for details.
Post operatively, Mr. [**Known lastname **] was transferred to the ICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
He was started on betablockade and diuretics and was transferred
to the step down unit on POD#1. His chest tubes and temporary
pacing wires were removed per protocol. He was evaluated by
physical therapy for strength and conditioning and was cleared
for discharge to home. He was started on coumadin therapy for
mechnical aortic valve. His primary care doctor Dr. [**Last Name (STitle) **]
will follow his INR and coumadin dosing. He was discharged to
home on post-operative day five by Dr. [**Last Name (STitle) 914**]. All follow-up
appointments were advised.
Medications on Admission:
MVI, Fish oil, flax seed oil, vit. C
Plavix 75 mg- last dose will be [**12-6**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(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. Outpatient Lab Work
INR check on [**2167-12-20**] and then as directed by Dr. [**Last Name (STitle) **].
Results to be faxed to Dr. [**Last Name (STitle) **] for coumadin dosing.
Fax [**Telephone/Fax (1) 83694**]
Phone [**Telephone/Fax (1) 35783**]
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever .
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Aortic Insufficiency s/p Re-do Sternotomy Aortic valve
replacement/Ascending aorta and hemiarch replacement
Past Medical History:
Hypercholesterolemia
Migraines
Lyme's disease
Sciatica
s/p AVR/homograft root replacement in [**2156-6-16**] (B&W)
s/p Appendectomy [**2155**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet 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**]
Your INR will be drawn by the VNA and results faxed to Dr.
[**Last Name (STitle) **] Phone [**Telephone/Fax (1) 35783**]/ fax [**Telephone/Fax (1) 83694**] for coumadin
dosing (confirmed with DR. [**Last Name (STitle) **]).
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name8 (NamePattern2) 21976**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 35783**] in [**12-19**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) 28075**] [**Last Name (NamePattern1) 2912**] [**Telephone/Fax (1) 83695**] in [**12-19**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Your INR will drawn on Sunday [**2167-12-20**] by the VNA and results will
be faxed to Dr. [**Last Name (STitle) **] for coumadin dosing fax
[**Telephone/Fax (1) 83694**].
Completed by:[**2167-12-19**]
|
[
"285.1",
"724.3",
"441.2",
"E878.2",
"272.0",
"692.9",
"424.1",
"346.90",
"996.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.22",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
6113, 6181
|
3851, 4830
|
386, 642
|
6497, 6592
|
2268, 3828
|
7357, 8075
|
1404, 1422
|
4960, 6090
|
6202, 6310
|
4856, 4937
|
6616, 7334
|
1437, 2249
|
265, 348
|
697, 1006
|
6332, 6476
|
1212, 1388
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,427
| 110,578
|
33561
|
Discharge summary
|
report
|
Admission Date: [**2150-4-2**] Discharge Date: [**2150-4-22**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Melena, hematocrit drop
Major Surgical or Invasive Procedure:
EGD
Tunneling of temporary HD line
History of Present Illness:
75 yo male with ESRD on HD, trach for resp failure who presents
from [**Hospital **] rehab with a hematocrit drop and melena in his
rectal tube. Per notes he had HD yesterday and received 2 units
PRBCS during HD and hct was 35 during HD. Today hct was
re-checked and was 19. Stools were noted to guaiac positive. INR
was noted to be 4.3 , so pt received 5 mg of vitamin K. VS at NH
were T 97.5 HR 104 BP 108/59 and sats of 98%.
.
In the ER he was noted to have melena in his rectal tube. Hs HR
was initialy in the 90s with BP 108/53. He had a lavage of his
g-tube that was clear and received protonix 40 IV x2. He
received an additional 5 mg of vitamin K and 2 units of FFP
here. He received ~1.5 L of fluid and had starte receiving 1
back of PRBCs prior to txfr to the ICU. While in the ER his SBPs
dropped to the 80s-90s.
.
Upon arrival to the floor, the pt's initial SBP was in the 70s,
with HR in the 120s. This improved to SBP of 90s. The pt
appeared comfortable and denied abdominal pain, chest pain,
lightheadedness or nausea. Said he had fevers several weeks ago
and one recent episode of emesis. He thinks he may have had
black stool for weeks.
.
Of note, pt recently admitted [**Date range (1) 77791**] for new atrial
fibrillation, septic shock (urosepsis), and acute on chronic
renal failure now requiring dialysis and was discharged to
[**Hospital1 **].
Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].
Family History:
N/C
Physical Exam:
VS: T: HR: 120s BP: SBP 70s-90s RR: O2 sat:
Gen: obese male, mentating appropriately, NAD, pale
HEENT: anicteric sclera, dry MM
Neck: supple, dialysis line in place
Cardio: distant heart sounds, tachycardic, no murmur appreciated
Pulm: CTAB anteriorly, no w/r/g
Abd: soft, obese, NT, ND, +BS, G tube in place
Ext: hyperpigmentation on shins, 1+ peripheral edema, 1+ DP
pulses b/l
Neuro: Alert, awake, mentating appropriately and responding to
commands. Moves all extremities
Skin: hyperpigmentation on shins, dry gauze wrapped on both
shins
Pertinent Results:
Admission labs:
[**2150-4-1**] 11:05PM WBC-12.0* RBC-2.01* HGB-5.8* HCT-18.6* MCV-92
MCH-28.9 MCHC-31.3 RDW-20.0*
[**2150-4-1**] 11:05PM NEUTS-77.0* BANDS-0 LYMPHS-16.4* MONOS-3.7
EOS-2.7 BASOS-0.2
[**2150-4-1**] 11:05PM PLT SMR-NORMAL PLT COUNT-162
[**2150-4-1**] 11:05PM GLUCOSE-127* UREA N-99* CREAT-3.5* SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2150-4-1**] 11:05PM CALCIUM-8.1* PHOSPHATE-3.4 MAGNESIUM-2.8*
[**2150-4-1**] 11:05PM ALT(SGPT)-6 AST(SGOT)-13 ALK PHOS-121* TOT
BILI-0.2
[**2150-4-1**] 11:05PM LIPASE-52
[**2150-4-1**] 11:05PM PT-24.5* PTT-36.1* INR(PT)-2.4*
.
Studies:
ECG Study Date of [**2150-4-1**]
Rate PR QRS QT/QTc P QRS T
117 0 124 346/445 0 20 0
Baseline artifact. Probable atrial fibrillation with rapid
ventricular
response. However, there are periods of regularization but no
discernible
flutter waves. There is right bundle-branch block. Since the
previous tracing of [**2150-3-15**] the ventricular response is more
regular.
.
CHEST (PORTABLE AP) [**2150-4-2**]
Tracheostomy tube tip terminates about 9 cm above the carina,
and the cuff is overdistended, as communicated by telephone to
Dr. [**Last Name (STitle) **] on [**2150-4-2**]. Heart is enlarged, pulmonary
vascularity is engorged, and there is bilateral perihilar
haziness attributed to pulmonary edema. More confluent left
retrocardiac opacification is present, likely a combination of
atelectasis and moderate effusion, but underlying infectious
consolidation is not excluded. Small right pleural effusion is
also evident.
.
EGD [**2150-4-2**]
Impression: Internal bumper of the recently placed PEG tube was
seen in place. There was a blood clot underneath the bumper
suggesting a site of bleed. It was washed, and did not reveal
any visible vessel or active bleeding.
There was no fresh or old blood (except the clot under the
bumper) seen in the stomach.
There was no fresh or old blood in the duodenum.
Erythema in the first and 2nd part of the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations:
- Bleeding likely to be from the site of the internal bumper of
the PEG in the setting of high INR, but seems to have stopped
now.
- PPI [**Hospital1 **]
- Watch Hct
.
TTE (Complete) Done [**2150-4-4**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Moderately dilated left ventricular cavity. Left
ventricular function is probably low-normal, a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen. Thickened aortic leaflets without frank stenosis.
Pulmonary artery systolic pressure could not be determined.
.
RENAL U.S. PORT [**2150-4-13**]
IMPRESSION: No hydronephrosis. No collections identified. Thin
cortex bilaterally consistent with chronic interstitial disease.
.
CHEST (PORTABLE AP) [**2150-4-17**]
FINDINGS: The image did not include the lung bases; however,
there is opacification in the right lung base secondary to
atelectasis and effusion. The left lung base cannot be
evaluated. The heart size is mildly enlarged and stable. More
opacification adjacent to the left heart border may indicate
left lower lobe atelectasis. A double-lumen central line tip is
in the proximal-to-mid one-third of the SVC. The tracheostomy
tube projects approximately 5 cm from the carina, unchanged.
Brief Hospital Course:
75 year old male with h/o ESRD on HD, tracheostomy who initally
presented with anemia and melena. The patient was recently
discharged from [**Hospital1 18**] to rehab. At rehab, he was found to have
a drop in his hematocrit from 35 to 18.6 associated with
hypotension and tachycardia.
.
# GI Bleed: On admission, he had melena in his rectal tube and
gtube lavage was reportedly negative. His melena at that time
was felt most likely to LGIB, in the setting of recent
initiation of anticoagulation and supratherapeutic INR. ASA and
coumadin were held on admission as well as his BB. The patient
had a tagged red blood cell scan to identify the source of
bleeding, which was negative. GI was consulted and performed
EGD on admission which demonstrated the source of bleeding to be
most likely from the site of the internal bumper of the PEG in
the setting of high INR, with no active bleeding noted. Aspirin
and coumadin were held in the setting of active GI bleeding. He
was transfused 8 units of PRBCs as well as 2 units of FFP on day
of admission, and his HCT remained stable above 30. Although
his HCT remained stable, he continued to be guaiac positive. He
was a second EGD on [**4-20**], which showed no source of bleeding.
His ASA and coumadin were restarted.
.
# Acute blood loss anemia: As above.
.
# Hypotension, Hemorrhagic, Hypovolemic and Septic: Pt was
initially hypotensive, likely hemorrhagic [**1-17**] GI bleed. With
aggressive IVF resuscitation and transfusions on admission,
patient became volume overloaded. With CVVH, over 40L of fluids
were removed. However, in the setting of diuresis, the patient
dropped his blood pressures and required Neo to maintain SBP
over 90 and MAP greater than 55. Neo was able to be weaned off
with IVF boluses. He was also treated for UTI and bacteremia.
At discharge, his SBP ranged at 100s-110s.
.
# Relative adrenal insufficiency: Pt was started on a course of
stress dose steroids after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test had a less than
target range increase after cosyntropin was administered. This
was discontinued after 6 days as he was not displaying other
signs of adrenal insufficiency.
.
# Chronic kidney disease, stage V: The patient was started on
dialysis for renal insufficiency during his previous admission.
He was seen by renal while in the hospital, who felt he could
benefit from CVVH while in the intensive care unit to help
mobilize some of his fluid overload. He was on CVVH initially
and then transitioned to HD 3x/week. Throughout his course of
stay, he was negative 29L at discharge; weight at time of
discharge is 147 kg. His temporary line was also tunneled in IR
during this admission without complication. However, the
insertion site became infected; catheter tip culture has no
growth to time of discharge. A second tunneled line was placed
by IR on [**4-20**]. He was started on midodrine to support his BP
during dialysis.
.
# Atrial fibrillation with RVR: On admission, the patient was
in afib with RVR. His beta blocker and anticoagulation was
initially held in the setting of his GIB. He was restarted on
his BB as tolerated by his BP. He was also transiently on
digoxin for improved rate control while on CVVH; this was
discontinued as his HR came under better control with BB. HR on
discharge was in the 50-60s.
.
# UTI: Pt was found to have pan-resistant Klebsiella UTI and
received a 10 day course of Meropenam.
.
# Bacteremia: Pt was found to have 2/2 bottles of coag.
negative Staph from the arterial line. The line was pulled and
a new one place. The catheter tip culture has no growth to time
of discharge. Pt was treated with a 14 day course of Vancomycin
given his hypotension, tachycardia, and elevated WBC at the
time.
.
# Respiratory failure: Pt has a tracheostomy and initially
required vent support. With mobilization of his excess fluid,
the patient was weaned to a trach mask while in the hospital.
On [**4-20**] he desatted to 80%, in the setting of having increased
volume (7L positive in the last two days). He had HD, where 3L
were removed and his sats did not improve significantly. He was
requiring .7% FiO2, CXR showed partial collapse of his left
lung. Mechanical ventilation was restarted and he was
maintained on this until discharge. Sputum culture from [**4-8**]
showed acinetobacter and stenotrophomonas, initially not treated
because it was felt these could be colonizers. However, in the
context of his increased oxygen requirement and cxr findings he
was started on tobramycin and was already on vanc for a presumed
line infection (positive blood cultures). He underwent a BAL on
[**4-21**] and results are pending. He will need to have his
tobramycin and vancomycin dosed at HD. Please give 80 mg of IV
tobramycin after HD and check level prior to HD. If tobramycin
level is >2, dose will required adjustment. IV vancomycin
should also be dosed after HD with levels drawn prior to HD.
Results of the BAL should be followed up and if pt has
clinically improved the antibiotics should be discontinued.
.
# ?MGUS: Pt had an elevated kappan and lambda. Heme/onc was
consulted and performed a bone marrow biopsy. Preliminary
results suggest MGUS. Heme/onc had recommended outpatient
follow up in Benign [**Hospital **] Clinic in [**1-19**] weeks.
.
# DM2: Pt was covered with a sliding scale for his Type II
Diabetes.
.
# Hyperlipidemia: Pt was continued on his simvastation.
.
# FEN: Pt received tube feeds via G-tube at goal.
# FULL CODE
# HCP: [**Name (NI) 77789**] [**Name (NI) 77792**] (wife) [**Telephone/Fax (1) 77790**]
Medications on Admission:
Insulin SS
lantus 48 units qhs
Simvastatin 10 mg daily
ASA 81 mg daily
Metoprolol 50 mg TID
Citalopram 20 mg daily
Lansoprazole 30 mg daily
Coumadin
Silver Sulfadiazine 1%
Epoetin 1000 units with HD
Acetaminophen 650 q6 hours prn
clonazepam 0.5 mg tid prn
trazodone 50 mg hs prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Insulin Glargine 100 unit/mL Solution Sig: Fifty Two (52)
units Subcutaneous once a day.
4. Insulin Regular Human 100 unit/mL Solution Sig: 0-18 units
Injection four times a day: As directed by sliding scale.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 4 PM).
16. Tobramycin in NS 80 mg/100 mL Piggyback Sig: Eighty (80) mg
Intravenous QHD (each hemodialysis) for 10 days: Please dose
after HD. Please call [**Hospital1 18**] to follow up BAL results from [**4-21**],
if no growth and pt clinically improving can d/c anitbiotics.
17. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
18. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous HD PROTOCOL (HD Protochol) for 10 days.
19. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
20. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary:
upper GI bleed
urosepsis with ESBL
Volume overload
Hypotension
.
Secondary:
ESRD on dialysis
Atrial fibrillation
Urinary tract infection
Bacteremia
Monoclonal gammopathy of undetermined significance
Hyperlipidemia
Type II Diabetes
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital with a drop in your blood
counts and melena (or blood in your stool). While you were in
the hospital, an EGD showed a clot around your PEG tube site,
which likely contributed to your bleeding. Your INR was also
high, which was a contributing factor. While in the hostpial
you had an infection of your urinary tract that was treated,
your blood pressure was also low. You had alot of fluid removed
in dialysis and your current weight, which is your dry weight is
147 kg.
GI reevaluated your upper GI tract and found no source of
bleeding, you were restarted on warfarin.
At the time of discharge your blood level (hematocrit) was
stable, and should be checked in 3 days.
.
You were also on CVVH, a type of dialysis, while you were in the
hospital to help remove some of the excess fluid in your
tissues. During work up of causes of renal failure, you were
noted to have abnormal blood tests leading to a bone marrow
biopsy. You were diagnosed with possible MGUS (monoclonal
gammopathy of undetermined significance). You will see a
hematologist as an outpatient for this.
.
For a brief time, you needed medications to help support your
blood pressure. Your blood pressure is now fine off the
medications.
.
You were also treated for a urinary tract infection and bacteria
in your blood with antibiotics. In addition you were started on
tobramycin for acetinobacter and stentrophomonas in your sputum
when your oxygen requirement increased. A BAL was done [**4-21**],
with no growth to date. This will need to be followed up.
.
Please continue to take your medications as directed.
.
Please keep your follow up appointments.
.
If you have more bleeding from the rectum, vomiting of blood,
abdominal pain, lightheadedness, palpitations, chest discomfort,
shortness of breath, or any other concerning symptoms, please
call your primary care provider or go to the Emergency
Department.
Followup Instructions:
Please follow up with your PCP within two weeks of discharge.
.
Please also follow up with the Benign [**Hospital **] Clinic in [**1-19**] months
regarding the diagnosis of MGUS. The clinic number is
[**Telephone/Fax (1) 68451**].
Completed by:[**2150-5-5**]
|
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"585.6",
"536.49",
"578.9",
"041.3",
"427.31",
"428.32",
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.95",
"33.24",
"45.13",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
14807, 14882
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6725, 12367
|
317, 354
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15166, 15185
|
2626, 2626
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2042, 2047
|
12696, 14784
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14903, 15145
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12393, 12673
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15209, 17134
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2062, 2607
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254, 279
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382, 1750
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2642, 6702
|
1772, 1948
|
1964, 2026
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,583
| 157,661
|
6411
|
Discharge summary
|
report
|
Admission Date: [**2138-5-30**] Discharge Date: [**2138-6-6**]
Date of Birth: [**2065-8-1**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Lipitor / Naprosyn / Penicillins / Amoxicillin /
Chocolate Flavor / Crestor / Morphine / Ativan
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
melena, ARF
Major Surgical or Invasive Procedure:
bronchoscopy
EGD
tunnelled HD line placement
History of Present Illness:
This is a 72 y/o male with a complicated medical history
including CAD, CRI, PVD, who recently had a strangulated ventral
hernia in [**3-5**] s/p small bowel resections x 2, c/b PNA and
respiratory failure requiring a trach, recently here at [**Hospital1 18**]
SICU from [**Date range (1) 13342**]/07 for PNA and worsening respiratory status,
who now presents from [**Hospital1 **] with melena and ARF. He was
treated for MRSA PNA and pseudomonas UTI with Linezolid and
Cefepime during that hospitalization. His respiratory status
stabilized and he also had trach change to improve his air leark
during that time. He was subsequently discharged to [**Hospital1 **] in
stable condition.
.
While at [**Hospital1 **], he was noted to have melena for the last [**6-6**]
days. However, he has been getting PRBCs transfusions since
[**2138-5-6**], receiving a total of 10 U since being there. He was also
noted to have worsening renal function and anuria for the last
few days. Per patient's wife, [**Name (NI) **] was adequate until 3-4 days
ago when it seemed to become dark and volume decreased. He
suffered a Hct drop to 27.7 [**5-23**] from 30 on [**5-20**], and was given
6 U PRBCs. He received another 2 U PRBCs this morning prior to
transfer and had a Hct of 27.8 prior to transfer. BUN/Cr at
rehab today are 175/4.8, elevated from 64/1.1 at the beginning
of [**Month (only) 116**]. His creatinine has risen from 1.4 on [**5-15**] to 2.0 on [**5-20**]
to 2.3 on [**5-21**]. His linezolid and cefepime course ended on
[**2138-5-7**], although he appears to have received a one-time dose of
Vancomycin on [**5-21**] for MRSA in sputum. He was transferred to
[**Hospital1 18**] for further evaluation of his melena and ARF today and
prior to transfer, received 2 U PRBCs. Hct on transfer was 27.8.
.
In ED, VS were Tc 95.8, BP 150/41, HR 68, RR 24, SaO2 96%/trach
mask. He was noted to have small amount of melena, guiac+, NG
lavage negative. He received 1 L NS and 40 mg IV protonix.
.
ROS - patient reports feeling tired generally. +loose stool x
several days with nausea. No f/c/s, no CP/SOB. No abdominal
pain. +burning in penile area.
Past Medical History:
. CAD - s/p LAD and OM1 stent in [**8-2**], s/p RCA PTCA in '[**28**]
2. NIDDM
3. HTN
4. PVD s/p bilat LE bypass surgeries (Dr.[**Last Name (STitle) **])
5. CRI - baseline Cr 1.6-2.0 (stage IV CKD)
6. cataracts
7. gout
8. BPH
9. Abd hernia
10. s/p CCY, ex-lap w/abd hernia resulting
11. Incarcerated ventral hernia containing strangulated small
bowel and requiring small bowel resection. This was complicated
by a leak leading to re-operation.
Social History:
Worked as head [**Doctor Last Name 7051**]. Hx Etoh abuse x 20 yrs, but quit [**2124**]. 86
ppy tob. Multiple family memebrs live nearby.
Family History:
Fa: died secondary to colon ca
Mo: died secondary to PNA
Siblings: Etoh abuse, HTN
Physical Exam:
VS: Tc 95.9, BP 155/45, HR 62, RR 23, SaO2 99%/PS 10/5, FiO2 40%
General: AO x 3, lying in bed, appears anxious and slightly
tachypneic
HEENT: left eye with cataract, right eye reactive. Dry MM, NGT
in place
Neck: supple, trach in place with collar
Chest: CTA-B anteriorly with few expiratory wheezes
CV: [**Last Name (un) **] distant s1 s2, no m/g/r
Abd: soft, NT/ND, large open wound 10 cm x 3 cm with granulation
tissue, no drainage. +guiac in ED
Ext: [**12-31**]+ pitting edema b/l
Neuro: AO x 3, no focal neuro deficits
Pertinent Results:
[**2138-5-30**] 05:30PM PT-11.4 PTT-30.4 INR(PT)-1.0
[**2138-5-30**] 05:30PM WBC-7.5 RBC-3.27* HGB-9.8* HCT-30.1* MCV-92
MCH-30.1 MCHC-32.6 RDW-18.9*
[**2138-5-30**] 05:30PM PLT COUNT-166
[**2138-5-30**] 05:30PM GLUCOSE-97 UREA N-197* CREAT-4.9*# SODIUM-139
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-21
[**5-30**] EKG (per ED read, not available to me) - Afib, HR 60s, LBBB,
LAD
.
[**5-30**] Renal u/s - Unremarkable son[**Name (NI) 493**] appearance of the
kidneys. No evidence of stone or hydronephrosis.
.
[**6-2**] CXR: Comparison with [**2138-6-1**], 16:13 p.m. Pulmonary
vascular congestion has slightly improved. Bilateral pleural
effusions, right moderate and left small, are slightly improved,
as is the lateral lower lobe atelectasis. Cardiac shadow remains
enlarged. Tracheostomy tube is in standard position.
.
EGD: no active bleeding. [**Last Name (un) 865**] esophogus, stomach and
duodenum were normal
Brief Hospital Course:
72 year old male with multiple medical problems, including
respiratory failure and recent surgery for a ventral hernia, who
was admitted to the MICU for melena and renal failure. His
hospital course is discussed by problem.
.
# GIB - concern for UGIB given melena, prior h/o Barrett's with
gastritis, although NG lavage negative. DDx included gastritis,
PUD, AVM's, etc. The patient was transfused PRBCs as needed to
keep his hct above 25. GI was consulted and he underwent an EGD
which showed no active bleeding, but Barrett's esophagus. Given
that his hematocrit was stable since admission after only 2 U
PRBCs, he had no further evidence of active bleeding, and he was
initiating hemodialysis, it was thought that a colonoscopy
should be deferred to outpatient management. It is recommended
that he obtain this 1-2 weeks after discharge. He was
maintained on a PPI.
.
# Acute on CRI - appeared to be intrinsic renal given FeNa of 6%
and urine Na of 30. Likely ATN in the setting of recent GIB and
given granular casts on sediment. Renal u/s without
hydronephrosis. The renal team was consulted and it was decided
to initiate hemodialysis. A tunnelled catheter was placed on
[**2138-6-3**] and HD was started on the same day. He was continued on
Epogen for his anemia. He has thus far completed 4 sessions of
dialysis, last session of HD was [**Date Range 2974**] [**2138-6-6**]. After this, he
should be on a regular HD schedule of Monday, Wednesday, [**Month/Day/Year 2974**].
.
# AG Metabolic acidosis - most likely in setting of acute renal
failure, although per DC summary, the patient had been on bicarb
tabs in the past. His bicarb was monitored without any
intervention necessary.
.
# Positive u/a - given recent UTI with Pseudomonas, he was
started on Cefepime. This was later discontinued once his
cultures returned negative. He remained afebrile without a
leukocytosis.
.
# Respiratory failure - occurred in setting of surgical history,
PNA, and failure to wean. Complicated by recent MRSA PNA. On PS
[**10-3**] at rehab overnight. He was started on trach collar trials
after HD on [**2138-6-3**]. Sputum cultures continued to show MRSA and
GNRs, however he did not have a fever, leukocytosis, change in
sputum production, or significant chest x-ray findings to
suggest a new infiltrate or infection. Therefore, no
antibiotics were administered after the initial Cefepime.
.
# h/o recent strangulated hernia - abdominal wound with
granulation tissue, healing by secondary intention. The trauma
surgery team followed him while he was hospitalized, continued
with collagenase dressing [**Hospital1 **], this was changed to Accuzyme
dressings daily.
.
# DM - His blood sugars were controlled with standing NPH and
RISS
.
# HTN - his anti-hypertensives were held in the setting in the
of a GIB, however his blood pressure normalized and he then
became hypertensive. Hydralazine and Imdur were started for
control, and these may be titrated for better control.
.
# F/E/N - He was initially kept NPO, then tube feeds were
resumed once there was no further evidence of GI bleed. He was
evaluated by speech and swallow and cleared for pureed foods,
thickened liquids as tolerated, but primary nutrition and
medications were still administered through the Dobbhoff tube.
.
# PPx - The patient was maintained on pneumoboots for DVT
prophylaxis and a PPI for the Barrett's esophagus.
.
The patient's code status was discussed with the patient and his
wife and it was decided that he was DNR.
.
# Communication - wife, [**Name (NI) **] [**Name (NI) **]
.
The patient was discharged to [**Hospital1 **] for further
rehabilitation.
Medications on Admission:
Amlodipine 5 mg daily
Vit C 500 mg [**Hospital1 **]
Clonidine 0.1 mg patch qThurs
Zinc oxide topical prn
Darbepoetin 100 mch qThurs
Advair HFA 231/21 inh daily
NPH 10 units qAM, qPM
RISS
Levothyroxine 25 mcg daily
Lidoderm 5% TP daily
Miconazole prn
MVI daily
PPI 40 mg IV bid
Papain TP tid prn
Risperdal 0.5 mg tid
NTG SL prn
Spiriva 18 mcg daily
Trazadone 50 mg qhs
Zinc 220 mg daily
Hydralazine 75 mg qid
Tylenol prn
Albuterol 2 puffs qid
Bisacodyl prn
Atrovent 4 puffs qid
Ativan 0.5 mg q8 hrs
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation Q4H (every 4 hours).
3. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Collagenase 250 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
8. Hydralazine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Four (4)
Puff Inhalation QID (4 times a day).
10. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
13. Papain-Urea 830,000-10 unit/g-% Ointment [**Hospital1 **]: One (1) Appl
Topical DAILY (Daily).
14. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]:
One (1) Inhalation [**Hospital1 **] (2 times a day).
15. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
16. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H/PRN ().
17. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed.
18. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
19. Risperidone 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
20. Insulin
Please continue fixed dose and sliding dose per attached sheet.
21. Lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours) as needed.
22. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
23. Isosorbide Dinitrate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
24. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Ten (10)
units Subcutaneous twice a day.
25. Lidocaine HCl 2 % Gel [**Last Name (STitle) **]: One (1) Appl Mucous membrane PRN
(as needed).
26. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H (every 8
hours).
27. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 4-6 Puffs Inhalation
Q4H (every 4 hours).
28. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: 4-6 Puffs
Inhalation QID (4 times a day).
29. Hydromorphone 2 mg/mL Syringe [**Last Name (STitle) **]: 0.5 mg Injection Q6H
(every 6 hours) as needed.
30. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary -
GI bleed
ARF
Secondary -
1. CAD - s/p LAD and OM1 stent in [**8-2**], s/p RCA PTCA in '[**28**]
2. NIDDM
3. HTN
4. PVD s/p bilat LE bypass surgeries (Dr.[**Last Name (STitle) **])
5. CRI - baseline Cr 1.6-2.0 (stage IV CKD)
6. cataracts
7. gout
8. BPH
9. Abd hernia
10. s/p CCY, ex-lap w/abd hernia resulting
11. Incarcerated ventral hernia containing strangulated small
bowel and requiring small bowel resection. This was complicated
by a leak leading to re-operation.
Discharge Condition:
Stable - Hct stable, no further bleeding.
Discharge Instructions:
-continue with medications as specified in discharge
instructions
-has completed 4 sessions of HD initiation, last HD session on
[**Last Name (LF) 2974**], [**6-6**]. He will then begin a 3x/week dialysis
schedule (likely M/W/F)
-he should have a colonoscopy in [**12-31**] weeks to evaluate for
source of his recent GI bleeding (EGD negative for active
source)
-please continue wound care for sacral decub and abdominal wound
as specified by nursing instructions
-please check QOD hematocrits to ensure stability
Followup Instructions:
Please have a colonoscopy
|
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[
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,202
| 118,057
|
42417
|
Discharge summary
|
report
|
Admission Date: [**2186-4-3**] Discharge Date: [**2186-4-13**]
Date of Birth: [**2109-10-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
pneumonia, sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 76 year old male with PMH significant for CAD s/p MI,
CHF, atrial fibrillation on Coumadin, PVD s/p right BKA, IDDM
complicated by ESRD on MWF dialysis who initially presented to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital from [**Hospital1 **] [**Hospital1 1501**] for further evaluation of
nausea/vomiting/hypoxia and was found to have right lower lobe
pneumonia and sepsis. Per his rehab records, the patient was
found to have an O2 sat of 63% on RA with a temperature of
102.1. He was reportedly alert and his O2 sat increased to 80%
after 4L NC. Blood glucose was 152 at the time. Per report, his
code status had previously been established as DNR/DNI, but it
was reversed upon arrival to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and he was intubated
and placed on peripheral Levophed and Neosynephrine to support
his blood pressure. He was given 6L of IV fluids and was started
on vancomycin/Zosyn/ceftriaxone at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital. He was
then transferred to [**Hospital1 18**] for higher level of care. During
transport, he was noted to be hypotensive despite peripheral
Levophed and Neosynephrine to the 60s-90s systolic.
In the ED, initial VS were not recorded. A left IJ central line
was placed. His neosynephrine and Levophed were titrated up to
3.5mcg/kg and 0.4mcg/kg respectively to maintain MAPs>65. He was
also started on a fentanyl drip for sedation. CXR showed
bilateral mediastinal and lower lobe infiltrates, right sided
pleural effusion, right sided tunneled HD catheter, and newly
placed left IJ central line. Labs were significant for a
positive UA, elevated coags with an INR=2.7, a white count of
14.8 with 16% bandemia, a Hct=38.9 with an MCV of 99, BNP of
27,394, and elevated BUN to 53 and Cr=3.5. Blood and urine
cultures were drawn. Of note, his lactate was within normal
limitis at 1.6. No additional antibiotics or IVFs were
administered. CVP was noted to be 19. On transfer, vitals were
noted to be HR=116, BP=99/63, RR=19, POx=98% on CMV with 100%
fiO2, 500cc TV, and PEEP=10.
.
On arrival to the MICU, the patient was intubated and sedated,
therefore further history was obtained through OSH records.
Past Medical History:
-IDDM
-PVD
-s/p right BKA
-ESRD on MWF dialysis
-CAD s/p MI
-Atrial fibrillation on Coumadin
-Congestive heart failure
-Chronic cough
-Anemia
Social History:
Patient currently lives at [**Hospital **] rehab. Contact person (not
HCP) is listed as [**Name (NI) **] [**Name (NI) 25139**] who can be reached at
[**Telephone/Fax (1) 91853**]. Per report, he quit smoking in [**2161**], but smoked
2PPD previous to that for an unknown number of years. He
reportedly worked as a book binder and is single per rehab
records.
Family History:
not relevant to current complaint
Physical Exam:
Admission Physical Exam:
Vitals: T: 101.2, BP: 125/57, P: 100s R: 22 O2: 99% on FiO2 80%,
TV 500, PEEP=10
General: intubated/sedated in no acute distress
HEENT: Sclera anicteric, MMM, ET tube in place, PERRL
CV: Irregularly irregular, distant heart sounds
Lungs: Clear to auscultation on the left anteriorly, with
predominantly right sided rhonchi, no wheezes
Abdomen: somewhat firm, mildly distended, non-tender, bowel
sounds present
GU: Foley in place
Ext: warm, well perfused, s/p right BKA, chronic venous stasis
changes in left lower leg, trace edema, left thigh with evidence
of resolving rash
Neuro: Intubated/sedated
.
Discharge Physical Exam:
VS: 97.5 (98.0) 120/70 (111-124/47-70)
78 (70s-80s) 18 (18-20) 97% RA (93-97% RA)
FSBS: 101-178, no Humalog
I/O: ~1000/oliguric UOP 100 + UF2L +BM x4 (loose)
Gen: Elderly white male, looks stated age, lying comfortably in
bed
HEENT: Sclera anicteric, MMM, PERRL
Neck: JVP elevated to 4 cm up neck, C/D/I dressing over previous
L IJ, no cerv LAD. HD catheter in plane in right chest.
CV: Irregularly irregular, no M/R/G
Lungs: Miminal rales at lung bases.
Abd: Normoactive bowel sounds, soft, NT/ND.
Ext: Warm, well perfused, s/p right BKA, chronic venous stasis
changes in left lower leg, trace edema, no noted rashes
Neuro: Alert, awake and oriented x3, moving extremities, CNs
II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
[**2186-4-3**] 01:10AM BLOOD WBC-14.8* RBC-3.86* Hgb-12.2* Hct-38.1*
MCV-99* MCH-31.6 MCHC-32.0 RDW-16.6* Plt Ct-172
[**2186-4-3**] 01:10AM BLOOD Neuts-73* Bands-16* Lymphs-3* Monos-6
Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-0
[**2186-4-3**] 01:10AM BLOOD PT-27.7* PTT-41.8* INR(PT)-2.7*
[**2186-4-3**] 01:10AM BLOOD Glucose-112* UreaN-53* Creat-3.5* Na-133
K-4.5 Cl-98 HCO3-24 AnGap-16
[**2186-4-3**] 01:10AM BLOOD Albumin-3.6
[**2186-4-3**] 06:46AM BLOOD Calcium-8.0* Phos-4.8* Mg-1.7
[**2186-4-3**] 01:10AM BLOOD Cortsol-27.6*
[**2186-4-3**] 02:41AM BLOOD Type-[**Last Name (un) **] Temp-37.8 Rates-14/ Tidal V-500
PEEP-10 FiO2-100 pO2-113* pCO2-68* pH-7.17* calTCO2-26 Base
XS--4 AADO2-545 REQ O2-89 -ASSIST/CON Intubat-INTUBATED
[**2186-4-3**] 01:20AM BLOOD Lactate-1.6
[**2186-4-3**] 01:10AM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2186-4-3**] 01:10AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG
[**2186-4-3**] 01:10AM URINE RBC-26* WBC-70* Bacteri-MOD Yeast-NONE
Epi-0
[**2186-4-3**] 01:10AM URINE CastHy-21*
.
RELEVANT LABS:
[**2186-4-7**] 06:57PM BLOOD Type-ART pO2-107* pCO2-50* pH-7.35
calTCO2-29 Base XS-0
.
DISCHARGE LABS:
[**2186-4-13**] 05:40AM BLOOD WBC-4.8 RBC-3.70* Hgb-11.3* Hct-34.8*
MCV-94 MCH-30.5 MCHC-32.5 RDW-16.6* Plt Ct-282
[**2186-4-13**] 12:45PM BLOOD PT-19.1* PTT-38.2* INR(PT)-1.8*
[**2186-4-13**] 05:40AM BLOOD Glucose-92 UreaN-14 Creat-2.4*# Na-134
K-4.3 Cl-98 HCO3-32 AnGap-8
[**2186-4-13**] 05:40AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.1
.
MICROBIOLOGY:
[**2186-4-3**] Urine culture: <10,000 organisms/ml
[**2186-4-3**] Blood cultures x2: negative
[**2186-4-3**] MRSA Screen: negative
[**2186-4-3**] Sputum: GRAM STAIN (Final [**2186-4-3**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2186-4-6**]):
RARE GROWTH Commensal Respiratory Flora.
[**2186-4-3**] Eye swabs: STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE
GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
[**2186-4-3**] Urine Legionella antigen: negative
[**2186-4-6**] C. diff toxin: negative
[**2186-4-7**] C. diff toxin: negative
.
IMAGING:
[**2186-4-3**] CXR:
SINGLE PORTABLE FRONTAL CHEST RADIOGRAPH: A large bore right
central venous
internal jugular catheter terminates in the low SVC. An
endotracheal tube
terminates 2.8 cm above the level of the carina. A nasogastric
tube courses
below the diaphragm, though the tip is incompletely imaged. A
left internal
jugular catheter terminates in the left brachiocephalic vein at
the midline. No pneumothorax is evident. Diffuse alveolar
opacities involve the entire right lung. Given the overall
diffuse interstitial opacities, hilar engorgement and
cardiomegaly, the right-sided density likely reflects
asymmetric pulmonary edema. Confluent consolidation such as
aspiration or
pneumonia are also within the differential though less likely.
Followup chest radiograph is recommended when patient is in a
more euvolemic state.
Additional opacities in the left lung base, likely reflect
atelectasis. Mild fullness of the right hila appears stable on
follow-up chest radiograph, suggesting that this reflects
vascular engorgement.
IMPRESSION:
1. Right large bore central venous line terminating in the lower
SVC. Left
central venous line terminating in the mid left brachiocephalic
vein.
Endotracheal and nasogastric tubes in standard position.
2. No pneumothorax.
3. Probable moderate asymmetric pulmonary edema, right greater
than left.
4. Left lower lobe atelectasis.
.
[**2186-4-3**] TTE: The left atrium is moderately dilated. The
estimated right atrial pressure is at least 15 mmHg. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild [1+] mitral regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
a very small circumferential pericardial effusion.
IMPRESSION: Severe pulmonary artery hypertension. Right
ventricular cavity dilation with free wall hypokinesis. Mild
symmetric left ventricular hypertrophy with preserved global
systolic function. Mild mitral regurgitation.
CLINICAL IMPLICATIONS:
Based on [**2181**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**2186-4-10**] CXR portable:
IMPRESSION:
AP chest compared to [**4-5**] through [**4-9**]:
The patient is rotated sharply to the right. Mild-to-moderate
pulmonary edema most readily appreciated in the left lung is
unchanged over several days as is moderate-to-severe cardiac
enlargement. Consolidation in the right lower lung is probably
confined mostly to the lower lobe, though the middle lobe may be
less severely affected. Moderate right pleural effusion has a
substantial fissural component.
Left internal jugular line ends in the left brachiocephalic
vein, and the
right supraclavicular dual-channel dialysis ends in the SVC. No
pneumothorax.
.
[**2186-4-10**] Video Oropharyngeal Swallow:
FINDINGS: A swallowing videofluoroscopy study was performed in
conjunction
with speech pathology service. The patient ingested multiple
consistencies of oral barium. Note is made of premature
spillover with thin, and nectar thick liquids as well as with
solids. There was extensive severe penetration and aspiration of
thin and nectar thick liquids, with spontaneous and prompted
coughing being minimally effective in clearance.
IMPRESSION: Severe aspiration of liquids as above. For further
details
please consult the speech pathology note in the online medical
record dated
[**2186-4-10**].
Brief Hospital Course:
76 year old male with PMH significant for IDDM complicated by
right BKA and ESRD on dialysis who initially presented to [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Hospital for further evaluation of nausea/vomiting/SOB
and was found to be hypoxic and hypotensive with a potential
right lower lobe pneumonia and sepsis, requiring intubation.
.
.
ACTIVE ISSUES:
#. Respiratory Failure/Pneumonia: Most likely secondary to
aspiration. Patient was intubated at OSH for hypoxia in the
setting of a likely pneumonia and sepsis. Initially required
pressors with Levophed and Neosynephrine, but was able to wean
off of these. Intermittently then needed neo for dialysis to
support BP. Was able to pass RSBIs early in MICU stay, but
remained intubated secondary to tachypnea/tachycardia during SBT
concern for respiratory distress. Ultimately he was extubated
successfully on on [**4-8**]. He receveived a total 8 days of HCAP
treatment, ending on [**2186-4-11**]. He also completed 5 days of Azithro
on [**4-8**]. His CXR had significant bilateral infiltrates, right
greater than left with a moderate sized right sided pleural
effusion; these have resolved somewhat with HD and UF, which
have removed several liters of fluid. Temporary central line
was removed prior to transfer from MICU to floor. Sputum gram
stain w/ GPCs and GNRs, but no growth. Speech and Swallow
bedside evaluation and video swallow study confirmed aspiration
of all textures of food and liquids. On the floor, he was
gradually weaned to room air. Risk of aspiration was discussed
with patient and family, who opted to continue oral feeding for
nutrition. Speech and swallow team recommended that pills be
given crushed in applesauce.
.
# ESRD on HD MWF: Likely secondary to longstanding IDDM.
Patient has right tunneled HD line for access. Trialed dialysis
on [**4-4**] but failed [**3-9**] hypotension. Dialysis was successful
with pressors initially, then patient graduated from need for
pressors. He continues to require dialysis three times per week.
# Atrial fibrillation: On Coumadin and beta blocker at home. INR
initally supratherapetic at 3, and remained so for several days
during ICU stay. Patient restarted 5 mg Coumadin daily for him
on [**2186-4-9**], which was uptitrated due to subtherapeutic INRs.
Given his normal pressures, his home metroporol at 25 mg [**Hospital1 **] was
also restarted.
.
# Aspiration risk: As described above in "Pneumonia." Patient is
aspirating all textures of liquids and foods. Patient and family
understand risks of aspiration. He will continue regular diet
with thin liquids, meds crushed in puree/applesauce.
.
# Rash: Developed pruritic morbilliform rash on R thigh,
evluated by Dermatology. Most likely drug rash vs. contact
[**Name (NI) 91854**]. [**Name2 (NI) **] improved after several days of clobetasol cream
[**Hospital1 **].
.
# Conjunctivitis: Green eye discharge noted in MICU, culture was
sent, growing coag negative staph. Patient had already been on
a week of erythromycin ointment. Eye shows He was started on
Ciprofloxacin 0.3% Ophth Soln 1-2 DROP BOTH EYES [**Hospital1 **] on [**2186-4-3**].
This was discontinued on [**2186-4-10**] given that he had received a
week of treatment.
.
# Diarrhea: There was a question of mucousy stool in the MICU,
most likely secondary to tube feeds in the unit. High suspicion
of C. diff colitis in the setting of broad antibiotics, but C.
diff toxin was negative x2. Diarrhea improved by the time of
discharge.
.
.
CHRONIC ISSUES:
# IDDM: Continue home insulin sliding scale.
.
# CAD/ diastolic CHF. Patient reportedly has a h/o MI with
diastolic CHF. TTE most recently with LV EF >55%, 1+ MR. We
continued home statin and ASA, and increased dose of BB to home
metoprolol. Patient had been on Lasix 120 mg PO daily prior to
this admission. After having hemodialysis with ultrafiltration
during this admission, he was more euvolemic. Because he was not
taking much fluid by mouth, we did not restart his standing
Lasix. If he does develop edema, weight gain or shortness of
breath, this medication should be restarted.
.
# CAD/diastolic CHF: Patient reportedly has a history of MI.
.
# Pulmonary HTN. PASP=62 on ECHO. We continued home Revatio.
.
# Possible COPD. Continue home Duonebs.
.
# BPH. Restarted home doxazosin, DC'ed foley
.
# Glaucoma. Continue home trusopt and timolol eye drops
.
# Insomnia. restarted home trazodone
.
.
TRANSITIONAL ISSUES:
# CODE: FULL, this was confirmed with patient and family
# Emergency contact: [**Name (NI) **] "[**Name2 (NI) 8214**]" [**Last Name (un) 25139**] c)[**Telephone/Fax (1) 91855**]
# Aspiration risk: Patient and family understand ongoing
aspiration and risks of further infections. They have elected to
continue oral nutrition.
# At rehab facility, patient will need to have re-evaluation by
Speech and Swallow to assess improvement.
# If patient develops edema, weight gain or shortness of breath,
he should restart Lasix.
Medications on Admission:
-Diprolene 0.05% cream twice daily to rashes on back, left leg,
and upper extremities
-Erythromycin ointment to OU TID for 7 days starting [**3-28**]
-Trusopt 2% to OU [**Hospital1 **]
-Coumadin 7mg daily
-ASA 81mg daily
-Colace 100mg daily
-Doxazosin 4mg daily
-Zantac 150mg daily
-Simvastatin 40mg daily
-Benadryl 25mg every 4 hours prn itching
-Humalog sliding scale
-Metoprolol 25mg [**Hospital1 **]
-Timolol 0.5% to OU [**Hospital1 **]
-Lasix 120mg PO daily
-Vicodin 5/500mg PO Q6 prn pain
-Compazine 10mg TID prn nausea
-Revatio 20mg TID
-Phoslo 1334mg TID with meals
-Duoneb QID
-Trazodone 50mg HS
Discharge Medications:
1. Diprolene 0.05 % Lotion Sig: One (1) application Topical
twice a day: apply to rashes on back, left leg and upper
extremities.
2. Trusopt 2 % Drops Sig: One (1) drop Ophthalmic twice a day:
to OU.
3. warfarin 1 mg Tablet Sig: Seven (7) Tablet PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
6. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Benadryl 25 mg Capsule Sig: One (1) Capsule PO q4 prn as
needed for itching.
10. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day): to both eyes.
13. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO q6 hours prn
as needed for pain.
14. compazine Sig: Ten (10) mg TID PRN as needed for nausea.
15. Revatio 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
16. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a
day: with meals.
17. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) nebulizer Inhalation four times a day.
18. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary diagnoses:
Pneumonia
Sepsis
.
Secondary diagnosis:
ESRD
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 **],
It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted with severe
pneumonia, and treated with antibiotics. You improved in the
Intensive Care Unit, and were extubated. We believe the source
of your pneumonia was uncoordinated swallowing, causing you to
choke on food and drink. You understand the risks of continuing
to eat a regular diet, even though food and drink will likely to
continue to go into your lungs.
Please note, the following changes have been made to your
medications:
- STOP standing Lasix. Should you develop any edema or shortness
of breath, please restart this medication. Please weigh yourself
every day to monitor your volume status.
- START Nephrocaps 1 capsule by mouth daily
Please continue all of them as prescribed before your
hospitalization.
You will be followed by the physicians at your rehabilitation
facility.
Wishing you all the best!
Followup Instructions:
Department: HEMODIALYSIS
When: FRIDAY [**2186-4-14**] at 7:30 AM
|
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78,215
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31580
|
Discharge summary
|
report
|
Admission Date: [**2118-11-24**] Discharge Date: [**2118-12-6**]
Date of Birth: [**2050-7-13**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Allopurinol / Vancomycin / Ciprofloxacin
/ Augmentin / Azithromycin / Linezolid
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever, Fatigue
Major Surgical or Invasive Procedure:
Desensitization to antibiotics, in the ICU.
History of Present Illness:
68 y/o gentleman with COPD, GERD, MDS evolving into AML in [**2116**]
(see oncologic history below), presents with shortness of
breath, fatigue, and fever. Patient states that he was doing
well until two days ago when he developed increased shortness of
breath and noted a fever of 101. This temperature decreased
without intervention to 98.8 at home. Walking from the car to
the clinic patient noticed increased shortness of breath and
required to be pushed in a wheelchair by his wife. Pt also
noticed left sided pleuritic chest pain. Pain increased with
deep inspiration and was not present with normal breathing. Pain
was not associated with palpitations, diaphoresis, or radiation.
Pain resolved without intervention. No recent travels. No sick
contacts. [**Name (NI) **] unusual foods.
.
Patient denies any recent diarrhea, nausea, or vomiting. Denies
abdominal pain, changes in bowel habits, or blood in stool.
Denies burning with urination or blood in urine. Notes increased
bruising when his platlets are low. Stable back pain associated
with DJD.
.
Past Medical History:
Oncologic history:
Patient initially presented in [**2116**] with easy bruising
and dropping cell counts (pancytopenic) as well as some
SOB/fatigue. BMBx was consistent by report with myelodysplastic
syndrome with presence of a 15-20% immature cells consistent
with blasts; Dr. [**Last Name (STitle) **] felt the pathology was consistent with
MDS with excess blasts in transformation, suggesting
acceleration of the disease towards acute leukemia.
Pt underwent induction and reinduction with single [**Doctor Last Name 360**]
clofarabine per protocol 07-013, last treated in 09/[**2116**]. Since
that time, he showed signs of dysplasia was dropping cell lines
and bone marrow biopsy done in [**9-/2118**] showed blasts occurring
in small clusters occupying an estimated 20% of the marrow
cellularity. Cytogenetics showed deletion of the long arm of
chromosome 20 and he was treated on [**2118-9-19**] with his first
cycle of decitabine. C2 decitabine started [**2118-11-1**]. He has
previously opted not to undergo allogeneic stem cell transplant
due to quality of life desires.
PAST MEDICAL HISTORY:
- COPD/emphysema
- GERD
- ? Angina (has been prescribed SL nitro for CP/neck pain that
occurs on exertion with SOB, but states the tabs do not help,
and reportedly has had normal stress MIBI)
- Degenerative joint disease/arthritis of the spine
PAST SURGICAL HISTORY:
- plan for port insertion next Tuesday
- Appendectomy as a child - age 8
- Submucous resection - age 12
- Left meniscus repair of the knee - age 37
- Right meniscus repair of the knee - age 64
- Hernia repair left side - age 65
Social History:
- Personal: married 44 years; 4 children (2 sons, 2 daughters) -
lives with one son's family. Family involved in patient's care.
- Tobacco: smoked heavily [**3-8**] ppd x 40 years, quit [**2096**]
- Alcohol: significant past alcohol intake, quit [**2091**]
- Occupation: former veteran from [**Country 3992**], ? exposure to [**Doctor Last Name **]
[**Location (un) **]. Retired from food and beverage industry.
- Hobby: sports
Family History:
His mother is deceased at age [**Age over 90 **] from a bowel obstruction. His
father is deceased at age [**Age over 90 **] from prostate cancer. He has no
siblings.
Physical Exam:
General: Patient able to communicate clearly, Appears slightly
short of breath but in no distress, Pleasant
HEENT: PERRL, Oropharynx clear, No mucosal lesions
Neck: No LAD, Non tender
CV: Distant S1,S2, NO M/R/G
Resp: CTA B
Back: No CVA tenderness, No tenderness to palpation of
spine/paraspinous muscles
Abdomen: Soft, Obese, Non Tender, NO HSM
Extremities: Without Lower Extremity Edema,
Neuro: CN II-XII Intact, Normal sensation to light touch in the
upper and lower extremity, Normal strength upper/lower extremity
Skin: Diffuse confluent macular Erythematous rash involving the
face, chest, back, and lateral thighs. Without desquamation or
vesicles.
******
On discharge:
Lungs CTAB, no wheezing
Without evidence of rash/erythema/edema
Pertinent Results:
Initially Notable for White Blood Cell count 2.2
(60%Neutrophils), ANC 1320. TT<0.01, CK 37.
[**2118-11-24**] 09:25AM PLT SMR-VERY LOW PLT COUNT-25* LPLT-1+
[**2118-11-24**] 09:25AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2118-11-24**] 09:25AM NEUTS-60 BANDS-0 LYMPHS-39 MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2118-11-24**] 09:25AM WBC-2.2*# RBC-3.23* HGB-9.7* HCT-28.6* MCV-89
MCH-30.0 MCHC-33.8 RDW-19.3*
[**2118-11-24**] 09:25AM CALCIUM-8.4 PHOSPHATE-1.3*# MAGNESIUM-2.0
[**2118-11-24**] 09:25AM cTropnT-<0.01
[**2118-11-24**] 09:25AM ALT(SGPT)-15 AST(SGOT)-13 LD(LDH)-154
CK(CPK)-37* ALK PHOS-56 TOT BILI-0.9
[**2118-11-24**] 09:25AM UREA N-13 CREAT-1.0 SODIUM-137 POTASSIUM-4.1
CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
.
[**11-24**] CT chest:
1)New right upper lobe pneumonia, with no imaging features to
suggest a
specific type of infection.
2)Diffuse severe centrilobular emphysema.
3) Triple vessel coronary artery calcification, possible aortic
stenosis.
.
[**12-2**] CT chest:
1. Interval improvement in right upper lobe pneumonia.
2. Diffuse severe centrilobular emphysema.
.
ECG [**11-25**]:
Sinus rhythm. Non-diagnostic Q waves in the inferior leads.
Compared to the previous tracing no significant change.
.
Discharge labs:
[**2118-12-6**] Glucose-155* UreaN-21* Creat-0.9 Na-140 K-4.5 Cl-105
HCO3-26 AnGap-14
[**2118-12-6**] Calcium-8.4 Phos-3.7 Mg-2.3
.
[**12-5**] CBC & differential:
[**2118-12-5**] WBC-1.9* RBC-3.31* Hgb-9.7* Hct-29.7* MCV-90 MCH-29.3
MCHC-32.6 RDW-18.6* Plt Ct-40*
[**2118-12-5**] Neuts-3.1* Lymphs-95.0* Monos-0.9* Eos-0.9 Baso-0.1
Brief Hospital Course:
1. Right Upper Lobe Pneumonia/Fever: Right upper lobe pneumonia
on CT scan. Patient initially required 2L NC, then weaned to
room air. Patient became afebrile. Micro data (cultures etc.)
did not point to one particular causative organism. Patient
treated empirically for both fungal and bacterial etiologies.
Infectious disease consultants followed the course. Repeat CT
scan of the chest on [**12-2**] showed improvement of disease but not
complete resolution. On the floor, patient afebrile, without
cough or SOB, breathing on room air. Patient's inpatient
antibiotic course was: tigecycline, meropenem, voriconazole.
Patient transitioned to doxycycline and voriconazole for
discharge. Plan, per Infectious Disease team, to continue on
doxy & vori through the next round of chemo and the patient's
cell count nadir, then if symptomatic to re-image, and if
asymptomatic to stop treatment.
.
2. Drug Rash/Allergies: Patient with extensive drug allergy
history. On admission patient had developed a beet red rash over
his entire body to clindamycin and aztreonam, drugs he had
received successfully in the past. Patient was started on
linezolid, doxycycline, and voriconazole. Further patient was
given Solumedrol 60mg IV and Benadryl 25mg. That night he
developed transient redness and shortness of breath/feeling like
throat was closing during linezolid infusion. Linezolid infusion
was stopped and this redness and shortness of breath resolved.
After discussion with both infectious disease and allergy it was
decided to desensitize the patient to linezolid and meropenem.
Patient was continued on prednisone 20mg daily, Diphenhydramine
25mg Q6hrs, and Prevacid 20mg Q12hrs. In the ICU within 15
minutes of linezolid infusion, the patient began to feel his
throat closing, an erythematous rash was noted on chest, and he
became hypertensive and tachycardic. The infusion was stopped
and symptoms resolved. EKG showed T wave flattening, but these
changes resolved after normalization of symptoms, and cardiac
enzymes were negative. He was continued on treatment with
steroids, benadryl, and an H2 blocker for the allergic reaction.
The patient was successfully desensitized to meropenem before
transfer back to the floor. On the floor, patient tolerated the
antibiotic regimen of meropenem, tigecycline, voriconazole,
without evidence of allergic reaction. Patient continued on 20mg
prednisone; benadryl dose decreased with addition of
fexofenadine to the regimen. Per allergy, patient discharged on
prednisone taper; discharged without [**Doctor First Name 130**] or benadryl. Given
prescription for pepcid and benadryl as PRN to have at home in
event of allergic reaction.
.
3. Tachycardia/HTN: Patient with multiple episodes of
tachycardia/htn during previous hospitalization. Patient
continued on Metoprolol 25mg [**Hospital1 **]; patient's vital signs stable.
.
4. MDS/AML: Finished C2 Dacogen on [**2118-11-1**]. Patient's blood
counts monitored daily, with transfusion if needed. Plan for
next round of chemotherapy as an outpatient.
.
5. COPD/EMPHYSEMA: Continued on Combivent four times daily and
continued on Advair daily. Initially patient required 2L NC,
oxygen saturation was titrated to 02 of 95% given history of
emphysema. Emphysema demonstrated on CT scan. Patient weaned to
room air.
.
6. GERD: Continued on Omeprazole daily.
Medications on Admission:
Home medications: as of [**2118-10-4**]:
- FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Dosage uncertain
- IPRATROPIUM-ALBUTEROL [COMBIVENT] - 103 mcg (90 mcg)-18
mcg/Actuation Aerosol - 1 (One) inhaled four times a day
- LORAZEPAM - 0.5 mg Tablet by mouth daily as needed for
insomnia (has not been taking)
- NITROGLYCERIN [NITROQUICK] - 0.4 mg Tablet, Sublingual PRN
(has not been taking)
- OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) PO daily
- PROCHLORPERAZINE MALEATE - 10 mg Tablet PO Q8h PRN for nausea
(has not been taking)
- METOPROLOL 25 mg [**Hospital1 **]
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: One
(1) Puff Inhalation Q6H (every 6 hours).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): 1 INH
twice a day.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*1*
6. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day for
2 days: Take 4 tabs (total 20mg) on both 11/4/9 and 11/5/9.
Disp:*8 Tablet(s)* Refills:*0*
7. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for
3 days: Take 2 tabs (total 10mg) each day on [**11-17**], [**12-11**].
Disp:*6 Tablet(s)* Refills:*0*
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Take one tab daily on [**12-12**] and [**12-13**].
Disp:*2 Tablet(s)* Refills:*0*
9. Benadryl 25 mg Capsule Sig: [**2-4**] Capsules PO every eight (8)
hours as needed for rash, shortness of breath, symptoms of
allergic reaction: Take this medication ([**2-4**] capsules) if you
have symptoms of an allergic reaction such as rash or difficulty
breath. Call your doctor immediately and/or return to the
hospital.
Disp:*12 Capsule(s)* Refills:*1*
10. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
Disp:*60 Capsule(s)* Refills:*1*
11. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for rash, shortness of breath, allergic symptoms: Take
this medication if you develop rash, itching, shortness of
breath, or other symptoms of an allergic reaction. Also
immediately call your doctor and/or return to the hospital.
Disp:*12 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
PNEUMONIA.
ACUTE MYELOGENOUS LEUKEMIA.
EMPHYSEMA.
ALLERGIES TO MULTIPLE ANTIBIOTICS.
Discharge Condition:
Stable. Afebrile. Vital signs stable.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing and
cough. You were found to have a pneumonia. Because of an
allergic reaction and multiple allergies to antibiotics, you
were desensitized to antibiotics in the ICU. Then, you were
treated with antibiotics as well as medications to help prevent
an allergic reaction. You had a repeat CT scan to see how the
pneumonia had changed, this showed improvement but not complete
resolution. On discharge, you were breathing well, without cough
or fever and without evidence of allergic reaction (no rash or
difficulty breathing).
.
Please call your doctor or return to the hospital if you develop
fever, chills, shortness of breath, cough, rash, chest pain,
abdominal pain, diarrhea, or other symptoms that concern you.
.
If you develop rash or shortness of breath - those symptoms
would be concerning for an allergic reaction - please
immediately take between 25 to 50 mg of benadryl (this will make
you sleepy - do not drive or operate machinery) AND 25 mg of
pepcid (famotidine); please make sure you have these medications
at home with you; and also immediately call your doctor and/or
return to the hospital.
.
You are on a medication called prednisone, this will need to be
tapered down by decreasing its dose over the course of the next
week until you finish.
Followup Instructions:
Oncologist - Dr. [**Last Name (STitle) **] - clinic appointment Thursday [**12-8**] at 12pm (noon).
Completed by:[**2118-12-7**]
|
[
"693.0",
"205.02",
"486",
"401.9",
"995.0",
"492.8",
"V14.0",
"530.81",
"E930.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"99.62",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
12062, 12068
|
6223, 9572
|
379, 425
|
12197, 12237
|
4544, 5851
|
13605, 13736
|
3599, 3766
|
10192, 12039
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12089, 12176
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9598, 9598
|
12261, 13582
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5867, 6200
|
2908, 3138
|
3781, 4445
|
9616, 10169
|
4459, 4525
|
325, 341
|
453, 1515
|
2640, 2885
|
3154, 3583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,426
| 103,254
|
31664+57758
|
Discharge summary
|
report+addendum
|
Admission Date: [**2186-6-23**] Discharge Date: [**2186-7-1**]
Date of Birth: [**2110-10-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Hypoxia s/p elective ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is a 75 yo F with a past medical history significant for
COPD, CHF, CAD s/p CABG, CVA, who became increasingly hypoxic
and tachypneic following an elective ERCP today. The patient was
recently admitted to an OSH with cholangitis, treated and sent
to [**Hospital1 599**] [**Hospital1 1501**] in [**Location (un) 1439**] with this ERCP scheduled electively.
.
On the last admission in [**4-24**], the patient reportedly had
cholangitis induced sepsis. She underwent an ERCP at that time
and had a stent placed in the CBD. She was treated with
antibiotics and volume resuscitation and discharged to [**Hospital1 1501**] with
a scheduled follow up ERCP when the patient had stabilized.
.
From the ERCP periprocedure notes, the patient arrived today
satting 88% on 4L by NC. She was intubated for the procedure and
received a total of 400cc LR during the procedure and 500cc of
fluid in the PACU. She then gradually became more tachypneic to
20-25 and desatted to 88% on 4L, which increased to the low 90's
on 6L. She was given a nebulizer and a MICU eval was requested.
.
On initial evaluation, the patient was slightly tachypneic,
satting 89-91% on 6L by facemask. An ABG and CXR were requested
and given the patient's history of CHF and the fact that she
takes daily lasix and received almost 1L of fluid in several
hours, a dose of 40mg IV lasix was suggested as well.
.
A foley was placed and lasix administered, which the patient
responded to promptly, with improvement of her symptoms. CXR was
confirmatory for diffuse perihilar infiltrates characteristic of
pulmonary edema. Anesthesia placed an a-line and then obtained
an ABG which was 7.30/66/93 and after several hundred cc's of
diuresis, it improved to 7.34/63/98 (on 6L facemask). She was
then transferred to the [**Hospital Unit Name 153**] for further management.
Past Medical History:
COPD
CAD s/p CABG, s/p MI
CHF (reported EF=50%)
HTN
s/p CVA, on coumadin - residual L hemiparesis
recent history of cholangitis s/p ERCP in [**4-24**] with gallstones
identified; reportedly was septic at this time.
Hyperlipidemia
Hx of psychosis
GERD, PUD
Hypothyroidism
5cm AAA
s/p R hip replacement
Paget's ds
depression, anxiety
Constipation
Diverticulosis
dementia
Family History:
NC
Physical Exam:
vitals: T 96.2 HR 101 BP 157/67 R 18 Sat 88-96% on facemask with
nasal airway in place
General: elderly female, asleep, drowsy, NAD
HEENT: AT/NC, PERRL, OP clear. MMM
neck: JVP elevated to earlobes
chest: RRR
lungs: decreased lung volumes with dependent rales
abd: obese, soft NT/ND +BS
ext: no e/c/c
neuro: unable to do full neuro exam as patient is extremely
sleepy. DTR's in tact bilaterally.
skin: wwp.
Pertinent Results:
[**2186-6-23**] 09:30AM WBC-5.3 RBC-3.67* HGB-11.3* HCT-32.6* MCV-89
MCH-30.7 MCHC-34.6 RDW-18.2*
[**2186-6-23**] 09:30AM PLT COUNT-306
[**2186-6-23**] 09:30AM PT-13.2* PTT-27.3 INR(PT)-1.2*
[**2186-6-23**] 06:38PM GLUCOSE-126* UREA N-35* CREAT-1.5*
SODIUM-146* POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-34* ANION
GAP-13
[**2186-6-23**] 06:38PM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-342*
CK(CPK)-88 ALK PHOS-88 TOT BILI-0.4
[**2186-6-23**] 06:38PM CK-MB-6 cTropnT-0.08*
[**2186-6-23**] 06:43PM LACTATE-0.8
[**2186-6-23**] 11:15PM CK-MB-6 cTropnT-0.08*
.
[**6-23**]: CXR: IMPRESSION: 1. Left lower lobe opacity, suspicious for
pneumonic consolidation. 2. Congestive heart failure.
.
ERCP report [**2186-6-23**]:
1. Stent in the major papilla which was removed.
2. Stones in the biliary tree
3. Cholagiogram showed the presence of 2 stones in the distal
CBD.
4. Balloon sweeps were done to remove the stones.
5. A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
.
Brief Hospital Course:
75 yo F with acute hypoxia and tachypnea following elective
ERCP, due to volume overload, exacerbated by sleep apnea.
.
1. Respiratory Distress: Given her improved CXR and clinical
picture post-diuresis, it appeared that the primary cause of
respiratory distress was likely fluid overload, and most likely,
given that her sats were already decreased pre-procedure, that
she was already volume overloaded before even receiving the
additional liter of fluid pre-procedure. She was successfully
diuresed about 3L with noticeable improvement in pulmonary
status. Cardiac enzymes were negative x 3. Of note, the patient
has multiple apneic episodes with significant desaturations
while sleeping highly suggestive of OSA / central sleep apnea.
Blood gas analysis suggests improvement of respiratory acidosis
with bipap 10/5/5L, likely chronic compensatory metabolic
alkalosis. By the time she was transferred out to the floor, she
was on her baseline O2 requirement of 2L by NC, and tolerating
bipap at night well. On the floor the patient had one episode of
oxygen desaturation to the 70s which resolved with increasing
oxygen via nasal canula to 5L. A cxr was obtained at that time
which showed prominent pulmonary edema. The patient's diuretic
regimen was increased to 40mg po bid however her serum
creatinine continued to rise and her lasix was held. Her oxygen
saturation however has remained stable at her baseline requiring
2Liters nasal canula to maintain oxygen saturation at 92-94%.
We have restarted her lasix at a lower dose of 20mg daily. She
has continued on her prior COPD regimen of spiriva, low dose
prednisone and nebs prn.
2. s/p ERCP - patient is stable from an ERCP perspective with
successful removal of stone from CBD and subsequent
sphincterotomy. LFTs trended down and normalized by [**6-28**]. She
will only need outpatient GI follow up with Dr. [**Last Name (STitle) **] if she
develops new abdominal symptoms or has recurrent evidence of
obstruction.
3. Cardiac
Ischemia - known CAD s/p MI, CABG. No evidence of ischemia on
EKG, enzymes negative. Her BP meds were initially held after
she was transferred to the ICU however the isosorbide was added
back upon transfer to the floor. The patient remained chest
pain free during the entire hospitalization. Given her history
of CAD, a lipid panel was obtained showing evidence of
hypercholesterolemia with a cholesterol total of 259, LDL 158,
and triglycerides 250. She was started on lipitor 20mg po daily
and will need to have her LFTs monitored in the future. We have
added back her lopressor at a lower dose of 12.5mg po twice
daily which can be titrated as needed.
5. ARF - unclear baseline creatinine, prior cr of 1.5 suggesting
likely CKD at baseline. As discussed above, her creatinine rose
to a maximum of 2.6 and we felt this was likely attributed to
lower BP (systolics in the 110s) in combination with diuresis.
On the day of discharge her serum creatinine is 1.7. There were
no electrolyte abnormalities during this hospitalization. She
will need future monitoring of her renal function while at
rehab. We suggest checking a complete metabolic panel on [**7-2**].
6. s/p CVA - coumadin held for ERCP
-Resuming coumadin at prior dose of 5mg po daily. She will need
follow up with her PCP and neurologist regarding goals of care.
She is currently subtherapeutic and will need continued
coagulation panels. She is not a candidate for lovenox given
her renal function and it was felt that the risks outweighed the
benefits for starting her on IV heparin at this time. This was
discussed with the patient's daughter who serves as the
health-proxy.
.
7. Depression, anxiety, ?psychosis
- continue ritalin, lexapro
- continue to hold all sedating meds
.
7. FEN: Low sodium diet, heart healthy, puree diet. Continue to
monitor electrolytes.
.
8. PPx: heparin subcut, bowel reg, ppi was administered while
she was an inpatient.
Medications on Admission:
Tylenol prn
Bisacodyl
MOM
nitroglycerin prn
compazine
colace
K-dur
Isosorbide dinitrate
Advair
Albuterol
Spiriva
reglan
ativan prn
vicodin prn
Amlodipine
zyprexa
MVI
prednisone 2.5mg qdaily
coumadin 5mg qhs (on hold for procedure)
Ritalin 10mg [**Hospital1 **]
lasix 20mg [**Hospital1 **]
metoprolol 25mg [**Hospital1 **]
lexapro 20mg
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 13089**] Care Center - [**Location (un) 1439**]
Discharge Diagnosis:
Respiratory failure
Acute renal failure
Altered mental status
Secondary diagnoisis:
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Dyslipidemia
Stroke
Discharge Condition:
stable
Discharge Instructions:
Patient should continue on 2L nasal canula titrated to keep
oxygen saturation between 90-92% given her CO2 retention. She
will require daily monitoring of her serum creatinine while her
lasix dose is titrated back to her baseline.
Followup Instructions:
She should follow up with her PCP [**Name9 (PRE) **],[**Name9 (PRE) 74395**]
[**Telephone/Fax (1) 74396**], in [**12-20**] weeks. She should also follow up with her
neurologist in 6 weeks time.
Name: [**Known lastname 12274**],[**Known firstname 12275**] Unit No: [**Numeric Identifier 12276**]
Admission Date: [**2186-6-23**] Discharge Date: [**2186-7-1**]
Date of Birth: [**2110-10-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids
Attending:[**First Name3 (LF) 12277**]
Addendum:
Lasix was not included in the prior discharge summary
medications on discharge. The revised list includes Lasix 20mg
po daily.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Metoprolol Tartrate 25 mg Tablet Sig: one half Tablet PO
twice a day.
20. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Furosemide 20mg tablet Sig: one (1) tablet po daily
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12278**] Care Center - [**Location (un) **]
[**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 12279**] MD [**MD Number(2) 12280**]
Completed by:[**2186-7-1**]
|
[
"V58.65",
"428.20",
"584.9",
"311",
"599.0",
"731.0",
"272.4",
"276.4",
"294.8",
"438.11",
"V45.81",
"428.0",
"V43.64",
"458.9",
"403.90",
"574.50",
"327.23",
"585.9",
"244.9",
"496",
"414.00",
"V58.61",
"441.4",
"997.5",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.88",
"93.90",
"97.55"
] |
icd9pcs
|
[
[
[]
]
] |
13142, 13435
|
4079, 8004
|
303, 309
|
10349, 10358
|
3026, 4056
|
10638, 11321
|
2579, 2583
|
11344, 13119
|
10160, 10328
|
8030, 8367
|
10382, 10615
|
2598, 3007
|
238, 265
|
337, 2170
|
2192, 2563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,774
| 155,794
|
24678
|
Discharge summary
|
report
|
Admission Date: [**2177-11-2**] Discharge Date: [**2177-11-20**]
Date of Birth: [**2104-2-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Motor cycle crash vs. car
Major Surgical or Invasive Procedure:
ICP bolt
Open tracheostomy
Percutaneous gastrostomy placement
History of Present Illness:
73 yo male, helmeted driver, s/p motorcycle crash vs. car;
struck head on. Medflighted from scene to [**Hospital1 18**] for continued
trauma care. Initial GCS 4; intubated prior to arrival to [**Hospital1 18**].
Past Medical History:
Sleep Apnea (uses CPAP @ home)
"Mini Stroke" w/ right eye deficit
Bilateral Carpal [**Last Name (un) 62282**] Syndrome
Bilateral ulnar neuropathy
Type II Diabetes
Right Carotid Artery Stenosis
Hypertension
Social History:
Married; lives with wife
Family History:
Noncontributory
Physical Exam:
VS upon admission:
HR 80 BP 120/palp
Gen: Intubated, not arousable
HEENT: abrasion on forehead; PERRLA
Neck: trachea midline
Chest: coarse BS bilat, sternum intact
Cor: RRR
Abd: soft, NT/ND FAST exam negative
Pelvis: stable
Extr: abrasions, no obvious deformities
Pertinent Results:
[**2177-11-3**] 12:00AM GLUCOSE-237* UREA N-23* CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-19* ANION GAP-15
[**2177-11-3**] 12:00AM CALCIUM-7.4* PHOSPHATE-2.9 MAGNESIUM-1.8
[**2177-11-3**] 12:00AM PHENYTOIN-5.4*
[**2177-11-3**] 12:00AM WBC-12.5* RBC-3.91* HGB-12.3* HCT-35.0*
MCV-90 MCH-31.4 MCHC-35.0 RDW-15.2
[**2177-11-3**] 12:00AM PLT COUNT-118*
[**2177-11-2**] 11:16PM TYPE-ART PO2-94 PCO2-33* PH-7.36 TOTAL
CO2-19* BASE XS--5
[**2177-11-2**] 11:16PM LACTATE-2.4*
[**2177-11-2**] 09:26PM PT-13.8* PTT-23.9 INR(PT)-1.3
CT HEAD W/O CONTRAST [**2177-11-2**] 5:19 PM
CT HEAD W/O CONTRAST
Reason: Please assess for bleed/fracture
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with motorcycle crash - trauma
REASON FOR THIS EXAMINATION:
Please assess for bleed/fracture
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Trauma.
TECHNIQUE: Head CT without contrast.
FINDINGS: A mild-to-moderate amount of subarachnoid hemorrhage
is visualized in the left temporo-parietal area. Additionally
there is a moderate amount of hemorrhage in the lateral
ventricles. Areas of low attenuation are visualized in the grey
and white matter of the right frontal and parietal lobes. There
are multiple small areas of density seen in the right
frontoparietal lobe region as well of unknown etiology. Most, if
not all, of these are probably subarachnoid in location. There
is evbidence of prior surgery with fixation in the cervical
spine on the scout view.
IMPRESSION:
1. Mild-to-moderate amount of subarachnoid hemorrhage in the
anterior cranial fossa.
2. Moderate amount of hemorrhage in the lateral ventricles.
3. Encephalomalacia right hemisphere, probably remote. Clinical
correlation suggested.
4. Densities in right anterior cranial fossa, possibly
Pantopaque or calcifications.
CT HEAD W/O CONTRAST [**2177-11-16**] 9:13 AM
CT HEAD W/O CONTRAST
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with mental status changes
REASON FOR THIS EXAMINATION:
interval change
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Mental status change.
COMPARISON: Head CT from [**2177-11-11**].
TECHNIQUE: Non-contrast head CT.
HEAD CT WITHOUT IV CONTRAST: There has been minimal decrease in
the amount of intraventricular blood demonstrated within the
occipital horns bilaterally, as well as within the sulci of the
left frontoparietal region. Again demonstrated is a low-density
right frontal subdural collection, which is stable in appearance
since the prior examination. Stable areas of low attenuation are
demonstrated within the right frontal, temporal, and parietal
regions with associated encephalomalacia, unchanged since the
prior exam. Tiny punctate calcifications are also again seen
within the right hemisphere.
There are no new areas of intercranial hemorrhage or mass effect
demonstrated. There is no shift in midline structures. The
ventricles are stable in size.
There is interval improvement in the degree of mucosal
thickening seen within the sphenoid and ethmoid sinuses. There
is continued opacification of both mastoid air cells.
Surrounding osseous and soft tissue structures are unchanged.
IMPRESSION: Minimal decrease in amount of intraventricular and
subarachnoid blood. Stable appearance of the ventricles. Stable
right frontal low-density subdural collection. No new areas of
hemorrhage or mass effect identified.
CHEST (PORTABLE AP) [**2177-11-16**] 8:27 AM
CHEST (PORTABLE AP)
Reason: fevers, secretions
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with trauma.
REASON FOR THIS EXAMINATION:
fevers, secretions
CHEST, SINGLE AP FILM
History of trauma with fever and increased secretions.
The tracheostomy tube is 5 cm above the carina. Left subclavian
CV line is in distal SVC. No pneumothorax. There are multiple
left-sided rib fractures with a small left pleural effusion and
atelectasis at the left lung base. Status post fusion lower
cervical spine. A focal opacity in the right lower zone is
likely composite rib and vascular density.
Brief Hospital Course:
Patient admitted to the trauma service. Neurosurgery and
Orthopedics immediately consulted. Patient loaded with Dilantin,
ICP bolt placed because of low GCS 4. He underwent serial head
CT scans which were stable. His pubic symphysis diastasis was
evaluated by Orthopedics; no surgical intervention. He underwent
tracheostomy and percutaneous PEG placement on [**2177-11-13**]; his
TF's are currently being cycled (see page 1 diet section).
Respiratory therapy has been following for his copious
secretions; does require frequent suctioning and he is on trach
mask. He does have a history of sleep apnea and uses CPAP at
home. Physical and occupational therapy were consulted and have
recommended acute rehab stay post hospitalization.
Medications on Admission:
Glyburide 5 [**Hospital1 **]
Colace 100 [**Hospital1 **]
Zocor 40 qd
Zantac 150 [**Hospital1 **]
Naproxen 500 [**Hospital1 **]
Plavix 75 qd
Atenolol 25 qd
Lisinopril 10 qpm
Actos 15 qd
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 160 mg/5 mL Solution Sig: [**1-5**] PO Q4-6H (every
4 to 6 hours) as needed for fever.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for HR <60 and SBP < 110 mmHg.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) dose
Injection four times a day: per flowsheet.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day). Tablet(s)
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
Five (25) units Subcutaneous qAM.
12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seventy
Five (75) units Subcutaneous at bedtime: give at start of
tubefeed cycle.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
s/p Motor cycle crash
Intraventricular hemorrhage
Left parietal subarachnoid hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Continue with your medications as prescribed.
Follow up in Trauma Clinic in [**3-7**] weeks.
Follow up with Neurosurgery in 6 weeks.
Follow up with your Primary Doctor, Dr. [**Last Name (STitle) **], after your
discharge from rehab.
Followup Instructions:
Call [**Telephone/Fax (1) 6439**] for an appointment in [**Hospital 46038**] Clinic in [**3-7**]
weeks.
Call [**Telephone/Fax (1) 1669**] for an appointment with Neurosurgery in 6
weeks.
Follow up with your Primary doctor, Dr. [**First Name4 (NamePattern1) 11556**] [**Last Name (NamePattern1) **],
[**Telephone/Fax (1) 61754**] after your discharge from rehab. You will need to
call for an appointment.
Completed by:[**2177-11-20**]
|
[
"805.6",
"250.00",
"593.2",
"873.40",
"428.0",
"518.0",
"518.81",
"E812.2",
"860.0",
"486",
"852.06",
"E849.5",
"861.21",
"433.10",
"562.10",
"780.57",
"807.07",
"807.4",
"401.9",
"808.43",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"34.04",
"86.59",
"38.91",
"01.18",
"96.72",
"43.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7464, 7522
|
5330, 6066
|
345, 409
|
7654, 7663
|
1254, 1920
|
7944, 8380
|
937, 954
|
6301, 7441
|
4797, 4826
|
7543, 7633
|
6092, 6278
|
7687, 7921
|
969, 974
|
276, 307
|
4855, 5307
|
437, 650
|
988, 1235
|
672, 879
|
895, 921
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,605
| 179,261
|
50688
|
Discharge summary
|
report
|
Admission Date: [**2199-11-12**] Discharge Date: [**2199-11-21**]
Date of Birth: [**2122-4-28**] Sex: M
Service: NEUROLOGY
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
Intracerebral hemorrhage, Headache, change in mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 105462**] is a 77yo LH man with a PMHx significant for
metastatic melanoma (mets to liver and lymph nodes), afib on
coumadin, placement of a pacemaker and lumbar spinal stenosis
who was originally admitted to neurosurg on [**11-12**] and transferred
to OMed on [**11-15**]. He is being transferred to the Neuro ICU
because of concern for altered mental status this AM.
To briefly recount his history: he had been in his USOH
until the day of admission, when he developed a sudden left
temporal headache. He was having difficulty walking and
eventually was unable to stand up. He was found down with
decreased movement of his left side next to his bed. Concerned,
his wife activated EMS and he was brought to an OSH for
evaluation. There, a NCHCT showed a right temporal IPH with
intraventricular extension. His INR at that point was noted to
be "supratherapeutic". He was intubated and then transferred to
[**Hospital1 18**] for further management (INR on arrival was 2.3). Upon
arrival, he was admitted to the Neurosurgery service for further
management. He was observed and his anticoagulation was reversed
while on that service. He was also started on PHT on admission
for seizure ppx. A head CT with contrast on [**11-13**] was concerning
for an intracerebral hemorrhage,
On the AM of [**11-15**], he was found to have decreased
responsiveness -- he barely responsive to name, would have
difficulty opening his eyes and and difficult to arouse. He
also had a fever to 100.4 with perseveration and [**Last Name (un) 6055**]-[**Doctor Last Name **]
breathing. Concerned, neuroonc was consulted and it was
recommended that he be transferred to the NeuroICU for further
management for concern for worsening of his bleed. He was
started on decadron and nimodipine. He also received an extra
dose of phenytoin (200mg) He also received a NCHCT prior to
transfer, that was unchanged from the one the day prior.
Past Medical History:
PAST MEDICAL HISTORY:
1. Metastatic melanoma, diagnosed in [**3-/2199**] (lesion on vertex
of
head) with mets to LNs of neck and LLL of lung.
2. Atrial fibrillation, status post pacemaker placement in
[**2196**].
3. Hypertension.
4. History of TIA.
5. Lumbar spinal stenosis with resultant severe symm.
peripheral
neuropathy -- followed by Dr. [**Last Name (STitle) **] in clinic for many years
6. Basal cell carcinoma.
7. Remote history of seizure.
PAST SURGICAL HISTORY:
1. Status post partial thyroidectomy 15 years ago.
2. Status post total laminectomy of L4-L5, partial laminectomy
of L3, fusion of L4-L5 in [**2187**].
Social History:
Married lives with his wife. Retired police officer. Does not
smoke or drink
Family History:
His father died at age 72 from complications of lupus. His
mother died at age [**Age over 90 **] from congestive heart failure. His
sister, age 79, is healthy. His 2 daughters and a son are
healthy.
Physical Exam:
Neurosurgery Exam on Admission:
PHYSICAL EXAM:
O: T: afebril BP: 130's/80's HR:62 R 10 vented / not
over breathing the vent O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: No hemotymapnum / no battles / no raccoon / NC/AT / no
csf
rhinorrhea otorrhea / Pupils: 2 trace rxn bilaterally gaze
conjugate
Neck: in collar
Neuro: GCS E=1 M=5 V=1T / =7T
No eye opening to stimulation or voice, perrl trace reaction at
2mm b/l / gaze conjugate wihtout nystagmus / no facial assymetry
noted / localizes with RUE to sternal rub / weak w/d of LUE /
trace withdrawal of b/l LE / no clonus / toes down going.
Neurology Exam on Transfer to Neurology Service:
Genl: Awake, alert, friendly, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: NABS, soft, NTND abdomen
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**]
backwards easily. Dysarthric speech, but fluent with normal
comprehension and repetition; able to make jokes. No right-left
confusion. No evidence of apraxia. $1.75 = 7 quarters. Has
dense left sided neglect (only able to ID half of people in the
room).
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. Difficult to assess visual fields with
neglect.
Extraocular movements intact bilaterally without nystagmus.
Sensation intact V1-V3. left sided facial droop. Hearing intact
to finger rub bilaterally. Palate elevation symmetric. Tongue
midline, movements intact.
Motor: Increased tone in left leg. No observed myoclonus,
asterixis, or tremor. Unable to keep left arm up to do pronator
drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE IP H Q DF PF
R 5 5 5 5 5 5 5 5 5
L 5- 5- 5- 5 4 4 4 4 4
Sensation: Decreased distally to all modalities in LE. Intact
to
light touch. + Extinction to DSS.
Reflexes: 2+ on UE bilaterally, unable to obtain in LE b/l. Toes
mute bilaterally.
Coordination: Weakness with finger-nose-finger, finger-to-nose,
L>R.
Gait: Deferred.
At time of discharge, Mr. [**Known lastname 105462**] had a waxing and [**Doctor Last Name 688**] mental
status and his orientation could be good on one day and patchy
on another, with an otherwise similar exam.
Pertinent Results:
ADMISSION LABS:
[**2199-11-12**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2199-11-12**] 05:30PM PT-24.3* PTT-33.4 INR(PT)-2.3*
[**2199-11-12**] 05:30PM NEUTS-87.6* LYMPHS-8.4* MONOS-2.9 EOS-0.9
BASOS-0.3
[**2199-11-12**] 05:30PM WBC-9.6 RBC-4.38* HGB-12.7* HCT-38.5* MCV-88
MCH-28.9 MCHC-32.9 RDW-14.4
[**2199-11-12**] 05:30PM GLUCOSE-107* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
CT Head [**11-13**]:
Large right temporal intraparenchymal hemorrhage with
intraventricular and subarachnoid extension. Given history of
melanoma, underlying mass lesion is a possibility and may be
evaluated with MRI (not possible given pacer).
Follow-up CT's stable on [**11-15**]/10-->done for altered
mental status.
EEG reveals encephalopathy (generalized slowing) with come
assymetry (possibly attributable to hemorrhage).
Portable chest films revealed cephalization and edema, resolving
during the admission. No frank consolidation.
EKG's revealed atrial fibrillation with atrial pacing and some
periods of AF with RVR earlier in admission. Telemetry with rate
control later in admission.
DISCHARGE LABS:
[**2199-11-21**] 05:45AM BLOOD WBC-9.6 RBC-4.51* Hgb-13.7* Hct-38.3*
MCV-85 MCH-30.3 MCHC-35.7* RDW-14.2 Plt Ct-132*
[**2199-11-21**] 05:45AM BLOOD PT-13.2 INR(PT)-1.1
[**2199-11-21**] 05:45AM BLOOD Glucose-126* UreaN-25* Creat-1.0 Na-136
K-3.1* Cl-101 HCO3-25 AnGap-13
[**2199-11-18**] 07:25AM BLOOD ALT-13 AST-17 LD(LDH)-276* AlkPhos-71
TotBili-1.2
[**2199-11-21**] 05:45AM BLOOD Calcium-8.8 Phos-2.6*
[**2199-11-20**] 06:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
[**2199-11-21**] 05:55AM BLOOD Vanco-12.2
[**2199-11-21**] 12:51AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2199-11-21**] 12:51AM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2199-11-21**] 12:51AM URINE RBC-[**10-26**]* WBC-0-2 Bacteri-RARE
Yeast-NONE Epi-0-2
[**2199-11-16**] 09:20AM URINE Mucous-RARE
Brief Hospital Course:
Initial Hospital Course with Neurosurgical Team
The patient was admitted to the SICU for further evaluation. He
was loaded with Dilantin, and his INR was immediately reversed
with FFP and Vit K for a goal INR < 1.4. He was extubated in the
morning, and on his exam he was following commands and MAE. A
Head CT with contrast on [**11-13**] demonstrated a right temporal
hamorrhage and was read as having no underlying mass. On further
inspection of the scan it was felt that there was an underlying
mass consistent with metastatic melanoma. On [**11-14**] he was deemed
fit to be trasnferred out of the ICU and the family was
thoroughly updated by Dr. [**Last Name (STitle) **]. He was medially stable
overnight on the floor however was agitated and required Posey
restraint and Geodon. What stable, he was transferred to the
care of Neurology and their floor service.
Intracerebral Hemorrhage
Contributors: Likely cerebral metastases of melanoma (difficult
to further evaluate in this context and given MRI could not be
performed owing to pacer), coumadin, striking of head (possibly
occurred after bleed - unclear). [**Name2 (NI) **] should remain on
Lovenox prophylaxis given lesser risk of more bleeding, but
likely hypercoagulable state at present. Please do not restart
coumadin at this time. Dr. [**Last Name (STitle) 724**] will re-address these questions
in clinic. He also is likely to have had a seizure, hence
starting of Dilantin. His mental status worsened slightly with
Dilantin, so we have started zonisamide and started tapering
Dliantin (was at 150 mg TID) - see instructino in med list
below. Gabapentin has likely been anticonvulsant and was
mistakenly continued at 300 mg TID rather than 600 mg TID, but
this is now continued at the lower dose given stability at
present and some sedation. This should be revised after Dilantin
is stopped and with continued evaluation of mental status. Given
underlying melanoma, dexamethasone was started, with dosing
revised by Dr. [**Last Name (STitle) 724**] at NeuroOnc follow-up. Given steroid
treatment, IV H2 blocker (now PPI on DC as per home regimen),
insulin were started. Vitamin D and calcium given. Dr. [**Last Name (STitle) 724**]
plans whole brain radiation and chemotherapy is also possible.
This is another reason why we preferred zonisamide (mostly renal
clearance) to Dilantin (non-linear/saturatable and inducing,
hepatic).
Melanoma
Scalp lesion presently not active. Metastatic disease. Was seen
by oncology in house. Present issue is likely cerebral
metastases.
Fluid Overload
Patient with significant pulmonary edema on transfer to
neurology. Self-resolving but also treated with small Lasix
doses (20 mg). Likely primary reason for increased respiratory
rate and hypoxia.
Pneumonia
Patient likely aspirated and given overall fragile state,
treated. Vancomycin and Zosyn chosen given less likely to
provoke seziures than other regimens. Treatment to finish on
[**2199-11-28**]. PICC line was placed and is in the correct location
for use.
[**Last Name (un) 6055**]-[**Doctor Last Name **] Respiration
Echo not performed, but may contributors likely low-output
cardiac state or due to hemorrhage or even metastases. Given
stability and attribution of increased work of breathing to
edema, was not further worked-up.
Atrial Fibrillation
Metoprolol continued through the admission with good rate
control. Patient typically takes metoprolol succinate 25 mg QAM
with additional 25 mg of tartrate if needed. Pacer interrogation
appointment on [**2199-11-25**] (same day as NeuroOnc appointment). He
was seen by the electrophysiology service while an inpatient.
Pacer working well but will be interrogated in clinic.
SSRI
Citalopram dose held at 20 mg. Can be increased when patient
stabilized to 40 mg if indicated, as intended by Dr. [**Last Name (STitle) **].
Hypothyroidism
Would recommend outpatient TSH check given interaction of
levothyroxine with calcium.
Hyperlipidemia
Continued atorvastatin at 10 mg.
Hematuria and Urinary Management
Trace in context of Lovenox treatment and Foley in place. Foley
removed prior to DC. Please repeat UA to see that blood does not
increase.
CODE STATUS: DNR/DNI
Medications on Admission:
MEDICATIONS:
ATORVASTATIN [LIPITOR] - 10 mg Tablet - one Tablet(s) by mouth
once a day
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth Daily start
after finishing 20mg tablets
GABAPENTIN - 300 mg Capsule - 2 Capsule(s) by mouth three times
a
day
LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 Tablet(s) by mouth
qam
LORAZEPAM - 0.5 mg Tablet - 1 Tablet by mouth Take 2 hours prior
to the MRI You may take an additional dose if there is no effect
in one hour
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice
a
day PRN as needed as instructed
OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - [**12-8**]
Tablet(s) by mouth Q4-6H as needed for pain please do not drive
or operate machinery while taking pain medications
QUINIDINE GLUCONATE - 324 mg Tablet Sustained Release - 1
Tablet(s) by mouth three times a day
WARFARIN - 2 mg Tablet - 3 Tablet(s) by mouth daily as directed
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Was to be increased to 40 mg daily - we leave this to discretion
of PCP after acute illness. .
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): .
4. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: PICC line
flush.
5. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours): Last day [**2199-11-28**].
6. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): Last day [**2199-11-28**]. Level
suggested 15-20. Please check level and adjust dose accordingly.
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain or fever.
10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day): With meals.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. insulin regular human 100 unit/mL Solution Sig: Per sliding
scale Injection ASDIR (AS DIRECTED): While receiving
dexamethasone. .
13. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day): Please give 100 mg TID for two
days, then 50 mg TID for two days, then 25 mg TID for two days,
then stop.
16. zonisamide 100 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)).
17. dexamethasone sodium phosphate 4 mg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours): Continue - Dr. [**Last Name (STitle) 724**] will
determine whether change needed in clinic.
18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary
Intracerebral hemorrhage
Seizure
Metastatic Melanoma, with likely cerebral metastases
Pneumonia
Secondary
Atrial fibrillation, status post pacemaker placement in [**2196**].
Hypertension.
Lumbar spinal stenosis.
Discharge Condition:
Mr. [**Known lastname 105462**] is typically alert, but inattentive, oriented to
self, and variably to place, time, context. A typical response
might be correct month, confusion with exact day or date,
"[**9-15**]" instead of [**2198**] and hospital. His mental status tends to
vary through the day from drowsy to alert. He often gives full
sentence, but inappropriate answers to questions. He is
typically quite cheerful and interactive. He needs assistance to
chair and will benefit from continued physical therapy.
Discharge Instructions:
You were admitted to the hospital after bleeding in your brain,
in the context of falling out of bed and likely metastases of
melanoma to your brain. This has also been associated with
seizures. We started Dilantin (an anti-seizure medication) and
changed this to Zonegran given some sedation. Your brain bleed
is now stable. You were seen by Cardiac Electrophysiology and
Oncology while an inpatient and will follow-up with both in
clinic. It is now safe for you to go to rehabilitation where you
will complete a course of antibiotics and undergo physical
therapy. Please take your medications as directed and attend
follow-up appointments.
your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? Please do not restart warfarin at this time.
CALL YOUR NEUROSURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Please attend the following appointments (we have shifted them
to the same day to minimize transportation):
1. Neurooncology: Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2199-11-25**] 10:30
2. Cardiology: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2199-11-25**] 1:30
Also:
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] , to be seen in [**3-12**] weeks.
?????? You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-12-12**] 10:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
|
[
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"276.69",
"V45.01",
"V10.82",
"431",
"244.9",
"345.90",
"V58.61",
"427.31",
"197.7",
"198.3",
"196.0",
"348.30",
"272.4",
"724.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15446, 15543
|
7890, 12082
|
344, 352
|
15807, 16326
|
5789, 5789
|
17985, 18937
|
3103, 3307
|
13280, 15423
|
15564, 15786
|
12108, 13257
|
16350, 17962
|
7016, 7867
|
2837, 2992
|
3370, 4234
|
244, 306
|
380, 2334
|
4682, 5770
|
5806, 7000
|
3355, 3355
|
4273, 4666
|
4258, 4258
|
2378, 2814
|
3008, 3087
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,870
| 105,091
|
43216+58600
|
Discharge summary
|
report+addendum
|
Admission Date: [**2156-11-10**] Discharge Date: [**2156-11-17**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Aortic valve replacement (23mm [**Company **] mosaic ultra
porcine valve) [**11-10**]
History of Present Illness:
[**Age over 90 **] year old female with history of aortic stenosis followed by
serial echos. Referred for surgical evaluation
Past Medical History:
Aortic Stenosis
Hypertension
Elevated lipids
Arthritis
Urinary incontinence
Cataracts
Osteoporosis
Hemorrhoids
s/p BOOP [**2140**]
Urinary tract infections
s/p right cataract laser treatment
tonsillectomy
hysterectomy
appendectomy
Social History:
Retired school teacher
Lives with spouse
[**Name (NI) 1139**] denies
ETOH denies
Family History:
non contributory
Physical Exam:
[**Age over 90 **] yo women in NAD
HR 80 RR 16 BP 122/35
Lungs CTAB
Heart RRR Holosystolic murmur
Sbdomen soft, NT, NT, +BS
Extrem war, trace BLE edema
Neuro grossly intact
No varicosities
Pertinent Results:
[**2156-11-16**] 06:25AM BLOOD WBC-7.4 RBC-3.10* Hgb-10.2* Hct-29.7*
MCV-96 MCH-32.8* MCHC-34.3 RDW-15.4 Plt Ct-185
[**2156-11-16**] 06:25AM BLOOD Plt Ct-185
[**2156-11-14**] 02:55AM BLOOD PT-11.6 PTT-31.5 INR(PT)-1.0
[**2156-11-16**] 06:25AM BLOOD Glucose-95 UreaN-37* Creat-1.1 Na-133
K-4.4 Cl-103 HCO3-24 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 93116**] (Complete)
Done [**2156-11-10**] at 11:55:33 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2064-7-21**]
Age (years): [**Age over 90 **] F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Patient with AS for AVR
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2156-11-10**] at 11:55 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW-:1 Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *76 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 43 mm Hg
Aortic Valve - Valve Area: *0.4 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal descending aorta diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: [**Pager number **] (2+) MR.
TRICUSPID VALVE: Mild to [**Pager number 1192**] [[**12-2**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation
is seen. [**Month/Day (2) **] (2+) mitral regurgitation is seen. There is no
pericardial effusion.
Post CPB: A prosthetic valve is seen in the aortic position. No
AI, no leak. MR [**First Name (Titles) 19947**] [**Last Name (Titles) 1192**]. Good biventricular systolic
fxn. Aorta intact. Other parameters as pre-bypass.
CHEST (PORTABLE AP) [**2156-11-15**] 4:17 PM
CHEST (PORTABLE AP)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with s/p AVR
REASON FOR THIS EXAMINATION:
evaluate effusion
INDICATION: Status post aortic valve replacement.
COMPARISON: [**2156-11-12**].
UPRIGHT AP CHEST: Sternotomy wires are unchanged, as is
cardiomegaly and the heavily calcified aorta. [**Month/Day/Year **] bilateral
pleural effusions are increased in volume from [**11-12**].
The upper lungs are well aerated, but there is bibasilar
atelectasis related to the effusions. The right IJ sheath has
been removed. No pneumothorax.
IMPRESSION: [**Month (only) **] bilateral pleural effusions are increased
in volume compared to [**11-12**].
Brief Hospital Course:
She was taken to the operating room on [**11-10**] where she underwent
an AVR. She was transferred to the ICU in critical but stable
condition on neosynephrine and propofol. She was seen by GU
immediately postop for hematuria in the setting of known bladder
tumor. CBI was started. She remained intubated overnight and was
extubated on POD #1. Her hematuria resolved. Her neo was weaned
to off on POD #4. She was transfused. She was transferred to the
floor on POD #5. She was seen by EP for afib with bradycardia,
and they recommended telemetry monitoring at rehab. She was
ready for discharge to rehab on POD #6.
Medications on Admission:
Dipyridamole ER 200", Lisinopril 40', Nifedipine 30', Lipitor
10', Omeprazole 20", Zyrtec 10', Nasocort AQ 55 mcg 2/nostril',
ca++ 500', FeSO4 325', MVI 1'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Dipyridamole 50 mg Tablet Sig: Four (4) Tablet PO twice a
day: 200 mg [**Hospital1 **].
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Cap(s)
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. 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:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Hypertension
Elevated lipids
Arthritis
Urinary incontinence
Cataracts
Osteoporosis
Hemorrhoids
s/p BOOP [**2140**]
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:
Please call to schedule all appointments
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr [**Last Name (STitle) **] after discharge
from rehab ([**Telephone/Fax (1) 250**])
Dr [**Last Name (STitle) **] after discharge from rehab
Dr. [**Last Name (STitle) **] after discharge from rehab
Completed by:[**2156-11-16**] Name: [**Known lastname 1974**],[**Known firstname 5185**] Unit No: [**Numeric Identifier 14683**]
Admission Date: [**2156-11-10**] Discharge Date: [**2156-11-17**]
Date of Birth: [**2064-7-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
She remained in house one more night after having several more
bursts of rapid atrial fibrillation. After speaking with
urology, given her history of hematuria and bladder tumor, She
was started on coumadin and her aggrenox was dc'd. If she has
any problems with hematuria, please contact Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 14464**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2156-11-17**]
|
[
"716.90",
"272.4",
"788.30",
"728.87",
"V45.61",
"733.00",
"E934.2",
"427.31",
"401.9",
"428.0",
"V13.02",
"428.30",
"599.7",
"397.0",
"438.89",
"997.1",
"188.9",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"35.21",
"96.49",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9587, 9828
|
5767, 6383
|
289, 381
|
7949, 7956
|
1150, 4757
|
8468, 9564
|
907, 925
|
6589, 7664
|
5112, 5159
|
7787, 7928
|
6409, 6566
|
7980, 8445
|
940, 1131
|
230, 251
|
5188, 5744
|
409, 537
|
559, 792
|
808, 891
|
4767, 5075
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,289
| 155,309
|
14933
|
Discharge summary
|
report
|
Admission Date: [**2127-4-30**] Discharge Date: [**2127-5-19**]
Date of Birth: [**2077-3-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
respiratory failure, pneumonia, hypovolemia
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
ATTENDING ADMISSION NOTE
Date: [**2127-4-30**]
Time: 2300
___________________________________________________
PCP: [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 4223**], Onc: [**Last Name (LF) **], [**First Name3 (LF) **] (thoracics)
.
CC: cough/vomiting/weight loss
___________________________________________________
HPI: Interviewed with phone interpreter. 50 yo M with T3N2
squamous cell esophageal cancer s/p Ivor-[**Doctor Last Name **] esophagectomy in
[**9-/2126**], chemo/XRT and CT in [**2-17**] with new para-aortic LAD
concerning for disease progression, lingular opacity now
presenting with 3 weeks of cough productive of yellowish
sputum-->vomiting. He denies dysphagia or odynophagia. He notes
that he has been afraid to eat because he thinks he will vomit.
He has lost about 10 lbs over the last few months. He notes that
the vomiting is usually precipitated by coughing spells. His
cough has been productive and he has had left sided chest pain.
He also notes mid-spine pain. No fever, nightsweats. He has not
had abdominal pain, nausea. He was seen as a walk-in at [**Hospital **]
clinic 2 days ago and then seen again today. At today's visit,
he was noted to be tachy to 150 and was referred to the ED.
He currently complains of left-sided, pulsating headache
without radiation, no acute visual change. He has had this
headache in the past. He has never had an HIV test nor a skin
test for TB.
In ER: (Triage Vitals: 98.2 110 95/68 20 97%) Meds Given:
Ceftriaxone/Azithro, Fluids given: NS x 2L, Radiology Studies:
CXR with ? multifocal PNA.
.
Past Medical History:
HTN
esophageal cancer s/p chemoradiation
h/o Tobacco abuse
h/o Alcohol abuse
Dyslipidemia
ONC history:
Esophageal cancer stage (T3N2M0) poorly differentiated with
squamous features with progressive disease
- [**2126-6-6**] Admitted with dysphagia and odynophagia which was
started 6 months PTA and had progressed over the past month. He
had an out pt barium swallow which showed an ulcerating mass at
the distal esophagus. Subsequently he was referred to [**Hospital1 18**] and
admitted to the medicine service. During this hospital stay
([**Date range (1) 43748**]), he had an EUS which revealed T3N2 disease with a
3x1 cm mass in the lower third of the esophagus and GE junction
involving the mucosa, submucosa, the muscularis and adventitia.
There were 4 lymph nodes in the peri-gastric and para-esophageal
region which were unable to be sampled but were suspicious for
malignancy. Biopsy of the mass revealed poorly differentiated
carcinoma with focal squamous differentiation. PET/CT scan
showed
FDG activity in the primary mass and peri-aortic lymph nodes as
well as a suspicious area in the left upper quadrant small bowel
(unclear significance). He was evaluated by both medical
oncology, thoracic surgery and radiation oncology and deemed a
good a good candidate for neoadjuvant chemoradiation followed by
resection.
- [**2126-6-18**] Portacath placed
- [**2126-6-20**] Radiation simulation in preparation to start
neoadjuvant chemoradiation
- [**2126-6-24**] to [**2126-6-29**] Elective admission for C1 cisplatin
75mg/m2 D1 and continuous 5FU 1000mg/m2 D1-4 with concomitant
XRT q28 days
- [**2126-7-23**] C2 cisplatin 75mg/m2 D1 and continuous 5FU 1000mg/m2
D1-4 with concomitant XRT q28 days
- [**2126-7-31**] Completed XRT
- [**2126-8-16**] to [**2126-8-30**] Admission for dehydration and
malnutrition. PEG placed.
- [**2126-8-22**] EGD with radiation esophagitis, no obvious recurrence
- [**2126-9-23**] PET CT showed new FDG-avid celiac lymph node
concerning for nodal metastasis as well as decreased uptake in
treated esophageal cancer.
- [**2126-9-25**] Esophagectomy showed poorly-differentiated squamous
cell carcinoma of the esophagus, 9 of 16 lymph nodes positive
for carcinoma
- [**2126-10-1**] Barium swallow with no leak, good gastric emptying
- [**2126-12-4**] CT torso showed several celiac axis nodes, the
largest of which measures 12 mm.
- [**2127-2-10**] CT torso showed new left para-aortic lymphadenopathy
as well as increase in previously noted celiac axis
lymphadenopathy consistent with disease progression.
Social History:
[**Location 7972**] but understands spanish. Work involved packing
vegetables for shipping. Former smoker, [**12-9**] ppd x 20 yrs.
History of EtOH abuse but quit drinking in [**2126-5-8**]. Lives
with his landlord in a [**Location (un) **] apartment. Married with wife
and children in [**Country 3587**].
Family History:
Mother - cancer, type unknown by pt.
Physical Exam:
T 99 P 104 BP 100/63 RR 18 O2Sat 99% RA
GENERAL: pleasant, non-toxic, mentating clearly
Eyes: NC/AT, PERRL, EOMI, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: RLL expiratory wheeze, left lung CTA
Cardiovascular: Reg, tachy S1S2, 4/6 systolic murmur
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted.
Genitourinary: no flank tenderness
Skin: R forearm tatoo, no rashes or lesions noted. No pressure
ulcer. small subcutaneous nodule in soft tissue of R shoulder
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric: pleasant and interactive
Pertinent Results:
[**2127-4-30**] 02:25PM WBC-12.4*# RBC-4.03* HGB-13.6* HCT-41.3
MCV-102* MCH-33.7* MCHC-33.0 RDW-11.4
[**2127-4-30**] 02:25PM NEUTS-79.8* LYMPHS-9.0* MONOS-5.1 EOS-5.7*
BASOS-0.4
[**2127-4-30**] 02:25PM PLT COUNT-286
[**2127-4-30**] 02:25PM ALBUMIN-3.8
[**2127-4-30**] 07:46PM LACTATE-1.1
[**2127-4-30**] 02:25PM GLUCOSE-131* UREA N-11 CREAT-0.9 SODIUM-135
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
[**2127-4-30**] 02:25PM ALT(SGPT)-51* AST(SGOT)-41* ALK PHOS-154* TOT
BILI-1.3
[**2127-4-30**] 02:25PM LIPASE-12
EKG: sinus rhythm @ 92, nml axis, J point elevation V2-5
CXR [**2127-4-30**]:
A central venous catheter terminates in the right atrium. The
heart is at the upper limits of normal size. There is a gastric
pull-up, which accounts for widening of the right side of the
mediastinum. The
mediastinal and hilar contours are unchanged. There is a
consolidation
involving the left upper lobe which layers along the major
fissure. In
addition, there is patchy opacification in the posterior
portions of the
lungs. To some extent, this probably resides in the right lower
lobe,
although the left lower lobe may also be affected by pneumonia.
There is no pleural effusion or pneumothorax. Bony structures
are unremarkable.
IMPRESSION: Findings consistent with multifocal pneumonia.
Followup
radiographs are recommended to show resolution within eight
weeks.
[**2127-5-3**] SPUTUM GRAM STAIN-PENDING; RESPIRATORY
CULTURE-PENDING; ACID FAST SMEAR-PENDING; ACID FAST
CULTURE-PENDING
[**2127-5-3**] urine culture pending
[**2127-5-3**] BLOOD CULTURE PENDING
[**2127-5-3**] BLOOD CULTURE PENDING
[**2127-5-2**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-PENDING
[**2127-5-2**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY
[**2127-5-1**] SPUTUM GRAM STAIN-NEGATIVE; RESPIRATORY
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-NEGATIVE; ACID FAST CULTURE-PRELIMINARY
[**2127-4-30**] BLOOD CULTURE PENDING
[**2127-4-30**] BLOOD CULTURE PENDING
[**2127-5-2**] Barium Swallow: Focal narrowing at the gastroesophageal
anastomosis, similar to prior fluoroscopic examination, but no
evidence of obstruction at this region, or leak.
[**2127-5-1**] MRI Brain
1. A small 0.8 x 0.9 cm ring enhancing lesion in the right
parietal lobe, posterior parasagittal in location without
significant surrounding edema or mass effect. Given the
history, this is concerning for the metastatic lesion.
However, infectious, inflammatory or subacute ischemic etiology
related lesions can also look similar. Correlate clinically and
followup.
[**2127-4-30**] 02:25PM BLOOD Lipase-12 GGT-157*
[**2127-4-30**] 02:25PM BLOOD cTropnT-<0.01
[**2127-5-2**] 07:30AM BLOOD Albumin-2.9* Calcium-9.9 Phos-2.7 Mg-1.6
[**2127-5-1**] 07:35AM BLOOD VitB12-310
[**2127-5-1**] 07:35AM BLOOD HIV Ab-NEGATIVE
[**2127-5-1**] 07:35AM BLOOD QUANTIFERON-TB GOLD-PND
[**2127-5-3**] 10:41AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
[**2127-5-2**] 01:30PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-3* Polys-4
Lymphs-56 Monos-40
[**2127-5-2**] 01:30PM CEREBROSPINAL FLUID (CSF) TotProt-20 Glucose-69
LD(LDH)-15
[**2127-5-2**] 01:30PM CEREBROSPINAL FLUID (CSF) Misc-CEA = < 1.
[**2127-5-2**] 01:30PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-PND
[**2127-5-2**] CEA DONE
cxr [**2127-5-17**]
There is complete opacification in left lung. There is an
endotracheal tube whose distal tip is approximately 4.5 cm above
the carina.
There is a right-sided central venous line with its lead tip in
the cavoatrial
junction. There are again seen multifocal opacities within the
right lung
which are stable. Contrast material in the colon is seen.
There are no
pneumothoraces.
Brief Hospital Course:
50 yo M with T3N2 squamous cell esophageal cancer s/p Ivor-[**Doctor Last Name **]
esophagectomy in [**9-/2126**], chemo/XRT and CT in [**2-17**] with new
para-aortic LAD concerning for disease progression, lingular
opacity now presenting with 3 weeks of productive cough,
vomiting, weight loss, hypovolemia and found to have multi-focal
PNA. Staging CT scan revealed LUL collapse, concerning for
obstructing mass, with bronchoscopy complicated by desaturation,
tachycardia, hypotension, requiring MICU admission. LUL
collapse was determined to be secondary to progression of his
primary malignancy. Pt went for bronchoscopy, and
post-procedure was hypotensive and in SVT in 150s. He was
emergently cardioverted and re-admitted to ICU. The following
day he was extubated. He initially did well off the vent, but
had persistent aspiration/vomitting secondary to malignancy and
once again, he went into respiratory distress requiring
reintubation. Pt's clinical status did not improve. Ultimately,
his entire left lung collapsed secondary to bronchial
compression from tumor burden and it was determined that he
would not be able to be weaned off of the mechanical
ventilation. Despite his clinical status, pt remained lucid and
was able to participate in a goals of care discussion with his
family. Together they made the decision to transition to CMO
with extubation but pt wanted to remain on the ventilator until
his wife could come from [**Country 3587**] to say goodbye.
Unfortunately, the patient's wife's visa was not granted (not
available in a timely manner), wo she was not able to travel to
the US to see the patient. Upon discussion with the family,
decision was made to transition to focus care on comfort. On
[**2127-5-19**], patient was extubated and quietly passed away. Famiy
members elected not to be present, but were notified of
patient's passing by phone.
Medications on Admission:
EXPIRED
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"518.84",
"783.21",
"V45.79",
"V66.7",
"197.0",
"427.1",
"401.9",
"785.59",
"V15.82",
"995.94",
"V49.86",
"305.03",
"130.9",
"275.42",
"536.2",
"V10.03",
"198.3",
"V87.41",
"196.1",
"276.51",
"507.0",
"518.0",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"33.22",
"99.62",
"96.72",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
11823, 11832
|
9845, 11733
|
348, 366
|
11883, 11892
|
6071, 9822
|
11948, 12084
|
4892, 4930
|
11791, 11800
|
11853, 11862
|
11759, 11768
|
11916, 11925
|
5792, 6052
|
4945, 5696
|
265, 310
|
394, 1983
|
5711, 5775
|
2005, 4552
|
4568, 4876
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,674
| 122,529
|
46021
|
Discharge summary
|
report
|
Admission Date: [**2118-4-11**] Discharge Date: [**2118-4-12**]
Date of Birth: [**2052-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
pre-syncope
Major Surgical or Invasive Procedure:
EGD x 1
History of Present Illness:
Mr. [**Known firstname 97961**] [**Known lastname **] is a very nice 66 year-old gentleman with
atrial fibrillation on coumadin who comes after a near-syncopal
episode with melena. He was in his prior state of health until 2
months ago when he started feeling fatigued and noticing very
small ammount of blood in his mouth in the mornings that he did
not pay much attention to. He denies any abdominal pain,
epigastric pain, easy bruising or bleeding. Yesterday he states
he did not feel good and that he had 5 loose bowel movements
(not watery) that were normal in color. He woke up in to go to
the bathroom to move his bowels and had [**Last Name (un) 23550**] stools, then on
his way back to the bed he felt dizzy, diaphoretic and fell to
the floor. He did not hit his head or lost consciousness. He dit
not feel confused or exhausted afterwards and there was no aurea
beforehand. He was transfered to the [**Hospital1 18**] for further
evaluation.
.
In the ER his initial VS were Pain 0/10, T 97.2 F, HR 63 BPM, BP
114/64 mmHg, RR 16 X', SpO2 100% on RA. His initial physical
exam he looked normal. His HCT was 24.3 from baseline of 35 on
[**8-22**] according to Atrius Notes and an INR of 2.7. Pt underwent
NG-lavage with brown fluid and after 500cc started to clear to a
pink fluid. However, they started to see [**Last Name (un) 97962**] blood afterwards.
Patient was started on IV pantoprazole gtt, received 4 mg of
zofran for nausea, was T&C and was ordered for 2 RBC Units and 2
units of FFP. He received 3 L of NS. After I discussed with ER
team, they decided to call GI and finally accepted to scope him
tonight in the ICU after elective intubation. Throughout the ER
admission his VS were stable with SBP in 110/70, HR 60 (on
diltiazem) prior to transfer. He has 2 18G for access.
Past Medical History:
* Diabetes Mellitus Type 2
* Hypernteion
* Dyslipidemia - Chol 160 HDL 44 LDL 61, TG 80 [**2-23**]
* Paroxysmal atrial fibrillation on coumadinm rate and
controlled with diltiazem
- S/p Appendectomy in [**2100**]
Social History:
He lives in [**Location 669**] with his wife. Denies any current or past
history of smoking, drinking or illegal substance use. He used
to work in the construction business and may have been exposed
to absestos.
Family History:
Denies history of MI
Physical Exam:
VS:
GENERAL - well-appearing man in NAD, comfortable, appropriate,
jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-18**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
[**2118-4-11**] 12:30AM BLOOD WBC-10.1 RBC-2.89*# Hgb-8.2*# Hct-24.3*#
MCV-84 MCH-28.5 MCHC-33.9 RDW-13.1 Plt Ct-227
[**2118-4-11**] 05:00AM BLOOD WBC-8.8 RBC-2.15*# Hgb-6.4* Hct-18.1*#
MCV-84 MCH-29.6 MCHC-35.3* RDW-12.8 Plt Ct-173
[**2118-4-12**] 05:43AM BLOOD WBC-14.3*# RBC-3.50*# Hgb-10.7*#
Hct-29.6* MCV-85 MCH-30.6 MCHC-36.1* RDW-13.5 Plt Ct-171
[**2118-4-11**] 12:44AM BLOOD PT-27.9* PTT-25.0 INR(PT)-2.7*
[**2118-4-12**] 05:43AM BLOOD PT-19.2* PTT-28.2 INR(PT)-1.8*
[**2118-4-11**] 12:30AM BLOOD Glucose-173* UreaN-54* Creat-1.0 Na-138
K-4.3 Cl-106 HCO3-22 AnGap-14
[**2118-4-12**] 05:43AM BLOOD Glucose-114* UreaN-19 Creat-0.8 Na-139
K-4.0 Cl-109* HCO3-23 AnGap-11
[**2118-4-11**] 12:30AM BLOOD ALT-24 AST-17 LD(LDH)-143 CK(CPK)-135
AlkPhos-44 TotBili-0.1
[**2118-4-11**] 05:00AM BLOOD ALT-23 AST-18 LD(LDH)-112 AlkPhos-35*
TotBili-0.1
[**2118-4-11**] 05:00AM BLOOD Albumin-2.9* Calcium-7.0* Phos-1.8*
Mg-1.6 Iron-54
[**2118-4-11**] 12:30AM BLOOD cTropnT-<0.01
[**2118-4-11**] 05:00AM BLOOD calTIBC-221* VitB12-340 Folate-10.7
Ferritn-27* TRF-170*
[**2118-4-11**] 09:55AM BLOOD freeCa-1.10*
[**2118-4-11**] - EGD report
Impression: Ulcer in the pre-pyloric region Ulcer in the
posterior bulb
The area of the ulcer was swollen raising the possibility of a
mass or cyst pressing on this area. Please obtain CAT scan to
make sure that there is o abnormality, Otherwise normal EGD to
second part of the duodenum
Recommendations: If any questions or you need to schedule an
[**Telephone/Fax (1) 682**] or email at [**University/College 21854**]. Ulcers
unlikely to rebleed give PPI [**Hospital1 **] for one week then daily, then
once daily. Check H. pylori antibody. Can restart coumadin in 72
hours if needed.
Brief Hospital Course:
Mr. [**Known firstname 97961**] [**Known lastname **] is a very nice 66 year-old gentleman with
atrial fibrillation on coumadin who comes after a near-syncopal
episode with melena and active upper GIB.
# Upper GI bleed - Patient on coumadin with INR of 2.7 coming
with melena, hemoptysis, active bleeding on NG-lavage and
pre-syncope with signs of hyperdynamic cardiovascular
hemodynamics, but stable VS. He drop from 35--->24 in hct, for
which he received total of 4 units PRBC, 4 units FFP, and
vitamine K. EGD showed a gastric ulcer (likely source of
bleed). There was extrinsic compression of stomach suggestive
of a mass (?pancreatic). Patient was suggested to follow up
with GI for outpatient workup with CT abdomen.
# Anemia - Pt with normocytic normochromic anemia with normal
RDW, most likely acute bleed.
# Diabetes Mellitus Type 2 - He is controlled with metfromin and
glyburide. He was placed on ISS due to bleed, strict NPO. He
was placed back on home meds at the time of discharge.
# Hypertension - Patient with normal BP, but due to bleeding,
home medications were held.
# Dyslipidemia - Chol 160 HDL 44 LDL 61, TG 80 [**2-23**] recently.
Held simvastatin given strict NPO for possible intubation and
EGD. Lipitor was resumed after patient tolerated PO.
# Paroxysmal atrial fibrillation - on coumadinm rate and
controlled with diltiazem. CHADS2 2.
# FEN - Strict NPO.
# Access - PIV with 18G x2
# PPx -
-DVT ppx with pneumoboots
-Bowel regimen colace/senna
-Pain management with morphine IV
# Code - Full code.
# Dispo - ICU until HCT stable and EGD.
# [**Name (NI) **] - Wife [**Telephone/Fax (1) 97963**].
Medications on Admission:
Diltiazem SR 360 Daily
Glyburide 5 mg PO daily
Metformin 1000 PO BID
Simvastatin 80 mg PO Daily
Coumadin 4 mg as directed
Viagra 50 mg PO PRN sex
Lisinopril 10 mg PO
Discharge Medications:
1. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: start tonight.
Disp:*14 Tablet(s)* Refills:*0*
3. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: Three (3)
Capsule,Degradable Cnt Release PO once a day.
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Viagra 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for sexual intercourse.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed
Gastric Ulcer
Duodenal Ulcer
P. Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with a bleed from an ulcer in your stomach.
This was made worse by the way that Coumadin thins your blood.
Additionally, you developed a pneumonia. You must follow up with
your PCP and complete the antibiotics as prescribed for your
pneumonia. Do not take coumadin until directed by your PCP.
Because of the shape of your stomach, we strongly reccommend
that you get a CT scan of your abdomen
START - Pantoprazole - an acid reducer for your ulcer.
START - Augmentin - an antibiotic
STOP - Coumadin - restart when instructed by your PCP
Followup Instructions:
APPOINTMENT WITH DR. [**Last Name (STitle) **] - [**Telephone/Fax (1) 80426**] - THURSDAY at 12pm
Please follow up with the gastroenterology team in [**2-16**] months.
You can get an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 86507**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"531.40",
"285.1",
"V58.61",
"250.00",
"401.9",
"276.52",
"272.4",
"427.31",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7833, 7839
|
5203, 6846
|
334, 344
|
7950, 7950
|
3460, 5180
|
8678, 9123
|
2650, 2672
|
7062, 7810
|
7860, 7929
|
6872, 7039
|
8098, 8655
|
2687, 3441
|
283, 296
|
372, 2168
|
7965, 8074
|
2190, 2404
|
2420, 2634
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,977
| 118,959
|
501
|
Discharge summary
|
report
|
Admission Date: [**2159-12-5**] Discharge Date: [**2159-12-20**]
Date of Birth: [**2090-1-18**] Sex: F
Service: MEDICINE
Allergies:
Losartan / Aspirin / Lisinopril-Hctz
Attending:[**First Name3 (LF) 4162**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Intubation for airway protection
tunneled line change over wire [**2159-12-18**]
History of Present Illness:
69 y/o female wtih PMH significant for ESRD on HD, type 2 DM,
and recent PE resulting in PEA arrest admitted through the ED
with sepsis of unknown etiology. Pt was recently admitted to
[**Hospital1 18**] from [**11-16**] thorugh [**11-23**] with hypotension thought to be
secondary to overdiuresis at HD. However, a septic component to
the hypotension was also considered as the pt was found to have
citrobacter in her urine and C diff in her stool. Pt was then
discharged to [**Hospital1 100**] Senior Life where she was in her normal
state of health until three days ago. Her son reports that she
then developed a headache and fevers started three days ago
which were treated with tylenol. Then, this morning she
developed fatigue and did not eat well. He son also notes that
she appeared to be working hard to breath. She was found to be
febrile to 101.9 and received levoflox and vancomycin. Pt was
then sent to the [**Hospital1 18**] ED for further evaluation. Per notes, pt
denied SOB, CP, and abdominal pain prior to intubation. She did
complain of a left frontal headache.
.
In the ED, the pt's VS were singificant for a fever of 103.8,
tachycardia in the 130s-150s, and initial hypertensive in the
140s. Her oxygen saturation was 96% on RA but she was tachypneic
to 31. She was obtunded and was thus intubated for airway
protection. Post-intubation, the pt's BP acutely dropped to
58/19 in the setting of propofol. When this medication was
discontinued, her BP came back up to the 70s-90s/30s-50s. Pt was
then initiated on the sepsis protocol. In the ED, she received
vancomycin, levofloxacin, flagyl, and cefepime (2 gm). She
received a total of 4 liters of NS then was started on levophed
for continued hypotension. Pt is now transferred to the [**Hospital Unit Name 153**] for
further care.
.
Per pt's son, she is bedbound at baseline due to her multiple LE
femur fractures.
Past Medical History:
1. Type 2 diabetes mellitus
2. Diabetic nephropathy resulting in ESRD for which she is on
HD. Pt was due for HD but missed it secondary to her illness.
She normally receives HD on Mon, Wed, and Fri.
3. Status post left femur fracture
4. Hyponatremia
5. Hypercholesterolemia
6. Unsteady gait
7. Cataracts
8. Back pain
9. Hypertension
10.Anemia of chronic disease
11. S/P L shoulder hemiarthroplasty following a left humeral
fracuture in [**10/2159**]- [**Last Name (un) 4163**] was complicated by a PEA arrest
secondary to PE.
12. PE [**2159-10-27**] leading to PEA arrest
Social History:
Lives with son who is very involved and well informed regarding
her care needs. Non smoker. No EtOH
Family History:
Noncontributory
Physical Exam:
94.5 132/50 108 15 100%
AC 500/15/.50/PEEP 5
Gen- Sedated and intubated. Grimaces eyes when they are opened.
HEENT- NC AT. Right pupil ERRL. Surgical left pupil. Anicteric
sclera. MMM.
Cardiac- RRR. S1 S2. No m,r,g.
Pulm- CTA anteriorlly.
Abdomen- Obese. Soft. NT. ND. Positive bowel sounds.
Extremities- Feet mildly cool. 2+ DP pulses bilaterally. 2+
pitting edema bilateral LE. Skin breakdown between toes.
Pressure ulcers under bilateral LE right above the ankles. Do
not appear infected. Question mild erythema and warmth of left
LE.
Neuro- Sedated. Downgoing toes bilaterally. Scruntches eyes
closed when try to open them.
Pertinent Results:
[**2159-12-5**] 11:10PM LACTATE-1.8
[**2159-12-5**] 10:53PM CRP-46.2*
[**2159-12-5**] 10:53PM SED RATE-33*
[**2159-12-5**] 09:54PM TYPE-MIX TEMP-35.6 RATES-/15 TIDAL VOL-500
PEEP-5 O2-50 PO2-34* PCO2-39 PH-7.32* TOTAL CO2-21 BASE XS--6
-ASSIST/CON INTUBATED-INTUBATED
[**2159-12-5**] 09:54PM LACTATE-1.6
[**2159-12-5**] 09:44PM GLUCOSE-210* UREA N-29* CREAT-3.2* SODIUM-139
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-17* ANION GAP-14
[**2159-12-5**] 09:44PM CALCIUM-6.2* PHOSPHATE-1.7* MAGNESIUM-0.9*
[**2159-12-5**] 09:44PM CORTISOL-10.3
[**2159-12-5**] 09:44PM WBC-9.0 RBC-2.93* HGB-9.0* HCT-29.7* MCV-101*
MCH-30.8 MCHC-30.4* RDW-24.1*
[**2159-12-5**] 09:44PM NEUTS-65.2 LYMPHS-25.2 MONOS-6.0 EOS-3.3
BASOS-0.4
[**2159-12-5**] 09:44PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+
[**2159-12-5**] 09:44PM PLT COUNT-177
[**2159-12-5**] 08:28PM CORTISOL-9.3
[**2159-12-5**] 08:28PM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.005
[**2159-12-5**] 08:28PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2159-12-5**] 08:28PM URINE RBC-225* WBC-8* BACTERIA-NONE YEAST-NONE
EPI-<1
[**2159-12-5**] 02:40PM CK(CPK)-350*
[**2159-12-5**] 02:40PM CK-MB-3 cTropnT-0.40*
.
MICRO:
sputum [**12-6**]: grm stn and cx negative
infl A and B [**12-6**]: negative
CSF grm stn / cx: negative
urine cx [**12-5**]: > 100K VRE likely colonized, [**12-13**] yest and VRE
c diff neg: [**12-7**], [**12-10**], [**12-11**], [**12-12**].
bld cx [**12-5**], [**12-6**], [**12-7**], [**12-10**] - NG. [**12-11**], [**12-12**] X 3,
[**12-13**], [**12-14**], 11/27X 2 NGTD.
Catheter tip [**12-15**], NG.
C. Diff B - negative
Tunnled catheter tip [**12-18**] - ngtd
.
HERPES SIMPLEX VIRUS PCR - PND
Brief Hospital Course:
A/P:
69 y/o female wtih PMH significant for ESRD on HD, type 2 DM,
and recent PE resulting in PEA arrest admitted through the ED
with sepsis of unknown etiology.
.
1. Sepsis/ID- Started on sepsis protocol. Unclear etiology
headache over the three days prior to admission in association
with fever was concerning for a CNS etiology. Covered broadly
with vancomycin, flagyl, and cefipime. Given stress dose
steroids empirically and [**Last Name (un) 104**] stim showed cortisol of 9.3-->10.3
therefore steroids continued. CXR, LP, UA and abdominal CT
showed no sign of infection. PICC line was removed empirically.
Tip could not be cultured due to contamination. Cultures drawn
off the HD cath are negative to date. Patient's LE ulcers appear
chronic and do not appear to be the source of infection. Her
left knee is slightly erythematous compared to the right but not
impressive. Joint is mobile. Nasal washings for influenza were
negative; culture pending. Patient improved over the next few
days. Steroids were discontinued. On [**11-27**] flagyl and cefepime
were discontinued as all culture data negative to date. Plan to
continue vancomycin for [**7-29**] day course to treat empiric line
infection. Urine culture came back positive for VRE, however,
since patient improved without treatement (ie Linezolid)
initially.
.
After transfer to the floor when she was stable. On the floor
the Vancomycin was discontinued as the catheter tip culture was
negative. ID was consulted who suggested broad spectrum
antibiotics if she were to spike. When pt spiked a temperature
and became hypotensive she was started on Linezolid was started
for presumed VRE infection in the urine. She will be treated
for total 14 day course. She was also started on fluconazole
for yeast in the urine, to be treated with fluconazole for total
7 days. She was given Flagyl for presumed C. Diff. Colitis,
however this was stopped when C. Diff B toxin came back neaative
on [**2159-12-20**]. The tunneled catheter line was changed over a wire
and the tip was also negative.
.
2. Respiratory- Intubated for airway protection due to change in
mental status. Extubated [**12-7**] with no incident.
.
3. ECG changes- Patient had an episode of chest pain during her
hospital stay that was both right and left sided with no
radiation and no associated symptoms. ECG showed new diffuse TWI
in all leads. Cardiac enzymes were cycled and were normal. Echo
was obtained which showed WMA and EF of 35-40%. Pt was note
started on ASA as she does not tolerate this well, BB was also
not started given SBPs in the 110s. Statin was also deffered.
She may be started on ASA,BB,statin by PCP as [**Name9 (PRE) 3782**].
.
4. Shoulder fracture- Patient is s/p a left hip fracture
(decision not to operate) and a left shoulder fracture with
hemiarthroplasty [**10-24**]. Patient was found to have a new humerus
fracture distal to the hardware on film this admission. Assumed
to be secondary to trauma when moving patient into ambulance.
Ortho service was consulted and recommended wtd woulnd care and
sling at all times. Wound care should be continued as described
after discharge.
.
5. Type 2 DM- Patient was initially covered with an insulin drip
while septic and then transitioned back to insulin sliding
scale.
.
6. ESRD on [**Name (NI) 4164**] Pt has ESRD secondary to her DM and is on HD. She
was dialysed but was slightly limited by hypotension. Dialyzed
[**12-7**] with plan to dialyze again [**12-10**]. Her dialysis was
managed by renal service in house.
.
7. PE ([**10-24**])- On heparin drip. Restared coumadin on [**12-8**].
Heparin discontinued on [**12-11**] when INR was 2.0. Coumadin was
stopped and she received fFP for tunneled line change over a
wire. Coumadin was restarted at a dose of 2mg qhs. This should
be titrated after discharge for INR goal of [**2-22**].
.
8. PVD: Dry gangrene of toes bilaterally w/ necrosis of the
heels and posterior calf. Continue to monitor for sign of
infection. On vit C. and zinc as well to aid w/ wound healing.
Wound care consult given anasarca to prevent decub.
.
9. Left UE markedly more edematous than right UE, this could be
from fracture, or there could be a clot, an abscess in the area
also a possiblity. Ultrasound without clot. Continue elevation
and tight dressing to LUE>
.
10. Access- Left IJ placed [**12-5**] in ED was discontinued during
the hospitilization. Right dialysis catheter ([**2159-10-15**]) was
changed over a wire [**2159-12-18**]. PICC line placed [**2159-12-18**], this
should be discontinued immediately after pt finishes the
linezolid course.
.
11. Code status- Initially full code then made DNR/DNI after
family meeting on [**2-6**]. Made full code again on [**12-9**] after
family meeting with son. [**Name (NI) **] would like everything done.
.
12. [**Name (NI) 2638**] With pt's son. His name is [**Name (NI) 4165**] and his
phone number is [**Telephone/Fax (1) 4166**].
Medications on Admission:
1. Ascorbic acid 500 mg [**Hospital1 **]
2. Folic acid 1 mg daily
3. Humulin insulin 2 units QAM
4. RISS
5. Pantoprazole 40 mg [**Hospital1 **]
6. Neutra phos 2 tabs [**Hospital1 **]
7. Vitamin B complex 1 tab daily
8. Coumadin- Dose unknown
9. Tylenol 650 mg Q4H PRN
10. Ondansetron 4 mg Q6H PRN
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl
Topical DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
7. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Hold for SBP<100, HR<60.
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
10. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous four times a day: Please administer 8
units glargine at dinner and regular insulin sliding scale as
prescribed.
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Titrate dose to Goal INR [**2-22**]. Tablet(s)
12. Linezolid 600 mg IV Q12H
13. 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.
14. 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
15. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
16. medication
Please complete a total 14 day course of linezolid. Stop
linezolid on [**2159-12-27**].
.
The PICC line should be discontinued promptly after the
linezolid course is completed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Sepsis -?source
Chronic Kidney disease - on hemodialysis
type 2 diabetes
hypercholestrolemia
anemia of chornic disease
h/o PE, s/p PEA arrest [**10-24**]
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with low blood pressure and fevers likely due
to an infection. Although there was never any bacteria isolated
from the blood you had some bacteria in the urine which you are
being treated for. It is important that you complete the
antibiotic course as prescribed.
.
Please continue to take all medications as prescirbed and follow
up with all your appointments.
.
If you have chest pain, shortness of breath, diahrrea or fevers
please contact your PCP. [**Name10 (NameIs) **] the shortness of breath gets worse
please return to emergency room. If you have fevers please
contact your PCP or return to the emergency room.
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] to set up an appointment with your
primary care doctor Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] in [**1-21**] wks after discharge.
Completed by:[**2159-12-20**]
|
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icd9cm
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|
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[
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12538, 12611
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304, 387
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12809, 12818
|
3716, 5510
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3032, 3049
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10817, 12515
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12632, 12788
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10495, 10794
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12842, 13484
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3064, 3697
|
259, 266
|
415, 2303
|
2325, 2898
|
2914, 3016
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,041
| 173,747
|
41230
|
Discharge summary
|
report
|
Admission Date: [**2182-4-8**] Discharge Date: [**2182-4-14**]
Date of Birth: [**2114-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2182-4-10**] Urgent coronary artery bypass graft x3: Left internal
mammary artery to left anterior ascending artery, saphenous vein
graft to right coronary and diagonal arteries
[**2182-4-8**] Cardiac cath
History of Present Illness:
67 year old male with a history of CAD s/p Cypher stent to RCA
[**1-5**] DES to LCx in [**11-9**], type 2 diabetes, hypertension and
hyperlipidemia. He reports that he has experienced worsening
intermittent chest pain with activity for the past 6 months. He
is completely pain free at rest. He sought evaluation with his
cardiologist and underwent a stress test on [**2182-4-3**]. The test was
stopped due to severe chest discomfort. He developed [**2181-6-11**]
chest pain, onset at 1minute of exercise with severity of chest
pain at worst at peak exercise. Chest pain resolved 5 minutes
into recovery. There was no arrhythmia during exercise or
recovery. There was a blunted BP response to exercise. There was
2mm planar ST depression during exercise in leads II, III, F,
V3-V6. EKG changes began at 1:21 minutes of exercise at a heart
rate of 102 bpm and persisted for 8 minutes into recovery. The
nuclear portion showed a large area of severe stress induced
myocardial ischemia in the distribution of RCA coronary artery
at a low cardiac workload. Presently he is able to tolerate his
ADLs but has curtailed any strenuous activities over the last 6
months. He also notes that his symptoms seemed to have worsened
since he underwent the stress test. He was referred for a
cardiac catheterization and was found to have 90% ISR of RCA and
complex 80% disease of the proximal LAD and septal branch and
is now being referred to cardiac surgery for revascularization.
Past Medical History:
Coronary artery disease s/p Cypher PCI to RCA [**1-5**] ; s/p
Xcience DES to LCx in [**11-9**]
Hypertension
Hyperlipidemia
Type 2 diabetes
Gastroesophageal reflux disease
Spinal stenosis
Skin CA - on back excision approx 10 years ago; left arm
-removed
[**2151**]
Appendectomy at age 10
Tonsillectomy at age 5
Social History:
Race:Caucasaian
Last Dental Exam:edentulous
Lives with:wife
Occupation:retired
Tobacco:quit at the age of 18
ETOH:occasional glass of wine
Family History:
mother had "heart problems" she died at age 60 and brothers had
MI and has CAD
Physical Exam:
Pulse:69 Resp:18 O2 sat:97/RA
B/P Right:129/64 Left:108/81
Height:5'6" Weight:174 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 0
Varicosities: +1
Neuro: Grossly intact
Pulses:
Femoral Right: dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2182-4-8**] Cardiac Cath: 1. Coronary angiography in this right
dominant system demonstrated 2 vessel CAD. The LMCA had a 20%
distal lesion. The LAD had a 70%-80% angulated stenosis in a
tortuous vessel. There was a 70% stenosis in the distal LAD.
The Lcx had a 30% ostial lesion with a widely patent stent in
OM1. The RCA had a proximal 90% ISR. 2. Limited resting
hemodynamics revealed normotension.
[**2182-4-10**] Echo: PRE-BYPASS: The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No spontaneous echo
contrast is seen in the body of the right atrium or right atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe regional left ventricular systolic
dysfunction with mid to apical inferior and inferosepatal
hypokinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-50 %). The remaining left ventricular
segments contract normally. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. There
are simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. There is no aortic valve stenosis.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Prioro
to initiation of CPB, RV suddenly became severely hypokinetic
with moderate TR. IABP in good position 2-3 cm below the aortic
arch
POST: 1. Unchanged LV and RV systolci function (Patient on
epinephrine infusion) 2. IABP in good position. 3. No other
change.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] has chest pain with a
positive stress test. He underwent a cardiac cath on [**4-8**] which
revealed severe two vessel coronary disease. In view of the
symptoms and via the fact he had some chest pain, he was kept in
the hospital for coronary artery bypass grafting and underwent
usual pre-operative work-up. A few hours before he was taken to
the operating room on [**4-9**], he developed chest pain and
intra-aortic balloon pump was initially placed before he was
taken to the operating room. Following placement of his IABP, he
was brought to the operating room where he underwent a urgent
coronary artery bypass graft x 3. Please see operative report
for surgical details. Following surgery he was transferred to
the CIVCU for invasive monitoring in stable condition.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was 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. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged in good condition with appropriate
follow up instructions.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet -
once daily
GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet -
twice daily
GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet -
twice daily
INSULIN GLARGINE [LANTUS SOLOSTAR] - (Prescribed by Other
Provider) - 100 unit/mL (3 mL) Insulin Pen - inject 12 units
[**Last Name (un) **] daily at bedtime
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100 unit/mL Solution - inject 12 units sc once daily at bedtime
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Extended Release 24 hr - once daily
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet -
once daily
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
twice daily
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - twice daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - twice daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet -
once every evening
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - once daily
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - (Prescribed by
Other Provider) - Strip - use as directed 3-4 times daily
LANCETS - (Prescribed by Other Provider) - Dosage uncertain
OMEGA 3-DHA-EPA-FISH OIL - (Prescribed by Other Provider) -
1,000 mg (120 mg-180 mg) Capsule - once daily
Discharge Medications:
1. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Lantus 100 unit/mL Solution Sig: One (1) 12 units
Subcutaneous at bedtime.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Omega 3 Fish Oil 684-1,200 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 10 days.
Disp:*60 Capsule(s)* Refills:*0*
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation for 10 days.
Disp:*30 Suppository(s)* Refills:*0*
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
14. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Packet(s)* Refills:*0*
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/temp.
Disp:*30 Tablet(s)* Refills:*0*
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 10 days: prn for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
vna [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
s/p Cypher PCI to RCA [**1-5**] ; s/p Xcience DES to LCx in [**11-9**]
Hypertension
Hyperlipidemia
Type 2 diabetes
Gastroesophageal reflux disease
Spinal stenosis
Skin CA - on back excision approx 10 years ago; left arm
-removed
[**2151**]
Appendectomy at age 10
Tonsillectomy at age 5
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/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**]
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 should be called by Dr [**First Name (STitle) **] [**Name (STitle) **] office
for a follow appointment. If you do not hear from his office,
you should call his office for the appropriate follow up.
Department: Surgery
Division: Cardiothoracic Surgery
Operating Unit: [**Hospital1 18**]
Office Location: W/LMOB 2A
Office Phone: ([**Telephone/Fax (1) 1504**]
We were unable to reach your cardiologist. You should see her in
two weeks. Please call her and schedule an appointment.
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**]
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**5-7**] weeks
You have an appointment to come in for a sternal incision check
on [**Wardname 5010**], One of the midlevlers will evaluate your wound. This
is scheduled for [**4-18**] at 1000 hrs
**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:[**2182-4-14**]
|
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[
[
[]
]
] |
9767, 9822
|
5025, 6610
|
319, 531
|
10235, 10445
|
3268, 5002
|
11368, 12546
|
2532, 2612
|
8079, 9744
|
9843, 9905
|
6636, 8056
|
10469, 11345
|
2627, 3249
|
269, 281
|
559, 2027
|
9927, 10214
|
2376, 2516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,280
| 174,036
|
5330
|
Discharge summary
|
report
|
Admission Date: [**2163-7-18**] Discharge Date: [**2163-8-25**]
Date of Birth: [**2114-8-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2163-7-19**] Mitral Valve Replacement(25/33 Onx Mechanical Valve) via
Right Thoracotomy
History of Present Illness:
Mr. [**Known lastname 1968**] is a 49 year old male with extensive cardiac history
and complicated past medical history. He has had progessive
dyspnea on exertion. Echocardiogram was notable for severe
mitral regurgitation and mild pulmonary hypertension. In
preperation for upcoming surgery, he underwent cardiac
catheterization which confirmed severe mitral regurgitation with
a mean PA pressure of 20mmHg. The vein graft to the LAD was
patent while there was only mild disease in the vein graft to
the right coronary artery. He was subsequently admitted to the
[**Hospital1 18**] for cardiac surgical intervention.
Past Medical History:
Diastolic Congestive Heart Failure secondary to Mitral
Regurgitation, History of Endocarditis - s/p
Bentall/Homograft/MV debridement [**2156**] and [**2157**], Coronary Artery
Disease - s/p CABG [**2157**], History of TIA, Hypertension,
Hypercholesterolemia, History of Paroxysmal Atrial Fibrillation,
Type II Diabetes Mellitus, History of Seizure, History of Acute
Renal Failure, History of Hypoxic Encephalopathy, History of
ARDS with ventilator dependence, Prior Septic Emboli(brain,
lung, kidney), Depression, History of PEG/J-tube for Necrotizing
Esophagitis, Peptic Ulcer Disease/GERD, Chronic Malnutrition,
History of Aspiration, Bowel Dysmotility, History of Fungemia,
Tracheal-cutanous fistula closure in [**2159**], s/p Right
Hemicolectomy, Chronic Intermittent Chemical Pancreatitis,
History of multiple pneumonias, Hypercalcemia, s/p Right
Cochlear Implant
Social History:
No history of tobacco and denies ETOH. He is currently disabled
but previously employed as a truck driver. He is divorced.
Family History:
Denies premature coronary disease
Physical Exam:
BP 108-117/69-74, HR 63, RR 14
Weight 150lbs, Height 5ft 8inches
Thin male in no acute distress, very HOH
Oropharynx benign, PERRL, EOMI, sclera anicteric
Neck supple with no JVD, full ROM. Transmitted murmurs noted.
Lungs clear bilaterally. Chest with well healed sternotomy and
thoracotomy.
Heart regular rate, [**3-4**] holosystolic murmur throughout chest
Abdomen soft, nontender, nondistended with normoactive BS.
Mulitple scard that are well healed.
Extremities warm, no edema. Well healed leg incisions.
Alert and oriented, cn 2-12 grossly intact, no focal deficits
noted.
Distal pulses 2+ bilaterally
Pertinent Results:
[**2163-7-18**] 04:05PM BLOOD WBC-5.2 RBC-4.87 Hgb-14.1 Hct-41.0 MCV-84
MCH-28.9 MCHC-34.3 RDW-13.9 Plt Ct-234
[**2163-7-18**] 04:05PM BLOOD PT-12.0 PTT-29.2 INR(PT)-1.0
[**2163-7-18**] 04:05PM BLOOD Glucose-85 UreaN-25* Creat-1.5* Na-138
K-5.1 Cl-102 HCO3-28 AnGap-13
[**2163-7-18**] 04:05PM BLOOD ALT-41* AST-31 LD(LDH)-180 AlkPhos-182*
TotBili-0.5
[**2163-7-19**] 09:32PM BLOOD Lipase-51
[**2163-7-18**] 04:05PM BLOOD Albumin-4.4
[**2163-7-18**] 04:05PM BLOOD %HbA1c-5.6
[**2163-8-24**] 05:59AM BLOOD WBC-11.7* RBC-3.07* Hgb-9.1* Hct-28.3*
MCV-92 MCH-29.7 MCHC-32.2 RDW-16.0* Plt Ct-534*
[**2163-8-25**] 09:03AM BLOOD PT-29.1* PTT-38.4* INR(PT)-3.0*
[**2163-8-24**] 05:59AM BLOOD PT-29.2* INR(PT)-3.1*
[**2163-8-23**] 06:22AM BLOOD PT-22.6* PTT-40.8* INR(PT)-2.2*
[**2163-8-22**] 06:22AM BLOOD PT-20.7* PTT-62.1* INR(PT)-2.0*
[**2163-8-22**] 12:37AM BLOOD PT-20.5* PTT-68.8* INR(PT)-2.0*
[**2163-7-29**] 04:36AM BLOOD Fact II-19* Fact V-180* FactVII-6*
FacVIII-341* Fact IX-30* Fact X-12*
[**2163-8-24**] 05:59AM BLOOD Glucose-101 UreaN-23* Creat-1.1 Na-133
K-4.4 Cl-100 HCO3-25 AnGap-12
[**2163-8-23**] 06:22AM BLOOD Glucose-100 UreaN-24* Creat-0.9 Na-135
K-4.5 Cl-102 HCO3-27 AnGap-11
[**2163-8-22**] 06:22AM BLOOD Glucose-98 UreaN-23* Creat-1.0 Na-136
K-4.3 Cl-102 HCO3-27 AnGap-11
[**2163-8-21**] 05:37AM BLOOD Glucose-101 UreaN-19 Creat-0.9 Na-136
K-3.8 Cl-100 HCO3-28 AnGap-12
[**2163-8-20**] 04:30AM BLOOD Glucose-92 UreaN-18 Creat-1.0 Na-136
K-3.9 Cl-102 HCO3-28 AnGap-10
[**2163-8-25**] 09:03AM BLOOD ALT-211* AST-130* LD(LDH)-338*
AlkPhos-438* Amylase-399* TotBili-1.0
[**2163-8-24**] 05:59AM BLOOD ALT-189* AST-121* LD(LDH)-296*
AlkPhos-428* Amylase-408* TotBili-0.9
[**2163-8-23**] 06:22AM BLOOD ALT-185* AST-139* LD(LDH)-261*
AlkPhos-391* Amylase-371* TotBili-1.0
[**2163-8-22**] 06:22AM BLOOD ALT-161* AST-187* LD(LDH)-315*
AlkPhos-369* Amylase-331* TotBili-0.9
[**2163-8-25**] 09:03AM BLOOD Lipase-757*
[**2163-8-24**] 05:59AM BLOOD Lipase-858*
[**2163-8-23**] 06:22AM BLOOD Lipase-845*
[**2163-8-22**] 06:22AM BLOOD Lipase-827*
[**2163-8-21**] 05:37AM BLOOD Lipase-642*
[**2163-8-25**] 09:03AM BLOOD Albumin-3.2*
[**2163-8-25**] Chest x-ray: The heart size is mildly enlarged but
stable. The prosthetic mitral valve is in unchanged position.
Mediastinal contours are unremarkable. There is no significant
change in right lower lobe atelectasis. Small right pleural
effusion is again noted, unchanged with no pneumothorax present.
The rest of the lungs are unremarkable. The right PICC line tip
terminates in mid SVC.
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted one day prior to surgery for further
work-up do to his extensive past medical and surgical history.
On [**7-19**] he was brought to the operating room where he underwent
a Mitral valve replacement via a right thoracotomy. Please see
operative report for surgical details. Following surgery he was
transferred to the CSRU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. He required multiple blood
transfusions during initial post-operative period. He required
Nitro for hypertension but was weaned off by post-op day two and
started on beta-blockers. He had episodes of atrial fibrillation
on post-op day two which was treated with beta blockers. Despite
this he continued to have intermittent atrial fibrillation and
Amiodarone was started. Coumadin with a Heparin bridge was
initiated on this day and he was transferred to the SDU for
further care. Chest tubes and epicardial pacing wires were
removed per protocol. On post-op day six Mr. [**Known lastname 1968**] was c/o
nausea. KUB revealed a right paracardiac density, compatible
with large hematoma. Liver/GB US showed Cholelithiasis with a
stone identified in the neck. General surgery was consulted for
the cholelithiasis and following day a chest CT was performed to
further evaluate hemothorax and drop in hematocrit. CT showed a
large right hemothorax and Heparin was immediately stopped. Mr.
[**Known lastname 1968**] was then transferred back to the CSRU where a chest tube
was inserted but without evacuation of hematoma. Therefore he
was brought to the operating room where he underwent an
exploration and evacuation of hemothorax through his Right
thoracotomy incision. Please see operative report for details.
Following surgery he has rapid atrial fibrillation which was
cardioverted and treated with beta blockers and diuretics. Mr.
[**Known lastname 1968**] remained intubated over two days and was weaned from
sedation and extubated on [**7-28**]. He continued to have slow
decrease in his hematocrit and he again was transfused. He did
have rise in his creatinine over next several days (over 3.2),
evident of acute renal failure, but he kidney function improved
and creatinine trended down. Chest tubes were ultimately pulled
on [**7-30**]. General surgery was reconsulted for prior GB US and
patient now having increased LFT's and Amylase/Lipase. They
believed patient had pancreatitis and hyperbilirubinemia
(secondary to hemolysis) and recommended to keep pt NPO.
Coumadin was eventually restarted with a Heparin bridge for his
mechanical valve. On [**8-2**] he appeared stable and was transferred
to the SDU for further care. Later on this day patient had tarry
black guaiac positive stools with emesis with small streaks of
blood. Therefore GI were consulted and recommended IV PPI's (d/t
his PMH) with checking H. Pylori serologies and following
lab-work. Over next several days he remained stable and NPO
without N/V. H. Pylori serologies were positive and he was
appropriately treated. Repeat GB US and ABD CT on [**8-6**] and [**8-7**]
showed mildly enlarged pancreas, which can be seen with early
pancreatitis and cholelithiasis without evidence of
cholecystitis. On [**8-8**] a PICC line was placed for TPN while
patient continued to remain NPO. A ERCP was recommended to
further assess the cholelithiasis with possible stone but
patient refused. Over the following week he remained stable
while receiving TPN and medical management and his LFT's and
Amylase and Lipase were closely watched. On [**8-15**] clear liquid
diet was initiated and slowly advanced and he was treated fir a
UTI. On [**8-18**] vascular surgery was consulted d/t swelling in his
upper extremity and patient was found to have a hematoma
possibly related to IV on US. Patient continued to receive
medical management while being treated for above complications
with help from multiple services. During this time he continued
to receive Coumadin with a Heparin bridge for his mechanical
valve. Eventually Mr. [**Known lastname 1968**] [**Last Name (Titles) 8337**] food well, TPN was
discontinued with resolution of his pancreatitis. On [**8-25**]
(post-op day 37) he was discharged to home with VNA services and
the appropriate meds and follow-up appointments.
Medications on Admission:
Lisinopril 20 qd, Fexofenadine 180 qd, Reglan 10 qd, Keppra 500
[**Hospital1 **], Lexapro 10 qd, Amoxicillin prn dental procedures
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
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:*0*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day for 2
days: Take as directed by Dr. [**First Name (STitle) **] for INR goal of [**1-29**].5.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Replacement via Right
Thoracotomy
PMH: History of Endocarditis - s/p Bentall/Homograft/MV
debridement x 2, Coronary Artery Disease - s/p CABG, History of
TIA, Hypertension, Hypercholesterolemia, History of Paroxysmal
Atrial Fibrillation, Type II Diabetes Mellitus, History of
Seizure, History of Acute Renal Failure, History of Hypoxic
Encephalopathy, History of ARDS, Prior Septic Emboli(brain,
lung, kidney), Depression, History of PEG/J-tube for Necrotizing
Esophagitis, Peptic Ulcer Disease/GERD
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)Please take Warfarin as directed. INR should be followed
closely by Dr. [**First Name (STitle) **] after discharge from hospital. Warfarin
should be adjusted for goal INR between 3-3.5.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**3-3**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**1-1**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**1-1**] weeks, call for appt
Dr. [**First Name (STitle) **] (Surgery) 7-10 days
Completed by:[**2163-9-22**]
|
[
"414.00",
"997.3",
"427.31",
"998.11",
"345.90",
"998.12",
"584.9",
"250.00",
"577.0",
"511.8",
"997.5",
"V45.81",
"997.1",
"486",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"33.23",
"99.61",
"34.03",
"99.15",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11095, 11153
|
5370, 9714
|
341, 433
|
11734, 11740
|
2809, 5347
|
12263, 12541
|
2129, 2164
|
9895, 11072
|
11174, 11713
|
9740, 9872
|
11764, 12240
|
2179, 2790
|
282, 303
|
461, 1080
|
1102, 1972
|
1988, 2113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,830
| 105,752
|
45202
|
Discharge summary
|
report
|
Admission Date: [**2169-10-11**] Discharge Date: [**2169-10-12**]
Service: MEDICINE
Allergies:
Aspirin / Percocet / Codeine / Ambien / Nutren Pulmonary
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is an 84 yo woman with h/o Steroid induced
hyperglycemia, COPD, MFAT, Asthma (recently on prednisone
taper), PVD, who presented to the GI suite as an outpt today for
colonoscopy to work up GI bleed. Prior to the procedure the
patient appeared confused and was difficult to [**Last Name (LF) 96592**], [**First Name3 (LF) **] her
FS was checked and was 19. Further questioning revealed that
although she had been NPO for her scope, she did receive her
full dose of lantus insulin last night at [**Hospital1 **]. Unclear if
she also received humalog this morning as well. In the GI suite
she was given 2 amps of D50 and was transferred to the ER. By
report her HR was 35 in the GI suite, however EKG performed
almost immediately thereafter revealed HR 70s; and in the ED she
was found to have HR of 80 with sinus rhythm and no ischemic
changes. On arrival to the ER her FS was 160. She had frequent
FS checks q1-2 hours and was found to have sporadic FS ranging
as high as 160 and as low as 52. In the ER she received a total
of 1.5 amps of D50 and was started on D5 1/2NS drip. On arrival
she was also found to be hypothermic with rectal temp of 32.5
degrees celsius. With a warming blanket this improved to 36.1
degrees. She was normotensive on arrival, however she had an
episode of hypotension in the ER to 80s/40s nad was started on
fluids immediately following which she was transferred to the
MICU. On arrival in the MICU and after one litre of NS and 500
cc bolus of D5 [**11-28**] she was still hypotense with sbp in the 80's.
Etiology unclear. She is admitted to the MICU for further
monitoring.
.
On arrival in the MICU, she was found to have a BP of 113/77,
and BG of 167, and appeared in NAD.
.
Called [**Hospital3 7**] and confirmed the following: pt. was
not given prednisone since [**10-9**] despite the fact that she was
due for this on taper schedule, furthermore: pt. was given
lantus eve of [**10-9**] then TF held at MN and prepped. At 1 am on
am [**10-11**], she had a BG of 45 and required a D 10 Gtt. This was
d/c'd prior to transfer to [**Hospital1 **].
Past Medical History:
1)Asthma > 5 hospitalization with no history of intubations. She
has been on steroids since the beginning of [**Month (only) 216**]. Prior to
this, she had been steroid free for the past 2 years. Recent
hospitalization with intubation complicated by MRSA pneumonia,
d/c on [**9-25**] to rehab.
2)Hypertension.
3)Steroid induced hyperglycemia. Discharged on insulin following
her [**Hospital1 **] admission.
4)Peripheral vascular disease, status post left fem-peroneal
bypass in [**2162**]
5)Multi-focal bacterial pneumonia.
6)Chronic obstructive pulmonary disease- PFT [**7-2**]- FVC 61% pred,
FEV1 56% pred, FEV1/FVC 92%, Reduced FVC related to gas
trapping, ~400 cc worse than PFT from one year ago.
7)Multi-focal atrial tachycardia.
8)Oral thrush.
9)Question left hilar mass.
10)Mult aspirations in past requiring now being on feeding tube
11)Hx. MRSA PNA
Social History:
Denies history of smoking. Only social alcohol, ~3 drinks /week.
No other drug use. Widowed, with 3 children and 8 grandchildren.
Family History:
Asthma in her father
Physical Exam:
97.1 92 SR 113/77 18 95% sat on 3 LPM
Asleep, NAD, [**Last Name (un) 96593**] arrousable
Dry MM
No JVD or LAD
RRR no MRG
CTA anteriorly
Soft, colostomy bag in place, NT, BS present
1+ LE edema with chronic venous stasis changes/scarring
Moves all four extremities
Pertinent Results:
[**2169-10-11**] 04:00PM PT-10.4 PTT-24.4 INR(PT)-0.9
[**2169-10-11**] 04:00PM PLT COUNT-253
[**2169-10-11**] 04:00PM WBC-5.8 RBC-3.01* HGB-9.8* HCT-29.3* MCV-97
MCH-32.5* MCHC-33.5 RDW-20.7*
[**2169-10-11**] 04:00PM cTropnT-0.01
[**2169-10-11**] 04:00PM ALT(SGPT)-16 AST(SGOT)-17 CK(CPK)-16* ALK
PHOS-67 TOT BILI-0.2
[**2169-10-11**] 04:00PM GLUCOSE-135* UREA N-56* CREAT-0.9 SODIUM-139
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
[**2169-10-11**] 05:14PM LACTATE-1.0
[**2169-10-11**] 06:29PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2169-10-11**] 06:29PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2169-10-12**] 04:00AM BLOOD WBC-5.3 RBC-2.84* Hgb-9.2* Hct-27.9*
MCV-98 MCH-32.5* MCHC-33.1 RDW-20.7* Plt Ct-259
[**2169-10-11**] 04:00PM BLOOD Neuts-88.1* Lymphs-7.8* Monos-3.5 Eos-0.4
Baso-0.2
[**2169-10-12**] 04:00AM BLOOD Plt Ct-259
[**2169-10-12**] 06:15AM BLOOD K-5.7*
[**2169-10-12**] 04:00AM BLOOD Glucose-230* UreaN-52* Creat-0.9 Na-134
K-5.8* Cl-102 HCO3-22 AnGap-16
[**2169-10-11**] 04:00PM BLOOD ALT-16 AST-17 CK(CPK)-16* AlkPhos-67
TotBili-0.2
1
CXR: IMPRESSION:
1) Slight improvement in right lower lobe atelectasis with
residual rounded opacity centrally. This is most likely due to a
rounded area of atelectasis given lack of mass on CT scan but
continued follow up recommended.
2) Persistent left lower lobe opacity, likely due to atelectasis
although underlying infection is not excluded.
3) Persistent small bilateral pleural effusions, slightly
improved on the right.
[**2168-12-12**] 04:00AM BLOOD Calcium-7.9* Phos-4.7*# Mg-2.5
Brief Hospital Course:
Ms. [**Known lastname **] is an 84 y/o woman with steroid dependent asthma
currently on prednisone taper who presented to outpatient
gastroenterology today for a colonoscopy to work up a past GI
bleed. Notably, she had not been given her prednisone doses for
the past two days despite her order for a slow taper. She
received her Lantus 22 units on the night prior to admission,
but was then NPO/tube feeds held for her colonoscopy. She had a
FS of 45 and was started on D10 at [**Hospital1 **], but this was
discontinued and the pt was sent to [**Hospital1 18**] where she was found to
have a FS of 19.
.
Hypoglycemia: She was transferred to the ER where she was
treated with D50 for a total of 3.5 amps. She was also put on a
D5 drip. Her fingersticks fluctuated in the ER between 52 and
160, however since arrival on the floor she had no fingersticks
below the 80s and on the day of discharge had fingersticks in
the 200s after we had held her lantus the night prior. We
restarted her tube feeds on arrival to the floor. She should be
covered with her insulin slide scale throughout the day on the
day of discharge, anticipating that she will likely run higher
than usual, and should be given her pm lanstus dose of 22 units
tonight. Please do not give the patient her full dose of lantus
if her tube feeds will be held in the future (consider halving
dose). Also please recall that the patient is not diabetic, but
her hyperglycemia is due to steroids, so as her steroids taper
(or if they are inappropriately held) she may require less
insulin.
.
Hypotension: The patient's hypotension in the ER was transient
and responded to fluids. This is likely in setting of her
completing a bowel prep and not taking tube feeds on the day
prior to admission, and may also reflect adrenal insufficiency
in the setting of a sudden d/c of her prednisone, which was
intended to be slowly tapered. The patient responded to fluid
boluses in the ICU and has had stable BP since arrival on the
floor. We restarted her prednisone at her home dose of 10mg po
qday and she should continue this dose until [**10-14**], at which
time she may decrease to 5mg po qday as directed.
-we held her usual diltiazem for HTN while she was in-house,
please monitor her BP throughout the day today and this can be
restarted today or toorrow as needed.
.
GIB: The patient has a hematocrit near her baseline at this
time. Colonoscopy to be scheduled again as an outpatient with
the patient's gastoenterologist to evaluate. Please be sure to
cut her lantus dose by about half when she has tube feeds held
for this procedure and confirm this with her gastroenterologist
prior to the procedure.
.
Asthma/COPD: Teh patient was continued on her outpt steroids and
inhalers and had no problems while in house.
.
The patient was discharged back to [**Hospital1 **] after staying
overnight in the [**Hospital1 18**] MICU. She was stable as described above
at the time of discharge.
Medications on Admission:
Allopurinol 100
Caldium/Vit D
Diltiazem 90 Q 6 hours
Docusate
[**Doctor First Name **]
Fluticasone/salmeterol 250/50 1 puff [**Hospital1 **]
Furosemide 40 daily
Gabapentin 600 mg 2200, 300 mg 0800 and 1400
Glargine insulin 22 U hs
RISS
Lansoprazole
Lidoderm patch (ant rt. thigh) Q O 12 h
Motelukast 10
MVI
Prednisone taper (was to have taken 10 mg this am, unclear if
she got this or not - was to take this [**10-11**] thru [**10-14**] then 5
mg for four days following this)
Tiotroprium
Discharge Medications:
Allopurinol 100
Caldium/Vit D
Diltiazem 90 Q 6 hours
Docusate
[**Doctor First Name **]
Fluticasone/salmeterol 250/50 1 puff [**Hospital1 **]
Furosemide 40 daily
Gabapentin 600 mg 2200, 300 mg 0800 and 1400
Glargine insulin 22 U hs
RISS
Lansoprazole
Lidoderm patch (ant rt. thigh) Q O 12 h
Motelukast 10
MVI
Prednisone taper 10mg [**10-12**] thru [**10-14**] then 5 mg for four days
following this)
Tiotroprium
Discharge Disposition:
Extended Care
Discharge Diagnosis:
hypoglycemia in setting of NPO, no steroids and given Lantus
dose
hypotension responsive to IV fluids
dehydration
Discharge Condition:
stable BP, stable (elevated) fingersticks.
Note pt did not receive her Lantus last night, so anticipate
that she will require her sliding scale insulin throughout the
day today [**2169-10-12**]. Please cover her fingersticks today and
restart her Lantus at its usual dose of 22u tonight [**2169-10-12**].
Discharge Instructions:
Please check patient's fingersticks at lunch, dinner and bedtime
today and treat with slide scale insulin. You can expect higher
FS than usual because we held her Lantus last night. Please
restart her Lantus tonight at her usual dose of 22units.
Please continue all medications as previously without changes.
Please call your gastroenterologist to reschedule your
colonoscopy to work up your gastrointestinal bleed. See below
for further instructions.
Followup Instructions:
Please call your gastroenterologist in the future to schedule
another colonoscopy. Please be sure that you take only half of
your Lantus dose if you are holding tube feeds for a
colonoscopy. Please note that patient only requires insulin
while on steroids, and discuss this with her gastroenterologist
if she is off steroids at the time her colonoscopy is
rescheduled.
|
[
"276.51",
"578.9",
"493.20",
"443.9",
"401.9",
"251.1",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9424, 9439
|
5489, 8449
|
279, 285
|
9596, 9903
|
3794, 5466
|
10406, 10779
|
3472, 3494
|
8989, 9401
|
9460, 9575
|
8475, 8966
|
9927, 10383
|
3509, 3775
|
227, 241
|
313, 2419
|
2441, 3306
|
3322, 3456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,704
| 171,806
|
12067
|
Discharge summary
|
report
|
Admission Date: [**2116-2-2**] Discharge Date: [**2116-3-5**]
Date of Birth: [**2090-4-1**] Sex: F
Service: SURGERY
Allergies:
Dicloxacillin / Ceclor / Provigil
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
sore throat, neck swelling
Major Surgical or Invasive Procedure:
-Endotracheal intubation and mechanical ventilation 1/9
-Neck exploration (ENT [**Doctor Last Name **] and [**First Name9 (NamePattern2) 16814**] [**Last Name (un) 14896**]) [**2-2**]
-Left Thoracostomy chest tube placement ([**First Name9 (NamePattern2) 16814**] [**Last Name (un) 14896**])
[**2-2**], removed on [**2-8**]
-Repeat debridement and exploration of chest wall (ENT,
[**Month/Year (2) 16814**]) [**2-3**]
-Right chest and shoulder debridement [**2-4**]
-Local advancement flaps and STSG to chest wall (Plastics [**Doctor Last Name **])
[**2-17**]
-PEG placement by IR [**3-3**]
History of Present Illness:
25yoF with 1 week of sore throat and sore tooth which progressed
to neck swelling and cellulitis. Went to OSH for evaluation.
Past Medical History:
SVT
multiple episodes of pancreatitis (s/p MVA) requiring drainage
anxiety d/o
PTSD
depression
s/p MVA
anorexia nervosa
Social History:
3 kids whom her mother cares for
remote relationship with father
1ppd smoker
multiple tattoos
Family History:
not obtained
Pertinent Results:
[**2116-2-2**] 09:20PM WBC-16.1* RBC-3.13* HGB-9.5* HCT-28.9* MCV-92
MCH-30.4 MCHC-33.0 RDW-15.2
[**2116-2-2**] 09:20PM NEUTS-85.4* BANDS-0 LYMPHS-10.9* MONOS-3.4
EOS-0.2 BASOS-0
[**2116-2-2**] 09:20PM ALT(SGPT)-44* AST(SGOT)-66* CK(CPK)-25* ALK
PHOS-139* AMYLASE-20 TOT BILI-0.5
[**2116-2-2**] 09:20PM GLUCOSE-112* UREA N-21* CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
[**2116-2-2**] 09:37PM LACTATE-1.1
[**2116-2-2**] 09:20PM PT-14.5* PTT-26.5 INR(PT)-1.3
[**2116-2-3**] 10:00AM BLOOD Hct-19.5*
[**2116-2-3**] 10:24PM BLOOD WBC-21.7* RBC-3.28* Hgb-9.9* Hct-29.7*
MCV-91 MCH-30.2 MCHC-33.4 RDW-16.8* Plt Ct-198
[**2116-2-12**] 03:02AM BLOOD WBC-5.8 RBC-2.34* Hgb-6.9* Hct-21.2*
MCV-91 MCH-29.3 MCHC-32.3 RDW-16.5* Plt Ct-567*
[**2116-2-12**] 06:22AM BLOOD Hct-20.8*
[**2116-2-13**] 01:53AM BLOOD WBC-5.6 RBC-2.15* Hgb-6.5* Hct-19.8*
MCV-92 MCH-30.1 MCHC-32.7 RDW-16.3* Plt Ct-490*
[**2116-2-14**] 01:42AM BLOOD WBC-4.3 RBC-2.90*# Hgb-8.5*# Hct-25.8*
MCV-89 MCH-29.2 MCHC-32.9 RDW-17.3* Plt Ct-431
[**2116-2-24**] 03:16AM BLOOD WBC-4.7 RBC-3.19* Hgb-9.3* Hct-28.9*
MCV-90 MCH-29.0 MCHC-32.1 RDW-16.2* Plt Ct-281
[**2116-2-2**] 09:20PM BLOOD PT-14.5* PTT-26.5 INR(PT)-1.3
[**2116-2-24**] 03:16AM BLOOD PT-14.6* PTT-33.0 INR(PT)-1.4
[**2116-2-2**] 09:20PM BLOOD Glucose-112* UreaN-21* Creat-0.6 Na-139
K-3.8 Cl-107 HCO3-24 AnGap-12
[**2116-2-24**] 03:16AM BLOOD Glucose-97 UreaN-8 Creat-0.6 Na-147*
K-3.3 Cl-108 HCO3-31* AnGap-11
[**2116-2-4**] 03:00PM BLOOD Cortsol-9.5
[**2116-2-4**] 04:30PM BLOOD Cortsol-26.6*
[**2116-2-4**] 05:00PM BLOOD Cortsol-28.4*
[**2116-2-3**] 02:00AM BLOOD Type-ART pO2-358* pCO2-41 pH-7.38
calHCO3-25 Base XS-0
[**2116-2-24**] 03:44AM BLOOD Type-ART pO2-137* pCO2-45 pH-7.44
calHCO3-32* Base XS-6
[**2116-2-2**] 09:20PM BLOOD ALT-44* AST-66* CK(CPK)-25* AlkPhos-139*
Amylase-20 TotBili-0.5
[**2116-2-3**] 10:00AM BLOOD ALT-21 AST-23 AlkPhos-67 Amylase-11
[**2116-2-6**] 02:25PM BLOOD CK(CPK)-25*
[**2116-2-7**] 02:59AM BLOOD LD(LDH)-149
[**2116-2-12**] 03:02AM BLOOD ALT-13 AST-16 AlkPhos-154* TotBili-0.2
CHEST CT [**2-2**] OSH: report of air and fluid in neck and anterior
mediastinum
PATH L molar [**2-2**]
The specimen was received fresh labeled with "[**Known firstname 5969**] [**Known lastname 8840**]"
and "left molar #18" and consists of a tooth that appears to be
molar that measures 2.5 x 1 x 1 cm. The crown of the tooth
appears to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]? that measures 0.4 x 0.4 x 0.5 cm. This
is a gross only dictation and has been reviewed by Dr. [**Last Name (STitle) **].
[**2-3**] CXR
IMPRESSION:
Probable left-sided pneumonia, new subcutaneous emphysema in
lower neck.
[**2-3**] CHEST/NECK CT
IMPRESSION CHEST:
1. Postsurgical changes within the mediastinum and left neck
with a soft tissue defect, left chest tube, mediastinal drains,
pneumomediastinum and anterior subcutaneous air. There is subtle
hypo-attenuation within the soft tissues/muscles of the right
neck as well as subcutaneous air. This may represent extension
of disease which has not yet been explored.
2. Bilateral pleural effusions with reactive atelectasis. Small
amount of free fluid within the abdomen and pelvis as well as
anasarca.
3. Areas of hyper-attenuation within the cortex of the left
kidney consistent with a persistent nephrogram. This can be seen
in sepsis although the left kidney does appear to enhance and
excrete contrast symmetrically to the right.
4. Significantly dilated pancreatic duct as well as prominence
of the common bile duct of unknown etiology.
IMPRESSION NECK:
1. Post-surgical changes identified within the left neck with an
open wound and packing, sternal drains and mediastinal air.
2. There is subcutaneous air and hypoattenuation within the
right neck which may represent extension of disease, and was not
debrided during the previous operation. No definite fluid
collections seen.
PATH [**2122-2-2**] tissue and rib from OR
1. Skin and subcutaneous tissue, left neck, debridement (A):
A. Necrosis and acute and chronic inflammation of deep
dermis and subcutaneous tissue.
B. Superficial skin with perivascular acute and chronic
inflammation. See note.
2. Skin and subcutaneous tissue, left sternal anterior cranial
mass and neck, debridement (B-E):
A. Necrosis and acute and chronic inflammation, with
abscess formation, of deep dermis and subcutaneous tissue.
B. Superficial skin with no significant pathologic change.
See note.
3. Second rib, removal (F): Bone and cartilage. Neg Gstain and
culture, The bone marrow is hypercellular for age with myeloid
hyperplasia.
*
Wound debridement): Skin and subcutaneous tissue with acute
inflammation, necrosis and hemorrhage in subcutaneous tissue,
and focal dermal acute and chronic inflammation.
Clinical: Necrotizing fasciitis.
CXR [**2-8**] IMPRESSION: Interval removal of the left chest
tube.Partial reexpansion of the lower lobes. Bilateral pulmonary
edema, unchanged. Continued application of the ET tube and NG
tube, unchanged in position.
CXR [**2-21**] s/p extubation and emergency reintubation
IMPRESSION:
Complete collapse of the left lung, which appears to be due to
central mucous plugging. Persistent right pleural effusion.
Relatively proximal location of endotracheal tube, terminating 2
cm above the carina.
Brief Hospital Course:
25yoF presented to OSH with 1 week of sore throat and sore
tooth, which had progressed slowly to neck swelling and
cellulitis. Afebrile. CT OSH demonstrated air and fluid in the
subcutataneous neck and in the anterior mediastinum. Pt was
transferred to [**Hospital1 18**] for further surgical management of likely
necrotizing fasciitis of the neck and mediastinum.
Thoracic surgery and ENT surgical services took patient to OR
for extensive neck exploration and chest tube placement on HD 1.
HD 2 required repeat right chest and shoulder debridement in OR
by [**Hospital1 **] and plastics. HD 3 required a sharp bedside
debridement. Pathology of all procedures demonstrated tissue
hemorrhage and necrosis as well signs of acute and chronic
inflammation. Wound cultures demonstrated yeast, strep milleri
and OSH would cx grew GPC and anaerobes. Vanco/Zosyn/Clinda
course for broad coverage switched to Unasyn (but pancytopenia)
then to Levo/Flagyl for three week coarse of broad spectrum. A
vaccuum dressing was placed over the large debridement site; on
HD 15 when plastic surgery did a split thickness skin graft from
left thigh to anterior chest and vac replaced until HD 20. On
removal, graft appeared well with good perfusion, with exception
of inferior edge which demonstrated a mild amt of dehiscence. A
trial of extubation was attempted on HD 20 but pt failed [**2-26**]
likely large mucous plugging and collapse of left lung, which
resulted in emergent reintubation. Culture positive Cdif treated
with Oral Vanco and Flagyl starting on HD 23. HD 25 patient
extubated without complication however remained emotionally
labile as well as extremely weak (unable to swallow safely,
unable to cough productively); psychiatry, physical therapy, and
speech and swallow were involved. Over subsequent 5 days of
hospital stay, pt remained unable to swallow safely after
multiple speech and swallow attempts, remained with doboff tube
feeds to goal- ENT consult evaluated patient and assessed her to
have a right vocal cord lateralization and therefore is an
aspiration risk. PEG tube placed by Interventional radiology on
HD 31, tube feeds brought to goal. Patient refused to go to
recommended rehabilitation center-- after much counselling on
the subject, patient discharged to home with VNA HD 33 with PEG
tube feeds for further physical therapy. She needs to followup
with Plastic Surgery (for likely future free flap), ENT (vocal
cord immobility), Dentistry (further tooth extraction), and
Speech/ Swallow (video swallow)- all appointments have been made
for her and multiple discussions on necessity of followup were
had with the patient and her boyfriend.
Medications on Admission:
toprol XL 75BID
Ambien
Trazodone
Adderall
Discharge Medications:
1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
may give by NGT.
Disp:*30 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
Disp:*qs * Refills:*0*
3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs * Refills:*0*
4. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
Disp:*qs * Refills:*0*
5. Vancomycin HCl 10 g Recon Soln Sig: One [**Age over 90 **]y Five
(125) mg Intravenous Q6H (every 6 hours) for 6 days.
Disp:*qs mg* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*1000 ML(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
8. bolus tube feedings: impact w/fiber Sig: Two (2) four
times a day: bolus tube feeds:
Imapct w/fiber
2 cans tid
1 can @ hs
H20 flushes:
30cc before & after each feeding 4x/day.
Disp:*120 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
-necrotizing fasciitis of neck and thoracic chest wall
-clostridium dificile colitis
-right true vocal cord immobility
Discharge Condition:
stable
Discharge Instructions:
-Followup with all appointments that have been made for you.
-Take all medications as prescribed.
-Keep your neck extended at all times (do not use pillows) to
prevent worsening of flexion contracture of your neck
-Call your doctors [**Name5 (PTitle) **] return to emergency department with any
concerns, including but not limited to shortness of breath,
chest pain, fevers, discharge from surgical area (leaking fluid,
redness, warmth).
Followup Instructions:
1. Plastic Surgery with Dr [**Last Name (STitle) **] to discuss further plastic
surgery needs- ([**Telephone/Fax (1) 37856**]- Appointment Thursday [**3-12**]
930am at [**Location (un) 470**] of [**Hospital Ward Name 23**] building at the corner of [**Hospital1 1426**]
and [**Location (un) **].
2. Ear Nose and [**Hospital 6212**] Clinic with Dr [**First Name (STitle) **] for vocal cord
evaluation, possible laryngeal strobe exam and EMG studies -
([**Telephone/Fax (1) 37857**]- Appointment Wednesday [**Month (only) 956**] 23d 830am at [**Location (un) **] [**Location (un) 55**] (Kinko building 3d floor)
3. Voice, Speech and Swallow Therapists for repeat video
swallowing evaluation (need for further tube feeds)- Appointment
[**3-31**] at 10am- Span Building [**Apartment Address(1) 37858**], [**Street Address(1) 592**] on [**Hospital1 18**]
[**Hospital Ward Name 517**]- ([**Telephone/Fax (1) 12787**]
4. [**University/College **] school of [**Hospital 37859**] clinic with Dr [**First Name (STitle) **] (oral
maxillofacial surgeon) for tooth extraction of teeth #2 and #3-
([**Telephone/Fax (1) 37860**]- Appointment [**3-6**] 3pm- [**University/College **] School of
Dental Medicine, [**Hospital1 37861**], [**Location (un) 453**]. Call for
payment plan information.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"522.5",
"309.24",
"008.45",
"933.1",
"518.0",
"478.32",
"038.9",
"728.86",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"83.09",
"38.93",
"83.39",
"86.74",
"43.11",
"83.02",
"99.11",
"83.19",
"34.1",
"96.6",
"99.04",
"33.24",
"23.19",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
10588, 10659
|
6750, 9427
|
317, 909
|
10822, 10830
|
1370, 6727
|
11316, 12729
|
1337, 1351
|
9519, 10565
|
10680, 10801
|
9453, 9496
|
10854, 11293
|
251, 279
|
937, 1065
|
1087, 1209
|
1225, 1321
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,207
| 153,457
|
10669
|
Discharge summary
|
report
|
Admission Date: [**2101-7-11**] Discharge Date: [**2101-8-1**]
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
woman with a history of hypertension, depression, anxiety and
dementia who was admitted to the [**Hospital6 3872**] on
[**2101-7-5**] with several day history of nausea, vomiting and
and emesis of coffee ground material. At the outside
17,000 and was started on initially Levofloxacin and then the
addition of Ampicillin and Flagyl. A CT scan performed on
[**6-6**] showed dilated common bile duct with gallstones. She was
thought to have bowel obstruction and was treated with bowel
rest and hydration. On [**7-9**] she had respiratory distress and
to have new left lower lobe infiltrate on chest x-ray.
Nasogastric tube was placed with return of 2500 cc of bilious
have increased lipase on [**7-7**] which was noted to be trending
downward. She was transferred to [**Hospital1 190**] for further management and was admitted to the
medical Intensive Care Unit.
PAST MEDICAL HISTORY: Includes hypertension, depression,
history of left hip fracture, anxiety, legally blind,
dementia, remote history of atrial fibrillation.
ALLERGIES: Pneumococcal pneumonia vaccine.
MEDICATIONS: At home, Coumadin, Zoloft, Prinivil and Colace.
On transfer, Ativan 1 mg q 3 hours prn, Morphine 2-5 mg subcu
q 3 hours prn, Tylenol prn, Levaquin 500 mg IV q d since [**7-10**],
TPN, Albuterol nebulizer prn, Flagyl 500 mg IV q 8 hours
since [**7-9**].
PHYSICAL EXAMINATION: Vitals at the outside hospital on [**7-11**],
temperature 101.0, heart rate 107, blood pressure 140/58,
respirations 24. On admission to the Intensive Care Unit at
[**Hospital1 69**], temperature was 100.8,
heart rate 101 to 116, respirations 18 to 23, blood pressure
135/51. In general she is arousable, calling out for her
husband, alert and oriented to self only. Neck was supple
with no jugular venous distension noted. HEENT: Pupils were
equal, round and reactive to light. Chest: short, shallow
respirations with no crackles, decreased breath sounds at the
left base. Heart, tachycardic, regular rate, normal S1 and
S2 without murmur. Abdomen soft, nontender, non distended
with hypoactive bowel sounds. Extremities were without
edema. Dorsalis pedis pulses were strong and symmetric.
LABORATORY DATA: From the outside hospital, blood cultures
drawn on [**7-5**] were sterile. Urinalysis was clean and culture
was sterile. White blood count on [**7-5**] was 17.4, down to
14.7 on [**7-11**] and then on admission to [**Hospital1 190**] 17.8. Hematocrit on [**7-5**] was 43.8. On [**7-11**]
31.8 and on admission to [**Hospital1 69**]
31.6. Platelet count on admission was 393,000. Chem 7 on
admission, sodium 135, potassium 4.4, chloride 98, CO2 25,
BUN 16, creatinine 0.6 and glucose 118. PT 13.2, PTT 30.3,
INR 1.2. ALT 22, AST 26, alkaline phosphatase 70, total
bilirubin 0.4, albumin 2.5, calcium 8.5, phosphorus 4.6,
magnesium 1.9, blood cultures and urine cultures were without
growth. The patient's amylase and lipase fluctuated
throughout her hospital course. On [**7-11**] her lipase was 37 and
her amylase was 64. On [**7-20**] her lipase was 810 and her
amylase was 209. On [**7-28**] her lipase was 218 and her amylase
was 68. On [**7-30**] the lipase was 289 and amylase was 79.
Chest x-ray on admission showed extensive left lower lobe and
possibly lingular pneumonia as well as probable effusions.
Repeat chest x-ray on [**7-15**] performed to evaluate PICC line
placement showed PICC in the middle superior vena cava with
no pneumothorax as well as improvement in the left sided
infiltrate. Another chest x-ray performed on [**7-21**] in the
setting of fever and hypotension showed further resolution of
the left lower lobe consolidation with some persistent
consolidation in this region.
CAT scan on [**7-12**] showed cholelithiasis without cholecystitis,
dilated common bile duct measuring up to 1.5 cm in diameter,
tapering to normal caliber at the level of the ampulla. No
stones were seen within the common or cystic duct. Normal
appearing pancreas without evidence of pancreatitis. Mildly
dilated loops of small bowel without obstruction. Bilateral
pleural effusion with associated consolidation or atelectasis,
left greater than right. Follow-up abdominal CT performed on
[**7-21**] showed abrupt common bile duct narrowing with focal proximal
dilatation of uncertain etiology. Given the presence of
gallstones and a pancreatic cyst, the most likely etiology is
a benign stricture from prior stone passage and/or
pancreatitis. An obstructing stone was not visualized.
Abdominal ultrasound performed at the outside hospital on [**7-6**]
showed numerous fluid filled loops of bowel in the right
upper quadrant with small amount of free fluid around the
liver. There was a 2 cm cyst seen in the head of the
pancreas. Common duct was dilated to 1 cm. An 8 by 5 by 7
mm cyst was seen in the body of the pancreas. It should be
noted that on the second CT mentioned above, there was a cyst
in the body of the pancreas noted that is consistent with the
ultrasound findings, however, there was no finding noted in
the head of the pancreas on CT. EKG showed normal sinus
rhythm notable only for nonspecific ST-T changes in leads 3
and AVF.
IMPRESSION: This is a 78-year-old woman with hypertension
and dementia, presenting from an outside hospital with
original presentation of several days of nausea and vomiting
with coffee ground emesis. She presented to the [**Hospital1 346**] for further management in the
context of increased oxygen demands.
HOSPITAL COURSE:
1. Gastrointestinal: A) The patient was found to have
dilated loops of small bowel with the differential diagnosis
being ileus vs small bowel obstruction. An NG tube was
placed and a large amount of bilious fluid was returned. CAT
scan was performed that demonstrated there was no source of
obstruction and it was felt that patient had an ileus
secondary to pancreatitis. The patient was placed on a bowel
regimen and after two weeks of constipation she voided large
amounts of stool. She did not have further evidence of ileus
after this initial void. B) Probable gallstone pancreatitis.
Although there was no gallstone seen in the common bile duct
and on multiple imaging studies obtained, the dilatation of
the common bile duct was suspicious for post obstructive
syndrome, especially in light of her increased lipase and
amylase at the outside hospital. Her lipase and amylase were
coming down at the time of admission so on the [**8-12**]
the ERCP service was consulted. They felt that she would be
a good candidate for ERCP but that in the setting of her
pneumonia as well as her impaired mental status, she would
probably require intubation for the procedure. This was not
acceptable according to the health care proxy who was the
patient's daughter, [**Name (NI) **] [**Name (NI) **]. However, in the next week
and a half the patient's amylase and lipase again trended
upwards, reaching their peak on the [**8-20**]. It
became clear that given the patient's documented gallstones,
that she would probably continue to have flares of
pancreatitis as a result of stone obstructing the pancreatic
duct. As a result of the patient's discomfort with this, the
option of ERCP was revisited with the health care proxy and
it was decided that she would proceed with ERCP. The patient
had ERCP on [**7-25**]. She, in fact, did not need intubation for
the procedure due to her good pulmonary status since
pneumonia had resolved. A sphincterotomy was performed and
sludge was extracted from the bile duct. There were no
complications with the procedure. The gastroenterologist was
[**Name6 (MD) **] [**Name8 (MD) **], M.D. The patient tolerated the procedure well
and had downward trend of amylase to normal levels by
discharge and the lipase was trending down. The patient was
started on Actigall 300 mg [**Hospital1 **] to reduce bowel sludging. She
was also given Protonix 40 mg po q d for GI prophylaxis.
2. Pulmonary: The patient presented with low oxygen
saturation secondary to pneumonia. It was thought that her
pneumonia was an aspiration pneumonia given her history of
emesis. The patient did well on Levofloxacin and Flagyl.
Oxygen was provided per nasal cannula but intubation was not
required. She was successfully weaned off her oxygen and had
good oxygen saturation for the final two weeks of her
hospital stay. In addition, resolution of the pneumonia was
seen on follow-up chest films.
3. Infectious Disease: The patient arrived to the [**Hospital1 1444**] on Levofloxacin, Flagyl and
Ampicillin. The Levofloxacin and Flagyl were instituted to
treat the aspiration pneumonia. The Ampicillin was added for
further GI prophylaxis in case of cholangitis. However, CAT
scan failed to document cholangitis. It was felt that
patient's elevated white count was secondary to her
pneumonia.
4. Renal: The patient had an episode of acute renal failure
that was probably prerenal in etiology at the outside
hospital. This apparently resolved with hydration. She had
no renal issues during her stay at the [**Hospital1 190**].
5. Hematology: On initial presentation to the outside
hospital the patient had a hematocrit of 43.8. On arrival to
the [**Hospital1 69**] she had a hematocrit
of 31.6. Iron studies were performed and it was found that
her anemia was consistent with that of chronic disease. No
transfusions were necessary and her hematocrit was stable
throughout her hospital stay. In addition, the patient was
found to have thrombocytosis on admission. This resolved
slowly throughout her hospitalization although she was
discharged with higher than normal platelet count. We
attributed this to reactive thrombocytosis.
6. Cardiovascular: The patient has a history of atrial
fibrillation although she was in normal sinus rhythm during
her hospital stay. This was discussed with her primary care
physician and it was decided to hold her Coumadin. She was
not discharged on Coumadin.
The patient was tachycardic and had hypertension so she was
treated with Lopressor initially at low dose and ultimately
at 50 mg po tid. She had several episodes of hypotension
that were responsive to IV fluid boluses.
7. Fluids, Electrolytes & Nutrition: The patient was
treated with IV fluids, initially with partial peripheral
nutrition and ultimately with total peripheral nutrition via
PICC line. During this time she was npo. One week prior to
discharge we tried her on sips of clears but she experienced
abdominal pain with this so we again made her npo for another
day, retried her on sips of clears and she tolerated this
well. We continued to advance her diet while continuing the
TPN and on [**7-30**] she pulled out her own PICC line and since
she was tolerating po feeds well, there was no need to put in
another PICC line.
8. Psychiatry: The patient was treated initially with
Ativan prn for agitation. Later we tried a course of Haldol,
however, she developed extrapyramidal side effects with this,
specifically she became somewhat Parkinsonian with
cogwheeling, masked facies and hypertonia. The Haldol was
discontinued and we changed her to Risperdal for management
of her agitation. The extrapyramidal side effects from the
Haldol resolved after 48 hours. She did well on Risperdal.
9. Prophylaxis: The patient received Heparin initially
subcutaneously, later in the TPN and finally after the TPN
was discontinued, she again received Heparin subcutaneously
for DVT prophylaxis.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: She was discharged to [**Location (un) 29789**] Country Manor
in [**Location (un) 29789**], Mass.
DISCHARGE DIAGNOSIS:
1. Pancreatitis.
2. Cholelithiasis.
3. Aspiration pneumonia.
4. Dementia.
5. Hypertension.
DISCHARGE MEDICATIONS:
1. Ursodiol 300 mg po BID
2. Lopressor 50 mg po TID
3. Colace 100 mg po BID
4. Senna I-II tablets po QD prn
5. Risperdal 0.5 mg PO BID
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-983
Dictated By:[**Doctor Last Name 34991**]
MEDQUIST36
D: [**2101-8-1**] 13:16
T: [**2101-8-1**] 16:24
JOB#: [**Job Number 34992**]
cc:[**Location (un) 34993**]
|
[
"577.2",
"290.0",
"511.9",
"263.9",
"574.21",
"577.0",
"584.9",
"560.31",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.84",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
11881, 12281
|
11761, 11858
|
5627, 11590
|
1497, 5610
|
102, 999
|
1022, 1474
|
11615, 11740
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,145
| 142,200
|
15883+56699
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-9-10**] Discharge Date: [**2162-10-14**]
Date of Birth: [**2128-5-14**] Sex: M
Service: Trauma
HISTORY OF PRESENT ILLNESS: This is a 34-year-old man trauma
transferred from [**Hospital **] Hospital on 4 pm on the day of
admission. The patient tripped in front of a dump truck and
was dragged approximately 20 feet with no loss of
consciousness. Patient did have alcohol on board. [**Location (un) 2611**]
coma score is 15, heart rate 114, blood pressure 130/70, and
91% on O2 sat.
He had a head CT scan which showed no bleed and no fracture.
A CT scan of lumbosacral spine which showed no fracture.
Chest x-ray with no pneumothorax and left second through
eighth rib fractures posteriorly. His hematocrit was stable.
His alcohol level was 129, and he had been given 1 gram of
Ancef.
At that point, patient was deemed stable to be transferred to
[**Hospital1 69**] for management of his
left shoulder laceration.
Patient had a past medical history significant for hepatitis
B and C, IV drug abuse, no past surgical history, no
medications, and no known drug allergies. He was single, and
smoked one pack per day, and used alcohol occasionally.
On presentation to our Emergency Department, physical
examination was 36.5, heart rate 110, blood pressure 93/58,
sating 90%. He was in mild distress. Pupils are equal,
round, and reactive to light and accommodation. Extraocular
muscles are intact. Tympanic membranes are clear.
Oropharynx is clear. Neck was placed in a C collar. Chest
was clear to auscultation. Heart was tachycardic, but
regular. Abdomen was distended and firm. The FAST
examination was positive. DPL was also positive. Patient
also had a left shoulder laceration with 2+ dorsalis pedis
pulses bilaterally, 2+ radial pulses, and no long bone
deformities.
His laboratories were white count 13.9, hematocrit of 39, INR
of 1.3, fibrinogen of 241. Urinalysis showed [**5-10**] red blood
cells, tox positive for opiates. Sodium 138, potassium 4.3,
chloride 109, BUN 7, creatinine 0.9, and glucose 130.
Alcohol was 74 in our Emergency Department.
Based on this, the patient was sent to the operating room for
an emergent exploratory laparotomy. In the operating room,
the patient was found to have a splenic laceration and had a
splenorrhaphy and his left shoulder laceration was closed.
The patient was then admitted to the Surgical Intensive Care
Unit.
Repeat chest x-ray showed a left pneumothorax. Chest tube
was placed on [**9-11**]. On [**9-15**], patient was
started on Vancomycin and ceftriaxone for temperature spikes.
Chest x-ray showed infiltrates bilaterally and Infectious
Disease was consulted. Antibiotic coverage was changed from
ceftriaxone to Zosyn.
The patient remained febrile for several days without
identifiable source. The patient underwent incision and
drainage of the left upper extremity on the 18th to the [**9-19**]. The patient continued to spike on broad-spectrum
antibiotic coverage. On [**9-28**], the decision was made
to observe the patient off antibiotics. The patient did
well, was stable, and was transferred to the floor.
On the floor, the patient did well. Pain was controlled with
Morphine PCA. Physical therapy was consulted for ambulation.
On [**10-7**], the patient was taken to the operating room
for a split thickness skin graft of the left upper extremity
by Dr. [**Last Name (STitle) 13797**].
On postoperative day five, the dressing was taken down with
100% take of the skin graft. Pain control was changed from
the Morphine PCA to OxyContin, and on postoperative day seven
from the split thickness skin graft, the wound was again
evaluated with good results on Xeroform dry dressing change.
Please look for addendum to this dictation to follow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 13577**]
MEDQUIST36
D: [**2162-10-14**] 02:22
T: [**2162-10-15**] 06:17
JOB#: [**Job Number 45616**]
Name: [**Known lastname 6212**], [**Known firstname **] Unit No: [**Numeric Identifier 8371**]
Admission Date: [**2162-9-10**] Discharge Date: [**2162-10-14**]
Date of Birth: [**2128-5-14**] Sex: M
Service:
This is an addendum to the dictation.
The condition on discharge is stable.
DISCHARGE MEDICATIONS: OxyContin 50 mg po bid and oxycodone
5-10 mg q6h prn pain. The patient was instructed to buy
over-the-counter Colace for stool softener.
DISCHARGE STATUS: Home with visiting nurses for qod dressing
changes. The patient will follow up with Trauma Clinic in
one week.
DISCHARGE DIAGNOSES:
1. Status post exlap with splenorrhaphy.
2. Split thickness skin graft to left arm.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D. [**MD Number(1) 3596**]
Dictated By:[**Name8 (MD) 1561**]
MEDQUIST36
D: [**2162-10-14**] 08:47
T: [**2162-10-14**] 09:05
JOB#: [**Job Number **]
|
[
"070.32",
"880.19",
"305.00",
"807.07",
"518.5",
"865.02",
"865.01",
"958.4",
"305.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.45",
"34.04",
"86.04",
"86.22",
"54.25",
"96.72",
"86.69",
"96.6",
"96.04",
"41.95"
] |
icd9pcs
|
[
[
[]
]
] |
4708, 5059
|
4416, 4687
|
165, 4392
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,165
| 187,267
|
38167
|
Discharge summary
|
report
|
Admission Date: [**2108-1-24**] Discharge Date: [**2108-2-3**]
Date of Birth: [**2041-10-12**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 56114**]
Chief Complaint:
pelvic mass
Major Surgical or Invasive Procedure:
exploratory laparotomy, bilateral salpingo-oophorectomy,
excision of pelvic mass, cysto with right ureteral stent
placement, illeocecal resection with primary re-anastamosis, low
anterior resection with colostomy for pelvic tumor
History of Present Illness:
Ms. [**Known lastname **] is a 66-year-old gravida 5, para 5 with a history of
breast cancer, diabetes, and chronic kidney disease who was seen
by her primary care and complaint of irregular bowel movements
with alternating constipation and
diarrhea as well as diffuse abdominal pain. She underwent a CT
scan, which revealed within the pelvis, a complex cystic and
solid right adnexal mass measuring 7.6 cm in maximal dimension.
The mass was inseparable from the
sigmoid colon, cecum, and right ureter. There was also mild
hydronephrosis with hydroureter extending from the pelvis. She
then underwent an MRI, which revealed this large multilobulated
heterogeneous mass in the right adnexa which appears to be
arising from the right ovary. Both the cecum and sigmoid were
inseparable from the mass and the right ureter was also
inseparable from the mass. This mass appears to be obstructing
the right ureter. She also complains of intermittent nausea,
denies any vaginal bleeding or blood in her stool. No chest
pain, shortness of breath.
Past Medical History:
- IDDM
- HTN
- CKD stage IV (baseline Cr 2.9)
- right-sided breast cancer s/p neoadjuvant chemo followed by
surgery, then radiation
- lung nodules (? mets)
- hypercholesterolemia
- cataracts
- morbid obesity
PAST SURGICAL HISTORY:
-Hysterectomy postpartum
-cholecystectomy
OB/GYN HISTORY:
- five spontaneous vaginal deliveries
- last menstrual period was age 25 with her hysterectomy
- Menarche at age 12 with regular periods lasting 3 days
- No history of abnormal Paps, STIs, fibroids, or cysts
- Her last Pap was approximately two years ago and was normal
Social History:
Lives in [**State 2748**] with her son. Retired transit authority
worker. Has other children and family members in the [**Name (NI) 86**]
area. Prior tobacco use, quit 10-15 years prior. No EtOH or
illicit drug use.
Family History:
Sister with DM, MI at age 46. Maternal grandmother with CAD, DM.
Mother deceased at age 80. Brother with DM.
Physical Exam:
On day of discharge:
GENERAL: No acute distress, well appearing.
CARDIOVASCULAR: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, diffusely tender. No rebound or guarding. +
bowel sounds. 15 cm
midline incision with wound vac in place. 1/2 cm JP port side
on right at the level of the umbilicus c/d/i. Ostomy pink with
stool and gas.
EXTREMITIES: Non-tender, no edema.
Pertinent Results:
[**2108-1-24**] 11:10PM TYPE-ART PO2-247* PCO2-37 PH-7.32* TOTAL
CO2-20* BASE XS--6
[**2108-1-24**] 11:10PM LACTATE-0.9
[**2108-1-24**] 11:01PM GLUCOSE-163* UREA N-29* CREAT-3.3* SODIUM-140
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-19* ANION GAP-15
[**2108-1-24**] 11:01PM CALCIUM-8.1* PHOSPHATE-5.3* MAGNESIUM-2.2
[**2108-1-24**] 10:57PM HCT-29.3*
[**2108-1-24**] 05:39PM GLUCOSE-180* UREA N-27* CREAT-3.2* SODIUM-141
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-19* ANION GAP-15
[**2108-1-24**] 05:39PM estGFR-Using this
[**2108-1-24**] 05:39PM CALCIUM-7.7* PHOSPHATE-4.6*# MAGNESIUM-1.7
[**2108-1-24**] 05:39PM WBC-8.5 RBC-3.40* HGB-10.1* HCT-28.4* MCV-84
MCH-29.8 MCHC-35.7* RDW-15.4
[**2108-1-24**] 05:39PM PLT COUNT-192
[**2108-1-24**] 05:39PM PT-13.0* PTT-28.6 INR(PT)-1.2*
[**2108-1-24**] 02:03PM TYPE-ART PO2-240* PCO2-39 PH-7.26* TOTAL
CO2-18* BASE XS--8
[**2108-1-24**] 02:03PM GLUCOSE-173* LACTATE-2.1* NA+-135 K+-4.9
CL--112*
[**2108-1-24**] 02:03PM HGB-8.1* calcHCT-24 O2 SAT-97
[**2108-1-24**] 02:03PM freeCa-1.10*
[**2108-1-24**] 02:03PM freeCa-1.10*
[**2108-1-24**] 01:50PM WBC-7.6 RBC-3.00* HGB-8.8* HCT-26.0* MCV-87
MCH-29.4 MCHC-33.9 RDW-15.7*
[**2108-1-24**] 01:50PM PLT COUNT-214
[**2108-1-24**] 01:50PM PT-14.0* PTT-27.1 INR(PT)-1.3*
[**2108-1-24**] 01:50PM FIBRINOGE-415*
[**2108-1-24**] 12:54PM TYPE-ART RATES-/8 TIDAL VOL-500 O2-50
PO2-235* PCO2-45 PH-7.24* TOTAL CO2-20* BASE XS--7 -ASSIST/CON
INTUBATED-INTUBATED
[**2108-1-24**] 12:54PM GLUCOSE-155* LACTATE-0.8 NA+-138 K+-4.0
CL--112*
[**2108-1-24**] 12:54PM HGB-7.4* calcHCT-22 O2 SAT-98
[**2108-1-24**] 12:54PM freeCa-1.11*
[**2108-1-24**] 07:50AM TYPE-[**Last Name (un) **] PO2-41* PCO2-35 PH-7.33* TOTAL
CO2-19* BASE XS--6
[**2108-1-24**] 07:50AM GLUCOSE-89 LACTATE-0.9 NA+-141 K+-3.9
CL--115*
[**2108-1-24**] 07:50AM HGB-11.5* calcHCT-35 O2 SAT-76
[**2108-1-24**] 07:50AM freeCa-1.16
Brief Hospital Course:
Ms. [**Known lastname **] is a 66 yo G5P5 with breast cancer, diabetes, HTN, and
chronic
kidney disease, admitted for resection of pelvic mass.
On [**2107-1-24**] she underwent an ex-lap, BSO, excision of pelvic mass,
cysto with right ureteral stent placement, ileocecal resection
with primary re-anastomosis, and LAR with colostomy.
Intra-operative consults included urology and [**Last Name (un) **]-rectal
surgery. Intra-operatively she received 5 units of PRBCs, 2 of
FFP and of 2 Albumin. Estimated blood loss was 2500 cc's.
Intra-operative findings included a mass filling the right
pelvis with involvement of the rectosigmoid and posterior
cul-de-sac. The cecum was also densely adherent to the mass.
Frozen pathology revealed low-grade adenocarcinoma. Please see
operative notes by Dr [**First Name (STitle) **] and Dr [**Last Name (STitle) **] for details.
.
# Post-op:
Post-operatively she was transferred to the ICU intubated and
sedated. She was weaned off ventilator a few hours after arrival
once the paralytics had worn off. She remained on high flow
facemask overnight, however she was weaned to nasal cannula by
the AM. On post-operative day 1, the patient was transferred out
of the ICU and to the floor.
On post-op day [**1-23**] her pain was controlled with an epidural, and
she was followed by the pain service. On Post-op day 2 the
epidural was discontinued and she was started on a Dilaudid PCA.
Over the next few days she was slowly transitioned off the PCA
and she received IV Dilaudid for pain control. By post-op day 5
her pain was controlled with PO pain meds with IV Dilaudid for
breakthrough.
.
# Anemia: Pre-operative Hct was 27. Intra-operative Hct was 22
and she received 5 units of PRBCs intraoperatively. Her Hct was
28 post-op however this was likely falsely elevated and had not
yet equilibrated from her large volume shifts and blood loss
during surgery. Over night on POD 0 to POD 1 she was transfused
and additional 2 units of PRBCs and she remained hemodynamically
stable with good urine output. On post-op day 1 her
post-transfusion was Hct was 29 and it remained stable on
several serial Hcts.
.
# Chronic renal disease: Her baseline Cr was 2.9. Her urine
output was poor intraoperatively and her Cr trended up to a peak
of 3.6 on POD 2. The renal consult team was called who suggested
that this was likely acute ATN secondary to intra-operative
hypovolemia. By post-operative day 4 her Cr trended back to her
baseline and she continued to have adequate urine output. The
right ureteral stent placed intraoperatively by urology was
removed at the bedside and the Foley catheter was discontinued.
She will follow up with her primary care provider as an
outpatient. Through her hospitalization nephrotoxins were
avoided, even fluid balance was attempted and she was started on
a low K/Phos & diabetic diet.
.
# DM type II: on NPH and Humulog at home, last A1C 10.4 in
5/[**2106**]. Started on [**1-23**] home dose of NPH and gentle sliding
scale, fingersticks kept in the mid 100s range. When tolerating
a regular diet NPH slowly advanced to home doses. She will
follow up with her primary care provider as an outpatient within
a week of discharge.
.
# Hypertension: on carvedilol 12.5 mg PO BID as an outpatient.
By post-operative day 3 her blood pressures trended up to the
170-180/70-80 range. She received several doses of IV
Hydralazine and IV metoprolol for elevated blood pressures. Her
carvedilol was increased to 25 mg PO BID and Amlodipine 5 mg PO
daily and Lasix 40 mg PO daily was added per Renal consult
recommendations. By discharge her blood pressures were in the
150-160/70-80 range. She will follow up with her primary care
provider as an outpatient within a week of discharge.
.
# History of breast cancer: held anastrazole in the acute
post-surgical setting, given pro-thrombotic risk. Re-started on
discharge from hospital.
.
# Wound: On POD 3 she developed a seroma and the inferior aspect
of her incision was opened up when the staples were removed. A
wound vac was applied. The fascia was probed and found to be
intact and there was clean granulation tissue without evidence
of infection. She was followed by the wound and ostomy nurse who
helped her care for her incision and wound vac. The JP drain was
discontinued on POD 5 by [**Last Name (un) **]-rectal surgery.
.
#) GI: She remained NPO with IVF and an NGT in place until POD
2. She received an IV PPI for prophylaxis. Overnight on POD 2
the NGT was clamped and then discontinued. On POD 3 she was
advanced to sips. On POD4 she tolerated clear without nausea or
vomiting. On POD 5 her ostomy started to put out stool. She was
advanced to a regular diet on POD 6. On POD 6 the output from
her ostomy stopped and she developed nausea and vomiting. A KUB
was done which did not show evidence of SBO. She was made NPO
and a PICC line was placed for IV hydration given that she had
no peripheral access. A suppository was placed in her ostomy. On
POD 7 her ostomy again put out stool and the nausea resolved. By
POD 8 she was tolerating a regular diet without nausea or
vomiting. The PICC line was discontinued.
.
#) L arm swelling: On POD 4 left upper extremity swelling was
noted but there was no erythema and no pain. A LENI was negative
for DVT. This was attributed to her PIV which was discontinued.
The swelling decreased on POD 5.
.
#) Prophylaxis: she received SQ Heparin 2-3 times a day during
her hospitalization. She worked with physical therapy to improve
her ambulation after she became deconditioned and she was
encouraged to ambulate.
She was discharged home in stable condition on POD 10. She was
tolerating a regular diet and her pain was controlled with oral
pain meds. She was ambulating and voiding spontaneously. A VNA
service was arranged to help her with her wound vac and ostomy.
Final pathology revealed a Colon Cancer. She will follow up with
[**Last Name (un) **]-rectal surgery, med-onc, radiation oncology and her primary
care provider in addition to following up with Dr [**First Name (STitle) **].
Medications on Admission:
anastrazole 1mg QD, carvedilol 12.5 QD, humalog w/[**Last Name (LF) 16429**], [**First Name3 (LF) **] 81
QD, NPH 40 units w/breakfast, 22 u w/dinner
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day). Tablet(s)
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*1 bottle* Refills:*2*
8. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
40 Subcutaneous q breakfast.
9. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
22 Subcutaneous q dinner.
10. anastrazole 1mg QD
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
colon cancer
acute on chronic renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for surgery for a pelvic mass. The mass was a
colon cancer. While in the hospital your renal function worsened
but then returned to your baseline. You will need outpatient
followup with your primary care provider, [**Name10 (NameIs) 5564**], radiation
oncology, [**Last Name (un) **]-rectal surgery and GYN-ONC surgery. You should
also follow up with your primary care provider to discuss your
diabetes and hypertension. While you were in the hospital
additional blood pressure medications, Amlodipine and Lasix were
added to better control your high blood pressure. Your insulin
was not changed.
You have a new colostomy and you received teaching on ostomy
care prior to discharge. A visiting nurse will come to the house
to take care of your wound vac and ostomy.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diabetic diet
Incision care:
* No bath tub. VNA will help you shower between wound vac
changes.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**].
Followup Instructions:
You will need to see Dr [**Last Name (STitle) **] in colorectal surgery, in [**2-24**]
weeks. Please call his office to make an appointment.
[**Telephone/Fax (1) 160**].
You should follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] at [**Location (un) 2274**]. You have
an appointment on [**2108-2-15**] at 2 pm to see her at the [**Location (un) **]
office. Dr [**Last Name (STitle) 349**] would like you to see a rad-[**Last Name (STitle) 5564**]. The
Rad-Onc physicians that visited you at [**Hospital1 18**] will call you to
make an outpatient appointment for you soon.
On [**2108-2-10**] at 1:20pm you have an appointment to see Dr
[**Last Name (STitle) **], [**Name8 (MD) **], MD your primary care provider.
You have an appointment to see Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2108-2-27**]
at 2pm on the [**Location (un) **] of the [**Hospital Ward Name 23**] building at [**Hospital1 18**].
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 16-ADL
Completed by:[**2108-2-4**]
|
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icd9cm
|
[
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[]
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[
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icd9pcs
|
[
[
[]
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12248, 12306
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330, 562
|
12394, 12394
|
3027, 4942
|
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|
2471, 2581
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,827
| 161,040
|
26324
|
Discharge summary
|
report
|
Admission Date: [**2105-8-29**] Discharge Date: [**2105-9-11**]
Date of Birth: [**2025-9-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
80 yo M with hx of alcoholic cirrhosis and varices who presented
with GI bleedindg, fever, hypotension, and LE cellulitis.
Major Surgical or Invasive Procedure:
1. Upper Endoscopy
2. Sigmoidoscopy
History of Present Illness:
79 yo M w/ a h/o EtOH cirrhosis, rectal cancer s/p chemotherapy
and XRT, h/o UGIB s/p variceal banding in [**11-3**], chronic LLE
ulcer, who initially presented to OSH w/ fever, hypotension, and
LE cellulitis. Before admission to OSH, found by wife standing
in the kitchen incontinent of stool and not responding to her.
Alert per EMT reports.
.
Patient admitted to OSH and treated for his cellulitis w/ IV
Zosyn. BP in 80s/30s on admission and given 1L NS bolus which
brought his BP up to the 100s. At OSH he was noted to have BM x1
with old, clotted blood. His Hct on admission to OSH was 34,
which then drifted down to 26. transfused 2U PRBC. No
hematemesis, hemodynamically stable.
.
Transferred to [**Hospital1 18**] for further care given he was seen here in
past for variceal banding. In MICU, Hct stable. Started on IV
PPI and transient octreotide. Seen by Liver team, s/p EGD
showing non-bleeding grade III esophageal varices. 3 bands
placed by Liver [**2105-8-31**]. Plan is for flex sigmoidoscopy this
morning. Per MICU team, patient also had episodes of
asymptomatic bradycardia to 30's while sleeping. EP curbsided
and recommended [**First Name9 (NamePattern2) 3782**] [**Doctor Last Name **] of Hearts monitor as an outpatient.
While in MICU, patient treated with Zosyn for LLE cellulitis.
Blood cxs from OSH now positive Group C strep. Wound cx positive
for pseudomonas.
.
After transfer to floor, [**Name8 (MD) **] RN report, patient had small amount
of BRBPR after 3rd enema. Patient remained asymptomatic.
Following morning patient continues to deny lightheadedness,
blurry vision, CP, SOB, abdominal pain.
Past Medical History:
1. Rectal Cancer
- diagnosed in [**2100**]
- s/p chemotherapy
- s/p XRT x 3, with resulting radiation proctitis
- elected not to have surgery b/c did not want a colostomy
2. EtOH cirrhosis with portal HTN
- has had esophageal and gastric varices
- several episodes of variceal bleeds, most recently in [**11-3**]
which required banding - 4 bands here.
3. Peripheral Vascular Disease
-Fem-Fem Bypass in [**2102**]
4. Diabetes, diet controlled
Social History:
Former EtOH abuse, last drink [**6-6**] yrs ago. Former tobacco abuse,
[**12-1**] pk/d x 58 yrs. Lives with wife. [**Name (NI) **] has 3 children.
Family History:
non-contributory
Physical Exam:
VS - T=97.7; BP=142/50; HR=52; RR=18; O2=96%RA FSBG 75
Gen: Awake, alert, interactive. NAD
HEENT: OP clear. Sclera anicteric.
neck: JVP ~ 8 cm
CV: RRR, normal s1/s2, distant heart sounds, no murmurs. R
sided port-o-cath C/D/I.
Lungs: Crackles at L base. Otherwise, CTAB
Abd: NABS. Asymmetrically distended, L>R. No tenderness to
palpation. No rebound or guarding. No HSM.
EXT:
LLE - +erythema to knee. Tracking to groin resolved. Large stage
3 ulcer on inner left foot. Stage 2 ulcer on L lower shin.
RLE - There is erythema on the dorsum of his R foot. No ulcers.
Neuro: CN2-12 intact, A&Ox3, No asterixis.
Pertinent Results:
[**2105-8-29**] 09:10PM GLUCOSE-90 UREA N-46* CREAT-1.1 SODIUM-138
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12
[**2105-8-29**] 09:10PM ALT(SGPT)-24 AST(SGOT)-37 LD(LDH)-184 ALK
PHOS-62 TOT BILI-1.6* DIR BILI-0.7* INDIR BIL-0.9
[**2105-8-29**] 09:10PM ALBUMIN-2.9* CALCIUM-8.1* PHOSPHATE-3.1
MAGNESIUM-2.2
[**2105-8-29**] 09:10PM TSH-2.6
[**2105-8-29**] 09:10PM WBC-9.9# RBC-3.30* HGB-10.7* HCT-30.7* MCV-93
MCH-32.5* MCHC-34.9 RDW-15.5
[**2105-8-29**] 09:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
ELLIPTOCY-1+
[**2105-8-29**] 09:10PM PLT COUNT-58*
[**2105-8-29**] 09:10PM PT-17.3* PTT-35.9* INR(PT)-1.6*
[**2105-8-29**] 09:10PM FIBRINOGE-440*
[**2105-8-30**] 03:55AM BLOOD WBC-8.2 RBC-3.22* Hgb-10.6* Hct-29.6*
MCV-92 MCH-32.9* MCHC-35.7* RDW-15.6* Plt Ct-46*
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2105-9-11**] 09:04AM 26.4*
[**2105-9-11**] 05:30AM 2.4* 2.58* 8.4* 24.0* 93 32.4* 34.8 14.8
67*
[**2105-9-10**] 12:24PM 28.1*
[**2105-9-10**] 06:00AM 2.3* 2.74* 8.9* 25.3* 92 32.6* 35.3* 14.7
69*
[**2105-9-8**] 07:25AM 2.5* 2.89* 9.4* 26.7* 92 32.5* 35.2* 14.8
57*
[**2105-9-7**] 07:48AM 2.9*# 2.93* 9.5* 27.1* 93 32.5* 35.1*
14.8 56*
[**2105-9-6**] 05:26AM 6.6# 2.95* 9.4* 27.1* 92 32.0 34.9 14.8
64*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2105-9-11**] 05:30AM 91 19 1.0 134 4.1 103 25 10
[**2105-9-10**] 06:00AM 89 21* 1.0 136 4.0 103 27 10
[**2105-9-9**] 05:48AM 84 22* 1.1 135 4.2 100 27 12
[**2105-9-8**] 07:25AM 80 21* 1.0 134 3.6 99 28 11
[**2105-9-7**] 03:15PM 3.8
[**2105-9-7**] 07:48AM 79 22* 1.0 136 3.2* 103 24 12
[**2105-9-6**] 05:26AM 171* 25* 1.2 136 4.0 101 28 11
ADDED [**Doctor First Name 674**] & LIP AT 9:47AM ON [**2105-9-6**]
[**2105-9-5**] 07:05AM 92 21* 1.0 136 3.6 100 28 12
[**2105-9-4**] 06:23AM 101 19 0.9 137 3.7 102 26 13
CRP ADDED 10:22AM
[**2105-9-3**] 06:08PM 3.9
[**2105-9-3**] 06:38AM 92 21* 0.9 137 3.0* 102 26 12
[**2105-9-2**] 05:15AM 126* 23* 1.0 140 3.4 108 22 13
[**2105-9-1**] 05:45AM 95 23* 0.9 136 3.4 104 24 11
[**2105-8-31**] 04:39AM 157* 35* 1.0 136 3.7 104 26 10
[**2105-8-30**] 03:55AM 141* 42* 1.1 137 4.1 105 23 13
[**2105-8-29**] 09:10PM 90 46* 1.1 138 3.3 104 25 12
BASIC COAGULATION ( PT PTT Plt Ct INR(PT)
[**2105-9-11**] 05:30AM 67*
[**2105-9-10**] 06:00AM 69*
[**2105-9-9**] 05:48AM 73*
[**2105-9-9**] 05:48AM 12.7 36.7* 1.1
[**2105-9-8**] 07:25AM 57*
[**2105-9-8**] 07:25AM 13.6* 39.1* 1.2*
[**2105-9-6**] 05:26AM 14.7* 44.1* 1.3*
[**2105-9-5**] 12:03PM 13.9* 80.9* 1.2*
[**2105-9-5**] 07:05AM 55*
[**2105-9-5**] 07:05AM 14.1* 57.0* 1.3*
[**2105-9-3**] 06:38AM 43*
[**2105-9-3**] 06:38AM 13.6* 36.6* 1.2*
[**2105-9-2**] 05:15AM 47*
[**2105-8-30**] 03:55AM 46*
[**2105-8-30**] 03:55AM 15.2* 36.6* 1.4*
[**2105-8-29**] 09:10PM 58*1
[**2105-8-29**] 09:10PM 17.3* 35.9* 1.6*
Radiology
[**8-30**] BILAT LOWER EXT VEINS. No evidence of lower extremity DVT.
[**8-30**] CT PELVIS W/CONTRAST
CT CHEST WITH IV CONTRAST: The airways are patent to the
segmental level. There are bilateral small pleural effusions
greater in the left side. There is continuos linear
calcification in the inferior and posterior aspect of the right
pleura. Small focal calcifications are seen in the posterior and
inferior left pleura. Aside from a few subsegmental atelectases
in the bases, the lungs are clear. The LAD, left circumflex and
right coronary arteries are heavily calcified, cardiac size is
top normal. Otherwise the aorta and great vessels are
unremarkable. Multiple paratracheal lymph nodes measure up10/4
to 7 mm, they do not meet CT size criteria for pathologic
enlargement. A 9 mm lymph node is seen in the right hilum.
In the abdomen, the liver has nodular contour with moderate
decrease in the size of the right lobe keeping with patient's
known cirrhosis. In the upper pole of the spleen there is a
subcentimeter hypodense lesion too small to be characterized.
There are esophageal varices. The gallbladder is mildly
distended. The pancreas, adrenal glands and left kidney are
unremarkable. In the medial aspect of the upper pole of the
right kidney there is a subcentimeter hypodense lesion too small
to be characterized. There is no mesenteric or retroperitoneal
lymphadenopathy. There is a small quantity of perisplenic and
perihepatic free fluid. Extensive calcifications are present in
the celiac axis, the splenic artery, the ostium of both renal
arteries and in the SMA. A infrarenal abdominal fusiform
aneurysm measures up to 34 x 33 mm. Extensive calcifications are
seen in both common iliac arteries greater in the right side.
There is moderate splenomegaly, the spleen measures up to 17 cm
AP.
The bowels are unremarkable.
PELVIC CT: There is no free fluid or lymphadenopathy. Coarse
calcifications are seen in the prostate gland. The bladder is
unremarkable. The sigmoid colon is unremarkable. The bifemoral
bypass is patent. There is a 37 x 20 mm fluid collection in the
right inguinal region (3:113).
[**9-2**] ART DUP EXT LO UNI;F/U; ART EXT (REST ONLY)FINDINGS: Duplex
evaluation was performed of the femoral-femoral bypass graft.
The velocities in the graft are 99 to 104 cm/sec. Right femoral
anastomosis and native artery is 169 and 81 cm/sec respectively.
Left corresponding velocities are 118, 135 cm respectively.
Doppler waveforms are monophasic at all levels from the femoral
to the dorsalis pedis artery. The ankle brachial index is 0.82
on the right and 1.1 on the left. Pulse volume recordings on the
right show mild drop-off at the thigh compared to the opposite
thigh, continued drop-off at the calf and metatarsal. On the
left, PVRs are relatively maintained to the calf level and show
significant drop-off at the ankle and metatarsals.
IMPRESSION: Widely patent femoral-femoral bypass graft without
evidence of stenosis. On the right side, there appears to be
significant SFA and tibial artery occlusive disease. On the
left, there is also severe SFA and tibial artery occlusive
disease with a severe flow deficit to the forefoot.
MR LEFT ANKLE WITH AND WITHOUT CONTRAST:
TENDONS: The peroneal, Achilles, and extensor tendons are
unremarkable. Incidental note of a peroneus quartus tendon is
made, a normal variant. There is edema seen in the plantar soft
tisues of the foot with a small amount of fluid around the
flexor hallucis longus tendon representing tenosynovitis.
Diffuse subcutaneous edema is noted.
LIGAMENTS: All of the ligaments are intact including the medial,
lateral, and Lisfranc ligaments.
SOFT TISSUE AND OSSEOUS STRUCTURES: There is a soft tissue
ulceration over the medial malleolus. There is a slight
increased T2 signal in the medial malleolus. There is no
evidence of an abscess or cortical destruction. Osteonecrosis in
the lateral aspect of the talar dome is seen. The joint spaces
are preserved. No fractures or dislocations are visualized. The
ankle mortise is congruent with the talus.
IMPRESSION:
1. Soft tissue ulceration over the medial malleolus.
Corresponding nonspecific increased T2 signal in the medial
malleolus. There is no evidence of abscess or cortical
destruction. The findings are nonspecific and could be seen in
reactive change, although early osteomyelitis cannot be
excluded. No soft tissue abscess.
2. Osteonecrosis of the talar dome.
3. Tenosynovitis of the flexor hallucis longus tendon.
LIVER OR GALLBLADDER US
FINDINGS: The gallbladder is distended and partly filled with
sludge and some shadowing stones. There is no son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign, however, and the wall is not thickened. There is
no intramural edema or pericholecystic fluid. There is no intra-
or extra-hepatic biliary ductal dilatation. The liver has a
coarse appearance consistent with the history of cirrhosis.
There is no ascites. The pancreas is not well seen because of
overlying bowel gas.
IMPRESSION: Distended gallbladder with stones and sludge, but no
other ultrasound findings suggestive of cholecystitis.
Correlation with clinical factors is suggested, however, and if
there is continued clinical concern for cholecystitis, a HIDA
scan could be performed in order to evaluate for gallbladder
filling.
TRANSTHORACIC ECHO
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy with normal cavity size and systolic
function
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular
chamber size and free wall motion are normal. The aortic root,
ascending
aorta, and the aortic arch are mildly dilated. The aortic valve
leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is a
0.8 x 0.3 cm
linear density on the ventricular side of the anterior mitral
leaflet, which
likely represents a torn chorda tendinae. However, a vegetation
cannot be
definitely ruled out. There is no significant associated mitral
regurgitation.
The estimated pulmonary artery systolic pressure is normal. No
vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No definite transthoracic echo evidence of
endocarditis. Mildly
dilated thoracic aorta. Mild aortic regurgitation.
A transesophageal study may better define the linear mitral
valve density and
assess for possible vegetations.
TRANSESOPHAGEAL ECHO
Conclusions:
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. There are simple
atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally
normal with good leaflet excursion and no aortic regurgitation.
No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve.
Physiologic mitral regurgitation is seen (within normal limits).
There are
redundant mitral valve chordae but no evidence of endocarditis.
There is no
pericardial effusion.
IMPRESSION: no abscess or vegetations seen. Redundant mitral
valve chordae.
Brief Hospital Course:
80 yo M w/ EtOH cirrhosis and known varices, presents w/
cellulitis, bacteremia, and GIB now being evaluated for possible
persistent bacteremia and osteomyelitis
1. GIB: Patient came in hypotensive and guaiac positive stool.
An EGD was ordered to r/o any upper GI sources. EGD found
unlikely to be an UGI bleed since there were no bleeding vessels
identified. grade III varices were identified and esophageal
banding was placed for bleed prevention. Flex sigmoidoscopy was
obtained to find any lower GI bleeding and found inflammatory
changes in the rectal mucosa consistent with radiation
proctitis--likely causing his GI bleeding. Hematocrit stabilized
by HD 2. He had some guaiac positive stools on HD 3, but no
further guaiac positive stools at time of discharge. pt will
need to f/u in 4 weeks with GI at [**Hospital1 18**] or [**Location (un) **] for further
banding. Appointment already scheduled at [**Hospital1 18**].
.
2. BACTEREMIA: bacteremia was likely caused by ulcer infection.
cultures on [**8-28**] at [**Hospital3 6592**] revealed 2 bottles positive
for gram + cocci (group C strep). Gp C strep was sensitive to
PCN, erythromycin and Clindamycin. Follow-up blood culture on
[**8-30**] was negative for organisms. pt had a port-o-cath in place,
presumably from previous chemotherapy. Since Group c strep was
cultured from ulcer site, it seemed less likely that bacteremia
derived from cath infection. PCP was [**Name (NI) 653**] and it was found
that the patient was no longer in need of port cath. blood
cultures were drawn for worsening cellulitis on [**9-3**]. IV Zosyn
started. on [**9-5**], patient spiked fever of 101.7. port cath was
removed in suspicion of bacteremia. IV antibiotics continued.
Blood cultures were drawn to exclude any bacteremia. patient has
remained afebrile through [**9-7**]. on [**9-8**] TTE was obtained in
order to rule out any cardiac vegetations. results of the TTE
showed mild aortic regurgiation and ruptured mitral cordae.
PICC line was placed for access of IV abx. on [**9-10**], patient had
a TEE which showed no abscess or vegetations. Redundant mitral
valve chordae. in preparation for discharge, PICC line was
removed and patient was discharged on oral antibiotics. Blood
cultures remained negative at this institution.
.
3. CELLULITIS/CHRONIC ULCERS: cellulitis most likely the result
of chronic LE ulcers from PVD s/p Fem-Fem bypass in [**2102**].
Arterial duplex son[**Name (NI) 867**] study of LE was ordered on [**9-2**] as
recommended by vascular surgery. Test revealed widely patent
femoral-femoral bypass graft without evidence of stenosis. On
the right side, there appears to be significant SFA and tibial
artery occlusive disease. On the left, there is also severe SFA
and tibial artery occlusive disease with a severe flow deficit
to the forefoot. Vascular surgery recommended no acute inpatient
intervention or revascularization for this problem. They
recommended that patient follow-up as an outpatient. wound
cultures from outside hospital revealed infection by group c
strep and pseudomonas. pseudomonas found to be pan sensitive.
Group C strep was also pan sensitive. Zosyn was discontinued on
[**9-2**] and was started on oral Keflex and Cipro. on [**9-3**] LLE
became more erythematous and warm. patient also reported
increased pain. there was a question of worsening cellulitis and
insufficient coverage by oral antibiotics. Oral abx were D/DC'ed
and he was started on Zosyn 4.5 gm IV. LLE erythema continued to
improve on IV antibiotics. By day of discharge, LLE was
diffusely pink up to proximal third of lower leg, greatly
improved from admission. He had completed 14 day course of IV
Zosyn and was transitioned to oral Levofloxacin at the
recommendations of Infectious Diseases. Patient will be
discharged with VNA assistance for dressing changes and wound
care. His QT interval will need to be monitored by EKG while on
levofloxacin as he has a baseline prolonged QTc.
.
4. OSTEOMYELITIS: On [**2105-9-3**] X-ray of the left ankle was
obtained. X-ray revealed periosteal reaction and bone sclerosis
about the ulcer site consistent with osteomyelitis. CRP was 9
and ESR 19, consistent with chronic osteomyelitis. The
Orthopedic service was consulted and recommended foot and ankle
MRI. Results of the MRI showed soft tissue ulceration over the
medial malleolus with underlying
nonspecific bone marrow edema in the medial malleolus. they also
found osteonecrosis of the talar dome. these findings were
consistent with early chronic osteomyelitis. Orthopedics
concluded that because MRI did not show any signs of abscess or
sequestra, patient did not require surgical debridement. they
recommended treatment with IV antibiotics as per ID
recommendations. Infectious disease recommended that the patient
be discharged on a regimen of PO Levaquin for adequate coverage
of his osteomyelitis as he had already completed a 14 day course
of IV antibiotics. they suggested that the patient remain on
Levaquin indefinitely until more definitive treatment can be
done by vascular surgery in the outpatient setting. As above,
his QTc will need to be monitored while on Levofloxacin.
.
5. FEVER/NAUSEA/TRANSAMINITIS: on [**9-5**], patient reported RUQ
pain with N/V and rising fevers. He had one bout of emesis.
Blood test revealed elevated liver transaminases, bilirubin, alk
Phos, amylase and lipase. symptoms improved overnight. he had a
negative [**Doctor Last Name 515**] sign. on [**9-6**] he underwent RUQ ultrasound that
found a distended gallbladder with sludge and stones. there was
no sign of acute cholecystitis. Findings were suggestive of a
passing stone, rather than acute cholecystitis or pancreatitis.
over the course of his hospital stay, LFTS continued to trend
down. By the time of discharge, LFTs had come down to within
normal limits. He had no further episodes of fever, RUQ pain, or
nausea for the rest of the hospital stay. Patient should be
evaluated as an outpatient for an elective cholecystectomy.
.
6. HYPOTENSION: Patient had episodes of hypotension on [**8-7**] with
heart rate in the 60's. hypotension was likely the result of
hypovolemia secondary to poor PO intake the day prior. 500 cc
bolus was given overnight and pressure raised 124/80. he had no
further episodes of hypotension throughout the rest of the
hospital stay.
.
7. CIRRHOSIS: pt has been diagnosed with cirrhosis for approx. 7
years. home therapy includes Nadolol, Aldactone, and bumetidine.
Pt has hepato-spleno megally on exam. he is oriented X3 with no
asterixis. he has grade 3 esophageal varices and internal
hemorrhoids, as confirmed by endoscopy. patient has been doing
well while maintained on home regimen of Nadolol, Bumetidine,
and Aldactone. RUQ US on [**9-6**] showed no ascites. pt was
scheduled for outpatient visit with GI for banding of esophageal
varices. He should continue home regimen of Nadolol, Aldactone
and Bumetidine for management of cirrhosis.
.
8. DM: Diabetes is well controlled on home with diet. while in
house, some glucose levels have been outside of ideal control.
He had no episodes of hypoglycemia. he was placed an insulin
sliding scale and had nor further issues on hyperglycemia during
the rest of the hospital stay.
.
9. PANCYTOPENIA: Patient has been noted to be chronically
pancytopenic. Daily CBC's were drawn to monitor pancytopenia and
values remained stable throughout hospital stay. Etiology of
pancytopenia is unknown, but probably related to cirrhosis
versus systemic infection leading to bone marrow suppression.
pancytopenia should be evaluated as outpatient by PCP.
.
10. BRADYCARDIA: episodes of asymptomatic bradycardia in MICU.
EP curb sided and recommended [**Doctor Last Name **] of Hearts monitor as an
outpatient. No further episodes of bradycardia while on nadolol
for the rest of the hospital stay. Patient will likely need a
[**Doctor Last Name **] of hearts monitor after d/c. to be followed up by PCP
.
11. ANEMIA: baseline Hct around 30. hematocrit ranged from 34.6
to 29.5. for most of the hospital stay, Hct remained consitantly
around 30. He was found to have Low iron and normal ferritin as
[**Doctor Last Name **] as normal B12 and folate. He is likely iron deficiency
anemia with reactive ferritin vs. anemia of chronic disease. Pt
was placed on iron supplements while in house. he should
continue iron supplementation at home.
Medications on Admission:
- aldactone: 25mg
- prilosec 20mg
- nadolol 20mg
- bumetinide - 1mg [**Hospital1 **]
- MVI daily
- Fe daily
- morphine sulfate: 30mg PRN
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Multi-Vit 55 Plus Tablet Sig: One (1) Tablet PO once a
day.
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*4*
9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
Primary:
1. Gastrointesitnal bleeding
2. Radiation proctitis
3. cellulitis
.
Secondary:
1. cirrhosis
2. rectal cancer
3. peripheral vascular disease
4. Diabetes
5. Osteomyelitis
Discharge Condition:
stable
Discharge Instructions:
Please continue to take all medications as prescribed. You will
need to continue to take Levofloxacin once daily indefinitely.
.
Please follow up with Dr. [**Last Name (STitle) **] as below. You should have a
repeat EKG to monitor your QT interval as it was prolonged
during your hospital stay and you are now on levofloxacin which
can increase your QT.
.
You will need to follow up with Gastroenterology to repeat an
upper endoscopy for variceal banding as below. You have been
scheduled for one at [**Hospital1 18**]. If you would prefer to have this
completed closer to home, please call your local
gastroenterologist to schedule and then cancel your [**Hospital1 18**]
appointment.
.
You have also been scheduled for follow up with the Infectious
Diseases department at [**Hospital1 18**] to follow your bone infection. If
this appointment is difficult for you, you should be sure to
have close follow up for your bone infection through your
Primary Care Provider.
.
You should also follow up with vascular surgery as specified
below for continuing care of your ulcers.
.
Please call your doctor or return to the hospital if you
experience bloody stools, dark tarry stools, chest pain,
shortness of breath, lightheadedness, abdominal pain, increased
abdominal size, or any other concerns.
Followup Instructions:
Please return to [**Hospital1 18**] to have a repeat Upper Endoscopy on the
[**Location (un) **] of the [**Hospital Ward Name 121**] Building on [**2105-10-9**]. You will need to
arrive by 8 am for a 9am procedure. You should not eat or drink
anything after midnight the night prior. You should not take
aspirin or ibuprofen for 1 week prior to the procedure. You
will need a ride home the day of the procedure. You should be
done around 12 noon.
.
Please follow up with your Primary Care Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2105-9-18**] at 1:30 pm. Phone: ([**Telephone/Fax (1) 65147**].
.
Please follow up with Dr. [**Last Name (STitle) 1391**] from vascular surgery at
[**Hospital1 18**] on Wed [**2110-9-23**]:45 AM. His office is located in the
[**Hospital Unit Name **] suite 5C.
.
You have been scheduled to follow up with Infectious diseases
regarding your osteomyelitis and bacteremia. please attend your
appointment on [**2105-10-9**] at 930 AM in [**Hospital Unit Name **] of the [**Hospital Unit Name **].
|
[
"456.21",
"682.6",
"572.3",
"730.17",
"E879.2",
"578.9",
"571.2",
"041.03",
"440.23",
"V10.06",
"250.00",
"303.93",
"574.90",
"284.8",
"429.5",
"707.13",
"041.7",
"556.2",
"427.89",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"86.05",
"42.33",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
23491, 23550
|
13968, 22354
|
437, 475
|
23772, 23781
|
3441, 13945
|
25126, 26230
|
2775, 2793
|
22542, 23468
|
23571, 23751
|
22380, 22519
|
23805, 25103
|
2808, 3422
|
275, 399
|
503, 2130
|
2152, 2595
|
2611, 2759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,554
| 111,784
|
24205
|
Discharge summary
|
report
|
Admission Date: [**2199-5-3**] Discharge Date: [**2199-5-8**]
Date of Birth: [**2133-6-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Increase fatigue/Chest tightness w/ activity
Major Surgical or Invasive Procedure:
s/p Coronary Artery Bypass Graft x 5 on [**2199-5-3**]
History of Present Illness:
65 y/o active male with h/o HTN and DM c/o increase fatigue and
chest tightness w/ activity. Had +ETT followed by cath which
revealed severe 3 vessel disease.
Past Medical History:
Hypertension
Diabetes Mellitus
s/p Back surgery [**2174**]
s/p L Hand tendon repair
s/p R. Thunb repair
s/p Cervical Laminectomy
s/p Varicocele repair
Social History:
Lives with wife. [**Name (NI) **]. Quit smoking 25 yrs ago. Doesn't
drink.
Family History:
Non-contributory
Physical Exam:
Vitals: 80 20 160/80 6'1" 270
General: Well-appearing 65 y/o male in NAD
Skin: Unremarkable, -lesions
HEENT: EOMI, PERRLA, NC/AT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/NT +BS
Ext: Warm, well-perfused, trace edema, -varicosities
Neuro: A&Ox3, CN2-12 intact, non-focal
Pertinent Results:
Pre-op CXR: No radiographic evidence of acute cardiopulmonary
process.
[**2199-5-3**] 12:12PM BLOOD WBC-14.0* RBC-3.40*# Hgb-10.2*#
Hct-30.3*# MCV-89 MCH-30.0 MCHC-33.6 RDW-12.5 Plt Ct-167
[**2199-5-7**] 05:55AM BLOOD WBC-9.5 RBC-3.93* Hgb-11.4* Hct-35.2*
MCV-90 MCH-29.1 MCHC-32.5 RDW-12.5 Plt Ct-246
[**2199-5-3**] 12:12PM BLOOD PT-14.6* PTT-25.5 INR(PT)-1.4
[**2199-5-3**] 12:24PM BLOOD UreaN-22* Creat-1.0 Cl-111* HCO3-24
[**2199-5-7**] 05:55AM BLOOD Glucose-158* UreaN-20 Creat-0.9 Na-138
K-4.8 Cl-101 HCO3-27 AnGap-15
[**2199-5-3**] 02:16PM BLOOD Mg-2.5
[**2199-5-5**] 04:14AM BLOOD Mg-1.9
[**2199-5-3**] 07:18AM BLOOD freeCa-1.20
[**2199-5-4**] 03:26AM BLOOD freeCa-1.24
Brief Hospital Course:
Pt. was a same day admit on [**2199-5-3**] and was brought to the OR
and after general anesthesia he underwent a CABG x 5. Pt.
tolerated the procedure well and had total bypass time of 96
minutes and cross-clamp time of 69 minutes. Please see op note
for full surgical report. Following the procedure he was
transferred to CSRU in stable condition with a HR of 96 a-paced,
MAP 82, CVP 14, PAD 18, [**Doctor First Name 1052**] 24 and being titrated on Nitro and
Propofol. He remained extubated through the next and early
morning on POD #1 he was weaned from propofol and mechanical
ventilation and extubated. He was awake, alert, MAE, and
following commands. His Swan Ganz catheter and Chest tubes were
removed pre protocol. Diuretic and B-blocker were started today.
CXR on POD #2 revealed a small left apical PTX. On POD #3 Repeat
CXR showed a regression in the PTX. He appeared to be doing
well. Exam was unremarkable. His epicardial pacing wires and
Foley were removed. He was transferred to telemetry floor. On
POD #5, he cleared physical therapy and was discharged to home.
Medications on Admission:
1. Atenolol 25mg [**Hospital1 **]
2. Accupril 20mg qd
3. Zantazc 150mg qd
4. Metformin 1000mg [**Hospital1 **]
5. Diltiazem 240mg qd
6. Glipizide 10mg [**Hospital1 **]
7. ASA 325mg qd
8. Humulin NPH 60 units at hs
9. MVI
10 Ibuprofen prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
7. Quinapril HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Packet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*1*
11. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
12. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection as directed.
Disp:*1000 units* Refills:*2*
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty
(60) units Subcutaneous dinner.
Disp:*100 cc* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Arterty Disease s/p Coronary Artery Bypass Graft x 5
Hypertension
Diabetes Mellitus
s/p Back surgery [**2174**]
s/p L Hand tendon repair
s/p R. Thunb repair
s/p Cervical Laminectomy
s/p Varicocele repair
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with warm water and mild soap.
Gently pat dry.
Do not bath or swim.
Do not apply lotion, creams, or ointments to incisions.
Do not lift greater than 10 pounds for 2 month.
Do not drive for 1 month.
Make/keep all follow-up appointments.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) 3659**] in [**1-17**] weeks.
Follow-up with Dr. [**First Name (STitle) **] in [**12-16**] weeks.
|
[
"414.01",
"250.00",
"E878.2",
"512.1",
"E849.7",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.14",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4853, 4902
|
1932, 3012
|
344, 401
|
5158, 5164
|
1230, 1909
|
871, 889
|
3300, 4830
|
4923, 5137
|
3038, 3277
|
5188, 5457
|
5508, 5707
|
904, 1211
|
260, 306
|
429, 589
|
611, 763
|
779, 855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,310
| 186,606
|
38824+58234
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-10-19**] Discharge Date: [**2162-10-22**]
Date of Birth: [**2110-5-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
fevers, malaise
Major Surgical or Invasive Procedure:
IR guided biliary tube exchange
History of Present Illness:
Patient is a 52F with history of pancreatic cancer metastatic to
the liver on hospice who presents with a several day history of
fever and malaise. She has a history of prior cholangitis with
biliary drain in place, which has had decreased output over the
past several days. the plan was for scheduled cholangiogram as
an outpatient tomorrow. Her VNA noted drainage around the stent
site. She has been febrile to 101 at home per VNA and notes
cough, but denies any chest pain, dyspnea, abdominal pain,
vomiting, or diarrhea. Blood cultures were drawn by VNA at [**Company 15819**] and were positive for GNRs. She was brought to ED
for evaluation. In the ED, initial VS were 98 109/70 29. She was
hypoxic to 85% on RA, but sats came up to 100% on NRB. Labs
notable for leukocytosis of 22.2, Na 127, K 5.2, Cr 2.1, anion
gap 15, lactate 2.5, ALT 146, AST 71, Tbili 6.4, Dbili 4.4, and
AlkPhos 256. She received vanc, cefepime, and flagyl, and repeat
blood cultures were sent. CXR showed right lower lobe collapse
vs. consolidation. IR was consulted, and patient underwent
replacement of biliary catheter. She was intubated for the
procedure then extubated and transferred to the ICU.
On arrival to the MICU, patient's VS T98.9, HR84, BP100/68,
RR21, O2sat: 100%. Patient states that she feels better after
the procedure and that she is no longer in pain. She states that
she feels weak and exhausted.
Review of systems:
(+) Per HPI
(-) Denies Denies shortness of breath, cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies
constipation, abdominal pain Denies dysuria, frequency, or
urgency. Denies other pain
Past Medical History:
Pancreatic Cancer diagnosed [**2160-2-8**]
EGD on [**2160-3-5**] disclosed a pancreatic head mass
s/p Whipple [**3-/2160**]
T3N1 (Stage IIB) adenocarcinoma of the pancreas
Adjuvant chemotherapy and chemoradiation therapy completed on
09/[**2160**].
[**2162-5-14**] multiple low-attenuation lesions were noted in the
liver.
EUS/FNA on [**2162-6-1**] disclosed a local recurrence
liver biopsy on [**2162-6-2**] disclosed metastatic recurrence
gemcitabine chemotherapy [**2162-7-14**].
[**2162-8-25**] - per outpatient visit, does not wish to undergo
further chemotherapy
[**2162-9-2**] initiated hospice services at home
Past Medical History:
Increased intraocular pressure
T3N1 (Stage IIB) pancreatic adenocarcinoma (see above history)
PSHx: Tubal ligation, Hysteroscopy, Bilateral knee
arthroscopies, Breast biopsy
Social History:
She lives with her husband. She has never smoked and drinks
socially. She works as a secretary.
Family History:
Mother with DM and "everything"."bone cancer" in her father per
[**Name (NI) **].
Physical Exam:
On admission:
Vitals: T98.9, HR84, BP100/68, RR21, O2sat: 100%
General: Alert, oriented, cachectic
HEENT: Sclera mildly icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, biliary drainage
catheter in place draining bilious, blood-tinged fluid
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
VS Tc 99.2 Tm 99.2 BP 96-107/56-70 HR 91-99 RR 18 SpO2 95-96%RA
General: Alert, oriented, cachectic
HEENT: Sclera mildly icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, biliary drainage
catheter in place draining bilious, blood-tinged fluid
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
On admission:
[**2162-10-19**] 06:08PM BLOOD WBC-22.2*# RBC-4.04* Hgb-11.7* Hct-36.5
MCV-90 MCH-29.0 MCHC-32.1 RDW-15.9* Plt Ct-347
[**2162-10-19**] 06:08PM BLOOD Neuts-90.0* Lymphs-6.0* Monos-3.4 Eos-0.1
Baso-0.4
[**2162-10-19**] 06:08PM BLOOD PT-17.4* PTT-34.0 INR(PT)-1.6*
[**2162-10-19**] 06:08PM BLOOD Glucose-165* UreaN-107* Creat-2.1*#
Na-127* K-5.2* Cl-88* HCO3-24 AnGap-20
[**2162-10-19**] 06:08PM BLOOD ALT-146* AST-71* AlkPhos-256*
TotBili-6.4* DirBili-4.4* IndBili-2.0
[**2162-10-19**] 06:08PM BLOOD Albumin-2.9*
[**2162-10-19**] 11:58PM BLOOD Calcium-7.3* Phos-3.4 Mg-2.6
[**2162-10-19**] 06:12PM BLOOD Type-[**Last Name (un) **] pO2-41* pCO2-35 pH-7.47*
calTCO2-26 Base XS-1 Comment-GREEN TOP
[**2162-10-19**] 06:12PM BLOOD Lactate-2.5*
Portable CXR [**2162-10-19**]:
Right basilar opacification with elevation of the right
hemidiaphragm suggests atelectasis or an infectious process.
Small bilateral pleural effusions.
Percutaneous Biliary Catheter Cholangiogram/Exchange [**2162-10-19**]:
FINDINGS:
1. Existing 10 French modified pigtail drain patent in its
intrahepatic
component, but obstructed distally with no contrast drainage
noted into the hepaticojejunostomy.
2. Several separate areas of stricturing identified within the
intrahepatic ducts in segments not directly accessed by the
existing tube. These do demonstrate some partial drainage of
contrast at the end of the procedure.
IMPRESSION: Occluded existing indwelling modified biliary
drain, successfully
replaced.
CT ABD/PELVIS [**2162-10-20**]:
IMPRESSION:
1. Multiple large liver and smaller uterine abscesses, likely
secondary to hematogenous spread of pathogen.
2. Possible bilateral lower lobe pneumonia, concerning for
aspiration
etiology. Correlate clinically.
3. Biliary drainage catheter in unchanged position, surrounded
by a locally recurrent mass at the Whipple resection bed.
Brief Hospital Course:
Assessment and Plan: This is a 52yo female with PMH of
pancreatic cancer s/p whipple and with metastases to the liver
who presents from home with fever, malaise, and leakage of fluid
from around her biliary drain site. This is concerning for
cholangitis with report of BC positive for GNR at outside lab
facility.
# Biliary Drainage: Patient presented from home with blockage of
external drainage from biliary drain and leakage of fluid from
around the tube. IR exchanged the drain on presentation with
good effect. Her bilirubin was elevated on presentation likely
from acute biliary drainage blockage and improved after the
exchange. However, following the tube exchange, she was noted
to have decreased drainage. CT abdomen was performed which
revealed her biliary tube to be in good positions, however there
are also multiple hepatic and uterine abscesses which may be due
to hematogenous spread of pathogen or possibly superinfection of
necrotic metasteses. She will continue to use her biliary
catheter at home as she did previously.
# GNR/GPC/GNC bacteremia: Patient reportedly has positive BC
from outside lab for GNR. She was empirically started on
vancomycin, cefepime, flagyl. [**Company **] was contact[**Name (NI) **]
and reported that blood culture grew enterobacter cloacae, [**Last Name (un) 36**]
to cefepime, levofloxacin, cipro. 1 blood culture in hospital
also grew GNRs and GPCs. Preliminary gram stain of bile culture
grew GPCs and GNRs. The likely source is biliary given the
acute blockage of the drain associated with onset of symptoms.
Subsequent organisms grown from culture include GNC as well. She
was continued on cefepime and flagyl in house with vancomycin
stopped on HD#3. Because she did not worsen clinically, it was
decided that [**Last Name (un) 34239**] was less likely. As such, the decision was
made to simplify her regimen to once daily ertapenem to provide
adequate coverage for her polymicrobial bacteremia, as the only
organism this would miss [**First Name (Titles) **] [**Last Name (Titles) 34239**]. Her bacteremia is likely
biliary in origin, with hematogenous spread to her liver,
resulting in these abscesses. The possibility of drainage was
discussed with IR, and it was decided that to do so would
require 1 or 2 more drains to be placed, and it would be
unlikely to be curative. The etiology of her bacteremia being
these multiple hepatic abscesses was discussed with the patient
and her family, and a decision was reached to forgoe IR
intervention, and to continue just with IV antibiotics and her
home hospice care. As such a PICC line was placed, confirmed via
CXR to be in good position, and she was discharged to home with
home hospice care.
# Pancreatic Carcinoma: Patient has pancreatic adenocarcinoma
with metastases to the liver. She has undergone surgery with
adjuvant chemotherapy and has decided to pursue no further
chemotherapy but has initiated hospice care. Her CT scan after
biliary stent replacement showed likely superinfection of
necrotic metasteses in her liver, which is a very poor
prognostic sign. This was communicated with her primary
oncologist. She will continue with her prior pain and nausea
regimen consisting of hydromorphone and morphine prn, as well as
ondansetron, compazine and lorazepam. She will continue creon
for pancreatic enzyme repletion.
# IDDM: The patient was maintained on her home glargine plus SS
insulin in-house.
# ARF: Cr was elevated to 2.1 on admission, likely pre-renal
azotemia. She was given IVFs and Cr returned to 1.1.
#Hypoxemia: Pt's oxygen saturation was reportedly 85% on RA at
the ED and improved to 100% on NRB. She had no further episodes
of hypoxia. CXR was clear. She did not require supplemental
oxygen at the time of discharge and does not experience any
shortness of breath of dyspnea.
Medications on Admission:
HYDROMORPHONE - 2 mg tablet - [**2-8**] tablet(s) by mouth every 3-4
hours as needed for pain
INSULIN GLARGINE [LANTUS SOLOSTAR] - (Prescribed by Other
Provider) - 100 unit/mL (3 mL) Insulin Pen - 10 Insulin(s) at
bedtime
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - as directed Solution(s) qac according to
sliding scale provided by [**Hospital 387**] clinic
LACTULOSE - 20 gram/30 mL Solution - 30 ml by mouth qd if no BM
in the am
LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000
unit capsule,delayed release(DR/EC) - [**2-9**] Capsule(s) by mouth
qac
LORAZEPAM - 1 mg tablet - 1 tablet(s) by mouth every six (6)
hours as needed for mild nausea, insomnia, anxiety
MORPHINE CONCENTRATE - 100 mg/5 mL (20 mg/mL) Solution - 0.5 ml
(
10 mg) by mouth every 1 hour as needed for pain
OMEPRAZOLE - 40 mg capsule,delayed release(DR/EC) - 1 Capsule(s)
by mouth twice a day
ONDANSETRON - 8 mg tablet,disintegrating - 1 tablet(s) by mouth
three times a day as needed for severe nausea may alternate with
compazine
PROCHLORPERAZINE MALEATE - 10 mg tablet - 1 tablet(s) by mouth
q8
as needed for moderate nausea [**Month (only) 116**] alternate with zofran
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit capsule - 1 Capsule(s) by mouth
DOCUSATE SODIUM - (OTC) - 100 mg capsule - 1 Capsule(s) by
mouth
twice a day
MULTIVITAMIN - (OTC) - tablet - 1 Tablet(s) by mouth
SENNOSIDES [SENNA CONCENTRATE] - (OTC) - Dosage uncertain
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
2. Lactulose 30 mL PO DAILY constipation
3. Lorazepam 1 mg PO Q6H:PRN mild nausea, anxiety
4. Mirtazapine 30 mg PO HS
5. Morphine Sulfate (Concentrated Oral Soln) 10 mg PO Q1H:PRN
pain
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 8 mg PO TID:PRN severe nausea
8. Prochlorperazine 10 mg PO Q8H:PRN moderate nausea
9. Vitamin D 800 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Senna 1 TAB PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
3. Lactulose 30 mL PO DAILY constipation
4. Lorazepam 1 mg PO Q6H:PRN mild nausea, anxiety
5. Morphine Sulfate (Concentrated Oral Soln) 10 mg PO Q1H:PRN
pain
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Ondansetron 8 mg PO TID:PRN severe nausea
9. Prochlorperazine 10 mg PO Q8H:PRN moderate nausea
10. Senna 1 TAB PO BID
11. Vitamin D 800 UNIT PO DAILY
12. ertapenem *NF* 1 gram Injection daily
13. 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.
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
One flush as directed once a day Disp #*30 Syringe Refills:*2
14. Creon 12 [**2-9**] CAPS PO TID W/MEALS
RX *lipase-protease-amylase [Creon] 3,000 unit-[**Unit Number **],500 unit-[**Unit Number **],000
unit [**2-9**] capsule(s) by mouth three times a day with meals Disp
#*60 Capsule Refills:*0
15. Sodium Chloride 0.9% Flush 10 mL IV DAILY
PICC - Please flush your PICC line as directed
RX *sodium chloride 0.9 % [Saline Flush] 0.9 % One flush as
directed once a day Disp #*30 Syringe Refills:*2
16. Mirtazapine 30 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary catheter obstruction
Polymicrobial bacteremia
Pancreatic carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure caring for you at [**Hospital3 **] Medical Center.
As you know, you were hospitalized when your biliary drainage
tube became clogged. Our interventional radiology team exchanged
your tube which appears now to be draining properly. You were
found to have a serious bloodstream infection, which we started
antibiotics to treat. You should continue these antibiotics at
home to help treat your infection. You should also resume your
home hospice care.
We made the following changes to your medications:
START
Ertapenem (Invanz)
Heparin flush
Normal saline flush
Followup Instructions:
You should follow up with your oncologist on an as-needed basis.
Name: [**Known lastname 13636**],[**Known firstname **] Unit No: [**Numeric Identifier 13637**]
Admission Date: [**2162-10-19**] Discharge Date: [**2162-10-22**]
Date of Birth: [**2110-5-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 342**]
Addendum:
To clarify on the discharge summary for [**Known lastname **], [**Known firstname **] dated
[**2162-10-22**]. Given the extensive abscesses in her liver, it is
doubtful that IV antibiotics alone would be curative in this
case. As such, the ertapenem she will be sent home on is solely
for palliative purposes.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 347**] MD [**MD Number(1) 348**]
Completed by:[**2162-10-22**]
|
[
"197.7",
"584.9",
"251.3",
"V87.41",
"V58.67",
"V10.09",
"E879.8",
"790.7",
"V15.3",
"996.59",
"799.02",
"041.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
15517, 15679
|
6500, 10324
|
322, 355
|
13922, 13922
|
4593, 4593
|
14736, 15494
|
2987, 3071
|
12518, 13774
|
13824, 13901
|
10350, 12495
|
14100, 14624
|
3086, 3086
|
14653, 14713
|
1802, 2017
|
267, 284
|
383, 1783
|
4608, 6477
|
13937, 14076
|
2680, 2857
|
2873, 2971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,036
| 154,127
|
37980
|
Discharge summary
|
report
|
Admission Date: [**2171-12-4**] Discharge Date: [**2171-12-6**]
Date of Birth: [**2099-12-9**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Wheat Flour
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Penetrating thoracic ulcers
Major Surgical or Invasive Procedure:
OPERATION PERFORMED:
1. Ultrasound-guided puncture right common femoral artery.
2. Ultrasound-guided puncture of left common femoral
artery.
3. Bilateral introduction of catheters into aorta.
4. Arch aortogram and a thoracic aortogram.
5. Endovascular stent graft exclusion of penetrating
abdominal aortic ulcer via a [**Doctor Last Name 4726**] TAG 34 x 20
endoprosthesis.
6. Perclose closure of bilateral common femoral
arteriotomies.
History of Present Illness:
Mrs. [**Known lastname 84863**] is a 72-year-old patient of Dr. [**First Name8 (NamePattern2) 1399**] [**Last Name (NamePattern1) 33667**] who had
also been followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Mrs. [**Known lastname 84863**] is status
post abdominal aortic aneurysm open repair on [**2171-4-29**] by Dr.
[**Last Name (STitle) **]. This procedure was complicated by renal failure. She
had one functioning kidney at that time. Her renal function has
never improved and she is now on chronic hemodialysis via a
tunneled subclavian line. About two months ago, she presented
to
the emergency room of [**Hospital3 14325**] Medical Center complaining of
upper back pain and underwent a CT scan which showed three
separate areas of "dissection" in her thoracic aorta. Most
recent CT shows three separate areas of penetrating ulcers of
the
aorta with some contained extravasation in the most distal
lesion
is noted. Review of the official report from the study dated
[**2171-10-8**] states that there has been interval enlargement of the
penetrating ulcer compared to a previous study done on [**2171-9-16**].
Since two months ago, she has had no further episodes of chest
or
back pain.
Past Medical History:
Past Medical History:
Hypertension
Chronic Renal Failure, on Dialysis
Degenerative Arthritis
Thyroid Nodules
Adrenal Adenomas
Depression
Past Surgical History:
- s/p Abd Ao Aneurysm open repair
- s/p Hysterectomy
- Deviated Nasal Septum repair
Social History:
Occupation: Retired
Lives with: Daughter
[**Name (NI) **]: Caucasian
Tobacco: Former smoker, quit [**2171-4-7**], 50 PYH
Family History:
Family History: Father died of MI at age 62
Physical Exam:
Pulse: 65 BP 160/67
Height: 61 inches Weight: 160 lbs
General: Pleasant female in NAD
Right subclavian catheter in place
Skin: Dry [x] intact [x] - well-healed midline abdominal
incision
is noted
HEENT: PERRLA [x] EOMI [x], full dentures
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] - decreased bilaterally
Heart: RRR [x] Irregular [] Murmur - soft SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema - none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: Left: ++ bruit
Pertinent Results:
[**2171-12-6**] 06:20AM BLOOD
WBC-14.8* RBC-4.75 Hgb-12.5 Hct-40.7 MCV-86 MCH-26.3* MCHC-30.7*
RDW-20.5* Plt Ct-224
[**2171-12-6**] 06:20AM BLOOD
PT-13.0 PTT-37.4* INR(PT)-1.1
[**2171-12-6**] 06:20AM BLOOD
Glucose-83 UreaN-24* Creat-7.2*# Na-135 K-5.7* Cl-94* HCO3-30
AnGap-17
Brief Hospital Course:
[**Known lastname **],[**Known firstname **] was admitted on [**12-4**] with Penetrating thoracic
ulcers. She agreed to have an elective surgery. Pre-operatively,
she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S -
were obtained, all other preparations were made.
It was decided that he would undergo:
OPERATION PERFORMED:
1. Ultrasound-guided puncture right common femoral artery.
2. Ultrasound-guided puncture of left common femoral
artery.
3. Bilateral introduction of catheters into aorta.
4. Arch aortogram and a thoracic aortogram.
5. Endovascular stent graft exclusion of penetrating
abdominal aortic ulcer via a [**Doctor Last Name 4726**] TAG 34 x 20
endoprosthesis.
6. Perclose closure of bilateral common femoral
arteriotomies.
prepped, and brought down to the endo suite room for surgery.
Intra-operatively, she was closely monitored and remained
hemodynamically stable. tolerated the procedure well without
any difficulty or complication.
Post-operatively, transferred to the PACU for further
stabilization and monitoring.
was then transferred to the VICU for further recovery. While in
the VICU received monitored care. When stable, delined, diet
was advanced. When she was stabilized from the acute setting of
post operative care, she was transferred to floor
status
On the floor, she remained hemodynamically stable with his pain
controlled. continues to make steady progress without any
incidents. discharged home in stable condition.
She did receive HD
Medications on Admission:
Diltiazem 240 qd, Hydralazine 15mg QID, Lisinopril 40 qd,
Simvastatin 40 qd, Diovan 160 [**Hospital1 **], Calcium
Discharge Medications:
1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
6. Hydralazine 10 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Penetrating ulcers of thoracic
aorta.
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Toracic Graft 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 [**3-12**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**5-13**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-1-6**] 1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2172-1-6**] 1:40
Completed by:[**2171-12-6**]
|
[
"716.90",
"403.91",
"241.9",
"311",
"585.6",
"441.01",
"285.21",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.95",
"39.73"
] |
icd9pcs
|
[
[
[]
]
] |
5794, 5800
|
3576, 5086
|
309, 764
|
5882, 5891
|
3270, 3553
|
8468, 8757
|
2463, 2492
|
5250, 5771
|
5821, 5861
|
5112, 5227
|
5915, 7888
|
7914, 8445
|
2207, 2293
|
2507, 3251
|
242, 271
|
792, 2025
|
2069, 2184
|
2309, 2431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,057
| 175,480
|
48302
|
Discharge summary
|
report
|
Admission Date: [**2133-5-31**] Discharge Date: [**2133-6-3**]
Date of Birth: [**2071-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Liver hematoma
Major Surgical or Invasive Procedure:
Left hepatic artery embolization
History of Present Illness:
Mr. [**Known lastname 35507**] is a 62yo male with PMH significant for hemophilia
A, HCC, HIV who is being transferred to the MICU for management
of hemoperitoneum. Of note, the patient was discharged from
[**Hospital1 18**] on [**5-29**] after being admitted for black stools which was
thought to [**1-31**] upper GI source. Per patient's wife, since being
discharged from the hospital on [**Month/Day (2) 2974**] he has been more tired
but did not have any abdominal pain until the morning. He woke
up this morning with severe abdominal pain. His wife also noted
blood in the toilet after he had a bowel movement. He was then
brought to [**Hospital1 18**] ED for further work-up.
In the ED his initial vitals were T 97.2 BP 107/55 AR 54 RR 18
O2 sat 95% RA. CT scan w/o contrast showed a hyperdensity within
the left lobe of the liver concerning for hemmorage from his
underlying malignancy. He received Vancomycin 1g, Levaquin 500mg
IV, Flagyl 500mg IV, and Refacto 1080 units, 2070 units. He also
received 2 units FFP and 2 units pRBCs.
He was immediately taken to IR for possible embolization of the
bleeding vessel. No bleeding vessel was found and the patient
was then transferred to the MICU for further monitoring.
Past Medical History:
1) Hemophilia A
- followed by Dr [**Last Name (STitle) 13933**], Drs [**Last Name (STitle) 2805**] and [**Name5 (PTitle) **]
- arthropathy in elbows, ankles, neck, on Ms Contin
- s/p multiple b/l knee replacements
2) HIV/AIDS
- followed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] at [**Hospital1 778**] ([**Telephone/Fax (1) 46100**]
- [**9-5**]: CD4% 9, CD4:221; CD8% 60, CD8:1412, CD4/CD8 0.2
3) HCV genotype II and IV
- followed by Dr [**Last Name (STitle) **]; relapsed [**9-3**] s/p peg interferon and
ribavirin for 48 weeks ([**Date range (1) 101752**]).
- EGD [**12/2131**]: Varices at the lower third of the esophagus. Mild
duodenitis.
4) HCC - diagnosed in [**1-6**], followed by Dr. [**Last Name (STitle) **], Dr.
[**First Name (STitle) **].
Social History:
Lives with wife. Is a former computer analyst. Founded an
international nonprofit organization. Currently working in real
estate. They have no children. Quit alcohol in [**2114**]. Denies
tobacco and prior intravenous drug use.
Family History:
Significant for hemophilia in brother (d of AIDS [**2110**]), other
relatives. [**Name (NI) **] and [**Name2 (NI) **] d. MVA, Fa w/ vascular dementia d. age 88.
Physical Exam:
vitals T 95.5 BP 126/63 AR RR 15 O2 sat 95% on 3L NC
Gen: Patient sleeping but arousable to voice, ashen appearing
HEENT: MMM
Heart: Sinus tachycardia, no audible m,r,g
Lungs: Poor air movement at the bases
Abdomen: Distended, tenderness in RUQ, mild guarding but no
rebounding
Extremities: Cachectic appearing
Neuro: +asterexis
Brief Hospital Course:
Mr. [**Known lastname 35507**] is a 62yo male with HIV, HCC, and HCV who presents
with worsening abdominal pain and found to be bleeding into his
liver.
1)Liver hematoma: Patient presented to emergency room with
severe abdominal pain. He was found to be bleeding into his
liver, likely from his HCC. This was confirmed on CT scan. He
presented similarly back in [**2-6**] and underwent successful
embolization. Embolization was attempted on day of admission but
no bleeding vessel was found. His Hct dropped approximately 10
points from his last admission. Upon transfer to the MICU his
hematocrit continued to drop and his INR remained elevated. He
required multiple transfusions of pRBCs and FFP with mild
improvement. When his Hct dropped to 20 he underwent a CT
abdomen with contrast which showed extravasation of contrast. He
was then brought to IR and his left hepatic artery was
embolized. Despite successful embolization, his condition
continued to decline. He became difficult to ventilate and his
Hct and coags did not normalize despite multiple transfusions.
After discussion with the patient's wife, the decision was made
to withdraw care and change code status to comfort measures
only. Patient expired on [**6-3**].
2)Respiratory: Patient was intubated in order to stabilize him
for the CT scan and IR embolization. He remained on the
ventilator and it became increasingly difficult to ventilate him
on the day of death. The patient was extubated and then expired.
3)Lactic acidosis: Patient presents with anion gap metabolic
acidosis. He has component of renal insufficiency as well as
bleeding into the liver with worseing liver function also likely
contributing. Bicarbonate is also low. He also has portal vein
thrombus which may be causing some ischemia to the liver. His
lactate after hydration improved but then increased on day of
death, likely due to end organ damage.
4)Acute renal failure: Patient presents with Cr~1.8 on
admission; elevated from baseline of 0.8. No history of
hepatorenal syndrome. Most likely prerenal etiology in light of
underlying bleeding and poor PO intake. His Cr increased
significantly to 2.1 on day of expiration, likely due to
significant blood loss and poor perfusion.
5)HCC: Patient was diagnosed earlier this year. He is not a
candidate for any further treatment. He was treated with
Sorafenib which was stopped recently. Likely causing current
presentation.
6)Hemophilia: Patient has history of self administering himself
Factor 8 when necessary. He was given Factor 8 in the ED.
Hematology was consulted in the ED and followed patient closely.
His factor 8 level was followed closely and he was given Factor
8 200 units to keep level >50%.
7)HIV: Patient is on anti-retrovirals as an outpatient. Given
current clinical scenario his regimen was held.
Medications on Admission:
Abacavir 300mg PO BID
Lopinavir-Ritonavir 400-100mg PO BID
Rifaximin 400mg PO TID
Tenofovir Disoproxil Fumarate 300mg Po daily
Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO 5X/DAY
Hydromorphone 4-8mg PO Q6H PRN
Omeprazole 20mg PO daily
Selenium Oral
Spironolactone 50mg PO daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver hepatoma
Hepatocellular carcinoma
Hepatitis C
Discharge Condition:
Patient expired on [**6-3**] at 12:12pm.
Discharge Instructions:
Patient expired on [**6-3**] at 12:12pm.
Followup Instructions:
Patient expired on [**6-3**] at 12:12pm.
|
[
"276.2",
"573.8",
"584.9",
"042",
"155.0",
"286.0",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.93",
"96.71",
"96.04",
"99.06",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
6405, 6414
|
3220, 6038
|
329, 363
|
6510, 6553
|
6642, 6686
|
2690, 2852
|
6376, 6382
|
6435, 6489
|
6064, 6353
|
6577, 6619
|
2867, 3197
|
275, 291
|
391, 1617
|
1639, 2426
|
2442, 2674
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,527
| 131,845
|
51812
|
Discharge summary
|
report
|
Admission Date: [**2174-10-26**] Discharge Date: [**2174-11-18**]
Date of Birth: [**2129-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex / Methotrexate / Zofran
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2174-11-1**] Mitral valve repair with mitral valve annuloplasty with
a 30-mm Physio II annuloplasty ring and a mitral valve
commissuroplasty.
.
[**2174-10-30**] Extraction of tooth #19
History of Present Illness:
Mr. [**Known lastname 18473**] is a 45 year old male with PMHx significant for
lupus, ESRD on hemodialysis (Tues/Thurs/Saturday) awaiting renal
transplant, and congestive heart failure secondary to severe
mitral regurgitation, who was recently admitted for shortness of
breath and chest pain with flat cardiac enzymes. During his last
admission his shortness of breath was attributed to his mitral
regurgitation and chronic renal failure. He was evaluated by
cardio-thoracic surgery and was found to be a surgical
candidate; however he left before complete evaluation given his
mother's death. He subsequently presented to the ED with
worsening dyspnea and shortness of breath at rest. Has had
multiple admissions for same complaints. Patient stated that he
had severe orthopnea. His chest pain was unchanged for the past
several months. He was subsequently admitted for management of
dyspnea and workup for mitral valve surgery.
Past Medical History:
- Chronic Diastolic Congestive Heart Failure
- Mitral REgurgitation
- Pulmonary Hypertension
- ESRD secondary to SLE vs FSGS, currently on the transplant
list
- SLE diagnosed in [**2162**]
- Hypertension
- Reflex sympathetic dystrophy
- Osteonecrosis of the foot
- Right ankle avascular necrosis
- GERD
- Panic attacks
- s/p Multiple AV fistula surgeries
- s/p laparoscopic cholecystectomy
- T&A as child
- Right foot bunionectomy
- Peritoneal catheter placement and subsequent removal
Social History:
Lives with 6 year old son in [**Name (NI) 1474**]. Has good relationship
with ex-wife. Retired. [**Name2 (NI) **] smoker with 30pk-yr smoking
history. Denies etoh, illicits. Mother recently died of bone
cancer.
Family History:
Several family members with autoimmune disorders. Denies history
of premature coronary artery disease.
Physical Exam:
On Admission:
VS: T 98 BP 112/91 P 76 100% RA
GENERAL: NAD, comfortable
HEENT: PERRL, EOMI, OP clear
NECK: Supple, JVD not evaluated
CARDIAC: RRR, III/VI holosystolic murmur, loudest at apex, w
loss of S2 and radiation to axilla, also heard at left carotid,
no carotid bruits
LUNGS: Resp unlabored, decreased breath sounds throughout,
crackles at bases
ABDOMEN: Soft, NT/ND.
EXTREMITIES: No c/c/e.
SKIN: dry skin
PULSES: DP 2+ PT 2+ bilaterally
Pertinent Results:
Chest CT Scan [**2174-10-27**]:
Moderate nonhemorrhagic layering left and small nonhemorrhagic
layering right pleural effusions. Associated left greater than
right bibasilar opacification, likely atelectasis. Moderate
cardiomegaly.
TEE [**2174-11-1**]:Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. Moderate (2+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. The mitral valve leaflets do not fully
coapt. Severe (4+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen.
POSTBYPASS
The patient is receiving epinephrine infusion at 0.3 ucg/kg/min
LV systolic function is borderline in the setting of inotropes.
RV systolic function now appears normal. There is a ring
prosthesis in the mitral position. Residual MR is now mild to
moderate. (1+-2+). The AI and TR are unchanged from prebypass.
The remaining study is unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**],
MD, Interpreting physician
Cardiac Cath [**2174-10-28**]:
1. Coronary angiography in this right dominant system
demonstrated no
angiographically-apparent flow-limiting stenosis. The LMCA was
patent.
the LAD had a mid 30% stenosis and a 40% D1. The LCX was patent.
The RCA
had a proximal 30% stenosis.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP 13 mmHg and LVEDP of 22 mmHg. Thre was
moderate
pulmonary arterial systolic hypertension with PASP of 58 mmHg.
The
cardiac index was preserved at 2.9 l/min/m2. There was normal
arterial
systolic and dyastolic pressures at the aortic level 98/64 mmHg.
3. Left ventriculography was deferred.
.
ADMIT LABS:
[**2174-10-26**] WBC-7.6 RBC-3.28* Hgb-9.3* Hct-29.3* RDW-18.5* Plt
Ct-270
[**2174-10-26**] PT-23.7* PTT-31.1 INR(PT)-2.3*
[**2174-10-26**] Glucose-85 UreaN-31* Creat-10.9* Na-138 K-7.7* Cl-99
HCO3-24
[**2174-10-26**] CK(CPK)-102
[**2174-10-26**] CK-MB-1 cTropnT-0.03* proBNP-[**Numeric Identifier 107266**]*
[**2174-10-27**] Albumin-3.5 Calcium-8.6 Phos-5.6* Mg-1.9
[**2174-10-27**] %HbA1c-4.6* eAG-85*
Brief Hospital Course:
Mr [**Known lastname 18473**] was transferred to [**Hospital1 18**] on [**2174-10-16**] for evaluation
of Mitral Valve replacement. His preoperative workup included
tooth extraction by OMFS. Cardiac cath revealed no obstructing
coronary lesions. Renal was consulted as Mr.[**Known lastname 18473**] has end
stage renal disease, is hemodialysis dependent and is awaiting
transplant.
On [**2174-11-1**] he was taken to the operating room and underwent
Mitral valve repair with mitral valve annuloplasty with a 30-mm
Physio II annuloplasty ring and a
mitral valve commissuroplasty with Dr. [**Last Name (STitle) **]. Cardiopulmonary
Bypass time= 79 minutes. Cross Clamp time=46 minutes. Please
refer to operative report for further surgical details. Of note,
his tunnel line catheter was noted to be displaced while
prepping. It was sutured down for protection. He tolerated the
procedure well and was transferred to the CVICU intubated and
sedated. He awoke neurologically intact and weaned to
extubation. He was weaned off inotropic and pressor support and
ultimately started diuresis.Postoperative heart block was noted
and Beta-blocker held. POD#1 he was started on CVVHD secondary
to hyperkalemia and volume removal. With improving hemodynamic
stability CVVHD was converted to hemodialysis. Steroids were
resumed for his SLE. Anticoagulation was resumed for atrial
fibrillation. All lines and drains were removed per protocol.
POD#3 he was transferred to the step down unit for further
monitoring. Multiple attempts to gain access via IR/Transplant
team were attempted and thwarted by the patient. A temporary
groin catheter was placed and HD was resumed. During this time,
anticoagulation was held for placing indwelling catheter.
Mr.[**Known lastname 18473**] was placed empirically on antibiotics for temperature
spikes and was fully cultured. A positive urine culture grew
Proteus while all other cultures are no growth to date.
[**11-15**] He was taken to the OR for IR tunnel line placement in his
right groin. Post procedure anticoagulation was resumed for SLE
as well as atrial flutter/line patency.
Physical Therapy was consulted for evaluation of strength and
mobility. On [**11-16**], a portion of his sternal wound was opened at
bedside for developing drainage. He was placed on IV vanco and
cefepime x 2 weeks per the recommendation of Infectious Disease.
On the day of discharge his ABx regimenwas simplified to vanco
and ceftaz with HD to comeplete a 2 week course. Wound cultures
had no growth at the time of discharge. He was cleared for
discharge to home with services on POD #17. All follow up
appointments were advised. Social work was following and the
patient states he is to contact his parole officer regarding his
discharge plans (see social work note for details).
His PICC line was removed at time of discharge as his abx will
be given during HD and labs will also be drawn at that time.
Medications on Admission:
- Chloroquine 250mg daily
- Albuterol / ipratropium inhaler
- ASA 81mg daily
- B complex / Folic Acid
- Atenolol 50mg daily
- Nexium 40mg [**Hospital1 **]
- Fluticasone INH 2 spray
- Coumadin 1mg daily (for SLE)
- Oxycodone 15mg q4hrs prn pain
- Ativan 2mg [**Hospital1 **] prn anxiety
- Trazodone 50mg qhs prn insomnia
- Prednisone 5mg daily
Discharge Medications:
1. ceftazidime 1 gram Recon Soln Sig: One (1) gm Intravenous
with HD for 12 days: 2 week course from [**2174-11-16**].
2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol) for 12 days: 2 week
course from [**2174-11-16**].
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. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. chloroquine phosphate 250 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID ().
Disp:*60 Tablet Extended Release(s)* Refills:*2*
11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 mdi* Refills:*2*
12. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-28**] Sprays Nasal
TID (3 times a day).
Disp:*1 vial* Refills:*2*
13. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*2*
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for wheezing.
Disp:*1 MDI* Refills:*0*
16. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) puff Inhalation twice a day.
Disp:*1 MDI* Refills:*2*
17. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
18. Coumadin 2.5 mg Tablet Sig: as directed based on INR Tablet
PO once a day: Indication SLE
Goal 2.0-3.0.
Disp:*60 Tablet(s)* Refills:*2*
19. lidocaine HCl 2 % Solution Sig: Ten (10) ML Mucous membrane
TID (3 times a day) as needed for tongue pain.
Disp:*120 ML(s)* Refills:*0*
20. Outpatient Lab Work
Goal INR 2.0-3.0
First draw [**2174-11-19**] at HD
Results to Dr. [**Last Name (STitle) 107267**] at South Suburban phone [**Telephone/Fax (1) 8729**];
fax [**Telephone/Fax (1) 92586**]
21. HD tunnel line
Care and flushes of HD tunnel line per protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
- Mitral Regurgitation, s/p MV repair
- Chronic Diastolic Congestive Heart Failure
- End Stage Renal Disease(secondary to SLE versus FSGS)
- SLE diagnosed in [**2162**]
- Hypertension
- s/p Multiple AV fistula surgeries
- atrial flutter
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - Surgically opened 4cm long by 1cm wide at mid
section-clean beefy red bed. No erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
No edema.
Right HD line in groin- clean at insertion site
Discharge Instructions:
Please wash incisions daily 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**
Labs: PT/INR for Coumadin ?????? indication SLE
Goal INR 2.0-3.0
First draw [**2174-11-19**] at HD
Results to Dr. [**Last Name (STitle) 107267**] at South Suburban phone
[**Telephone/Fax (1) 8729**];fax [**Telephone/Fax (1) 92586**]
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] on [**12-7**] at 1:15pm in the [**Hospital **] medical
office building [**Doctor First Name **] Suite2A
Wound check [**2174-11-25**] at 10:00am in the [**Hospital **] medical office
building [**Doctor First Name **] Suite2A
Cardiology: Dr [**Last Name (STitle) 88768**] [**Name (STitle) 10102**] (cards at [**Location (un) 2274**] in [**Location (un) 38**]) on
[**12-19**] at 3:40pm
Dr.[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2174-12-19**]
10:40
Provider [**Name9 (PRE) 2105**] [**Name9 (PRE) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-1-6**] 10:40
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) **] in [**3-1**] weeks
.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication SLE
Goal INR 2.0-3.0
First draw [**2174-11-19**] at HD
Results to Dr. [**Last Name (STitle) 107267**] at South Suburban phone [**Telephone/Fax (1) 8729**];
fax [**Telephone/Fax (1) 92586**]
Completed by:[**2174-11-18**]
|
[
"416.0",
"428.33",
"998.59",
"521.00",
"518.51",
"458.29",
"V45.11",
"599.0",
"403.91",
"585.6",
"710.0",
"424.0",
"427.31",
"276.7",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"38.93",
"39.95",
"86.05",
"88.56",
"38.95",
"37.23",
"39.61",
"23.19"
] |
icd9pcs
|
[
[
[]
]
] |
11595, 11650
|
5514, 8440
|
307, 497
|
11931, 12270
|
2797, 5491
|
13324, 14673
|
2211, 2315
|
8835, 11572
|
11671, 11910
|
8466, 8812
|
12294, 13301
|
2330, 2330
|
260, 269
|
525, 1457
|
2344, 2778
|
1479, 1966
|
1982, 2195
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,825
| 134,164
|
13990+13991+13992
|
Discharge summary
|
report+report+report
|
Admission Date: [**2158-7-24**] Discharge Date: [**2158-7-27**]
Date of Birth: [**2124-11-7**] Sex: M
Service: [**Hospital1 **]-MED
HISTORY OF PRESENT ILLNESS: The patient is a 33 year old
homosexual male with medical history significant for asthma,
chronic headaches and internal and external hemorrhoids
status post banding times five, with most recent banding in
[**2158-3-4**]. He presented with two weeks of worsening
bright red blood per rectum, fatigue and three episodes of
syncope.
The patient reports that he has had chronic internal and
external hemorrhoids since his teenage years and the rest of
his immediate family members also suffer from them. He has
had rectal bleeding for years, and he believes anxiety,
stress, caffeine and hot weather exacerbates the bleeding, as
well as large bowel movements; however, in the past two
weeks, he has experienced increased bright and dark red blood
per rectum, approximately three times a day. At times, the
bright red blood per rectum is mixed with stool, and at other
times it is just blood. However, he denies any history of
melena or dark, tarry stools and reports no hematemesis.
On [**2158-7-8**], the patient states that he felt warm,
lightheaded, developed a headache, and subsequently had a
syncopal episode with a fall down a flight of stairs. He did
not suffer any lasting acute trauma from this event.
His second syncopal event occurred on [**2158-7-20**], when he
experienced "hot flashes" and headaches, and later awoke on
the bathroom floor.
Most recently, on [**2158-7-24**], his date of admission, he woke
up in the a.m. with a headache, nausea, which resulted in a
green-yellow vomitus and had a syncopal event. The patient
then presented to the [**Hospital1 69**]
Emergency Department for evaluation and treatment.
In the Emergency Department, the patient was evaluated for
his multiple syncopal episodes. He also complained of rectal
discomfort with bowel movements, crampy lower abdominal pain
radiating to the rest of the abdomen, sometimes relieved with
bowel movements. The patient noted that he had had
constipation a few days ago but had been experiencing
diarrhea recently.
His vital signs in the Emergency Department were as follows:
Temperature 97.2 F.; heart rate 91; blood pressure 121/75;
respiratory rate 16; oxygen saturation 100% on room air. This
patient appeared pale, but resting comfortably and in no
acute distress. A nasogastric lavage was negative for blood.
External hemorrhoids were noted on physical examination and
he was guaiac positive. The rest of his physical exam was
unremarkable.
Moreover, an EKG demonstrated sinus tachycardia at the rate
of 122, with ST depressions noted in leads II, III, AVF, and
V4 through V6. The complete blood cell count came back with
a white blood cell count of 18.5, platelet count 310, and
hematocrit of 12.2.
Therefore, the patient was transfused two units of packed red
blood cells, and admitted to the Medical Intensive Care Unit
for close management and treatment.
PAST MEDICAL HISTORY:
1. Internal and external hemorrhoids: The patient reports
having had hemorrhoids since his teen years, prevalent among
his family members. [**Name (NI) **] is status post banding times five,
with most recent banding in [**2158-3-4**] by Dr. [**Last Name (STitle) 3314**].
Last colonoscopy in [**2154**]. He indicates that bleeding has
become more frequent for the last two weeks.
2. Rectal Prolapse: Intermittently reduced by the patient t
home.
3. Chronic headaches.
4. Status post trauma to the head in [**2158-4-4**]: This
occurred at work at [**University/College **] [**Location (un) **], when a speaker on
stage hit his head. CT scan of the head and cervical spine
films, and MRI of cervical spine were all negative.
5. Asthma: Controlled on Albuterol.
ALLERGIES: No known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Albuterol.
2. Flovent.
3. Advil.
SOCIAL HISTORY: The patient reports an eleven pack year
smoking history; he is still a smoker. He denies any alcohol
or illicit drug use. He identifies himself as a homosexual
male, reports being active in receptive anal intercourse.
Reports intermittent condom use. Works as a costume
technician. Lives in [**Location **]. He is single with no
children.
FAMILY HISTORY: Pertinent for hemorrhoids, pancreatic and
breast cancer. No history of colon cancer. History of
thalassemia [**Doctor First Name **] in his mother.
PHYSICAL EXAMINATION: Upon admission, vital signs were
temperature of 98.6 F.; blood pressure 120/66; heart rate 74;
respiratory rate 20; oxygen saturation 98% on room air.
General appearance: Resting comfortably in bed in no acute
distress. Appears stated age, thin, pale, pleasant. HEENT:
Normocephalic, atraumatic. Sclerae anicteric, noninjected.
No lesions noted in oropharynx. Pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. No rhinorrhea noted. Neck: Soft, trachea midline;
jugular veins flat. No thyromegaly. No lymphadenopathy.
Chest clear to auscultation bilaterally. Heart regular,
audible but distant S1 and S2 heart sounds. No murmurs, rubs
or gallops noted. Abdomen: Soft, nondistended, positive
bowel sounds. Mild mid-epigastric tenderness. No
hepatosplenomegaly. Back with no costovertebral angle
tenderness bilaterally. Rectal examination with prominent
external hemorrhoids noted. The rest of the examination is
deferred. Pulses: Two plus radial pulses and palpable two
plus pedal pulses bilaterally. Extremities with no
peripheral edema. Neurological: Alert and oriented times
three; cranial nerves II through XII intact. Dermatologic:
No lesions appreciated.
LABORATORY AND PERTINENT STUDIES: Complete blood cell count
on transfer to the General Medicine Floor demonstrated a CBC
with white blood cell count of 9.5, hematocrit 29.5, platelet
count 197. Serum chemistry showed a sodium of 141, potassium
4.0, chloride 110, bicarbonate 25, BUN 8, creatinine 0.7,
glucose 85.
Calcium 9.1, phosphorus 3.9, magnesium 2.0. Urinalysis was
negative.
Esophagogastroduodenoscopy on [**2158-7-25**], was normal
esophagus, normal stomach, normal duodenum; no signs of
gastrointestinal bleed.
Colonoscopy on [**2158-7-25**]: Normal colon; no sign of lower GI
bleed.
Abdominal ultrasound on [**2158-7-27**], with normal abdominal
ultrasound.
Small bowel follow through on [**2158-7-28**]: Normal small bowel
follow through.
Head CT scan with contrast on [**2158-7-26**], with no evidence of
chronic subdural hematoma or intracranial mass effect. There
is a small mucous retention cyst or poly in the sphenoid
sinus and a few opacified ethmoid air cells; otherwise
normal.
SUMMARY OF HOSPITAL COURSE:
1. GASTROINTESTINAL BLEED: The patient was admitted
directly to the Medical Intensive Care Unit on [**2158-7-24**],
for an acute gastrointestinal bleed and symptomatic anemia
requiring two units of packed red blood cells in the
Emergency Department.
In the Medical Intensive Care Unit course, the patient
received a total of four units of packed red blood cells and
was started on pantoprazole 40 mg intravenously q. 24 hours.
The patient continued to have bright red blood per rectum and
the Gastrointestinal Consultation Service was notified. On
[**2158-7-25**], an esophagogastroduodenoscopy and colonoscopy
were performed.
The esophagogastroduodenoscopy was normal and demonstrated no
cause of upper gastrointestinal bleed. The colonoscopy
revealed a normal appearing colon with the stigmata of recent
bleeding and his internal and external hemorrhoids.
Following these studies, Mr. [**Known lastname **] was stabilized and
transferred to the floor for further evaluation and
management on [**2158-7-25**]. Overnight, however, his hematocrit
dropped from 29.5 to 25.6, and he received another unit of
blood in the early morning of [**2158-7-26**]. His hematocrit
subsequently rose back to the level of 30.5.
Subsequently, the patient received a small bowel follow
through which was unremarkable and revealed no source of
bleeding in the small bowel.
Given these studies, the most likely bleeding source was
thought to be his internal and external hemorrhoids. Of
note, the patient reports that he can hold the blood in,
suggesting accumulation of blood from the internal
hemorrhoids.
The patient was informed of the importance of reducing trauma
to his rectum and advised of the risks involved in receptive
anal intercourse. Moreover, Dr. [**Last Name (STitle) 3314**] from Surgery was
consulted and at the time of this dictation, the patient was
being evaluated for possible inpatient versus outpatient
hemorrhoidectomy. The further results of his surgical
decision making and hospital course will be dictated in a
separate addendum to this report.
2. CHRONIC HEADACHES: The patient reports more acute
headaches status post trauma to this head in [**2158-4-4**].
Previous headaches had been more diffuse and dull, but
recently the headache has been more focal to the occipital
region, with a sharp quality, rating a ten out of ten on the
pain scale.
He received a head CT scan with contrast which was normal,
and was evaluated by the Neurology consultation service.
They indicated that a head MRI would not be necessary as this
appeared to be an acute on chronic headache with a component
due to post-concussive syndrome. There also seems to be an
underlying anxiety and depression, which have exacerbated the
headache.
They recommended outpatient follow-up with a psychiatrist.
Additionally, the patient was started on Sertraline 50 mg
p.o. q. day.
At this time of this dictation, arrangements were being made
to link the patient to an outpatient psychiatrist or
outpatient program.
3. ASTHMA: The patient's asthma was well controlled on
inhaled steroids and albuterol throughout the hospital
course.
4. SYNCOPE: The multiple syncopal episodes were thought to
be most likely secondary to hypovolemia and anemia. Once the
patient's hematocrit and volume status was under control,
there were no other incidences of syncope.
5. ABDOMINAL PAIN: The patient complained of right upper
quadrant abdominal pain, with positive [**Doctor Last Name 515**] sign;
however, there were no fevers or leukocytosis noted. Given
the patient's acute gastrointestinal bleed, a right upper
quadrant ultrasound was performed which was normal. His pain
was controlled alternately with Tylenol 325 to 650 mg p.o. q.
day and Ultram.
The rest of the hospital course including condition on
discharge, discharge status, discharge diagnosis and
discharge medications with follow-up plans will be dictated
as an addendum to his dictation summary by a second
physician.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 41068**]
MEDQUIST36
D: [**2158-7-27**] 17:01
T: [**2158-8-9**] 21:31
JOB#: [**Job Number 41790**]
cc:[**Last Name (NamePattern4) **] Admission Date: [**2158-7-24**] Discharge Date: [**2158-8-3**]
Date of Birth: [**2124-11-7**] Sex: M
Service: MICU WEST
The date of transfer to the Floor is [**2158-7-25**].
HISTORY OF PRESENT ILLNESS: This is a 33 year old male with
a history of hemorrhoids since his teens requiring multiple
bandings, who presents with rectal bleeding, syncope, and
vomiting with a hematocrit of 12.2 in the Emergency
Department. This patient reports waking up and having a
bowel movement with bright red to dark blood mixed in the
stool, loose stools times two days, feeling lightheaded and
nauseous and then subsequently passing out and awakening in a
puddle of vomit. His friends convinced him to come to the
[**Hospital1 69**].
He reports having blood per rectum for many many years, but
it has been increasing in frequency over the past couple of
weeks. He has been having loose stools as well for the past
couple of days, so with every bowel movement he has bleeding
and then even at times he will have bleeding from his rectum
without bowel movements. He reports cramps in his abdomen
which are relieved after bowel movements. Symptoms of reflux
disease. No melena, no hematemesis.
In addition, he reports feeling short of breath, tired, weak,
headachy, having a lack of energy. Additionally this patient
reports using advil and Tylenol alternating between the two,
of using up to 400 mg of Advil every four hours for the past
several months for his headaches.
No sick contacts, no travel, no contaminated food.
In the Emergency Department, he was lavaged through an
nasogastric tube with air and then with 50 cc of normal
saline and it was a negative lavage.
PAST MEDICAL HISTORY:
1. Significant for hemorrhoids since his teens.
2. He reports a flexible sigmoidoscopy in [**2154**] that was
normal.
3. He has had five bandings of hemorrhoids since [**2154**].
4. He also reports a history of asthma for which he takes
albuterol and Flovent.
MEDICATIONS:
1. Albuterol and Flovent.
2. Motrin 400 mg alternating with Tylenol q. four hours for
headaches for the past several months.
3. Multivitamins.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No alcohol and no drugs. Smokes one pack a
day times ten years. He is single. He is a costume
technician and lives in [**Location **].
FAMILY HISTORY: Significant for his mother with beta
thalassemia, hemorrhoids and a sister with hemorrhoids as
well. No history of colon cancer or inflammatory bowel
disease in his family.
CODE STATUS: Full.
PHYSICAL EXAMINATION: On physical examination, vital signs
were temperature of 97.2 F.; blood pressure 121/75; heart
rate 100; respiratory rate 19; O2 saturation 100% on two
liters nasal cannula. In general, this is a pale man,
resting in bed, conversing appropriately. No stigmata of
liver disease. HEENT: Normocephalic, atraumatic. Pupils
are equal, round and reactive to light. Clear oropharynx.
Positive angular chilosis. No cervical lymphadenopathy.
Pale conjunctivae. Cardiovascular is regular rate,
tachycardia, flow murmur II/VI systolic ejection murmur in
the right sternal border. Chest clear to auscultation
bilaterally. Abdomen is soft and nontender. Bowel sounds
present. Mid epigastric pain with deep palpation. Smooth
liver edge. His extremities were warm, no clubbing or edema.
Capillary refill about three seconds. On rectal examination,
there is no stool in the vault to guaiac but no external
fissures, no external hemorrhoids.
LABORATORY: White blood cell count 18.5, hematocrit 12.2,
with an MCV of 62, platelets 310. Coagulation studies were
within normal limits. Liver function tests within normal
limits. Electrolytes were sodium 139, potassium 4.1,
chloride 107, bicarbonate 23, BUN 16, creatinine 0.6, and
glucose 111 with an anion gap of 9.0. Troponin was less than
0.01.
Iron studies with iron 7.0, ferritin 1.4, TRS 415, calculated
TIBC 540.
HOSPITAL COURSE WHILE IN THE MEDICAL INTENSIVE CARE UNIT:
The patient was transfused four units of packed red blood
cells with a subsequent bump in his hematocrit to 21.7. He
was then transfused another two units of packed red blood
cells for a hematocrit of 29.6. He also received GoLYTELY
for a colonoscopy the next day.
The colonoscopy showed external hemorrhoids with stigmata of
recent bleeding. The impression of the colonoscopy was mixed
hemorrhoids, otherwise normal colonoscopy to the cecum.
Recommendations were follow-up with surgeon for banding;
follow-up with referring physician as needed. In addition,
the patient received an esophagogastroduodenoscopy which
showed a normal esophagus, normal stomach, normal duodenum
with impression of normal esophagogastroduodenoscopy to the
third part of the duodenum.
Both the colonoscopy and esophagogastroduodenoscopy were
performed on [**7-25**].
Subsequently, the patient was found to be hemodynamically
stable with a hematocrit of 29.6 with a normal EGD and
hemorrhoids found on colonoscopy and resolution of symptoms.
Thus, the patient was transferred to the floor for further
observation and also a small bowel follow through was to be
done on the floor to rule out small bowel causes of bleeding.
On the day of transfer on [**7-25**], the patient was
complaining of headache present since [**Month (only) 547**] since injury on
the job to his head.
He was seen in the Emergency Department right after the
injury and no bleeding was found on the CT scan of the head.
Please see the full report on CCC. The patient also had an
MRI of the spine and was essentially normal but please see
the full report in the computer.
The patient was seen and examined by me, the intern, and the
patient reports constant headache since [**Month (only) 547**], pain 10 out of
10, on the scale of 10, decreasing to about a 6 out of 10
when he takes Tylenol or Motrin. This is primarily a
posterior headache, posterior in his head. The patient
reports seeing black spots but no other photophobia or
worsening was found.
The patient reports some slight weakness and some sensory
changes in his arms, primarily left more than right, however,
on neurological examination strength was five out of five
throughout upper extremities and lower extremities.
Sensation was intact to both touch and pinprick and cold.
Reflexes were two plus throughout biceps, brachioradialis,
patellar, Achilles bilaterally. Cerebellar examination was
normal finger-to-nose, normal heel-to-shin, no dictyokinesis
bilaterally.
Recommend outpatient follow-up with his primary care
physician for these chronic headaches.
CONDITION ON TRANSFER TO THE FLOOR: Good.
TRANSFER DIAGNOSES:
1. Lower gastrointestinal bleed secondary to hemorrhoids.
TRANSFER MEDICATIONS:
1. Continuation of Albuterol and Flovent per his primary
care physician.
DISCHARGE INSTRUCTIONS:
1. He is to follow-up with his primary care physician for
evaluation of chronic headache.
2. He is to follow-up with his surgeon, Dr. [**Last Name (STitle) 3314**], phone
number [**Telephone/Fax (1) 41791**], for further surgical management of his
hemorrhoids.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 9789**]
MEDQUIST36
D: [**2158-7-26**] 15:54
T: [**2158-8-3**] 22:53
JOB#: [**Job Number 41792**]
cc:[**Last Name (NamePattern1) 41793**] Admission Date: [**2158-7-24**] Discharge Date: [**2158-8-3**]
Date of Birth: [**2124-11-7**] Sex: M
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old
homosexual male with a history of internal and external
hemorrhoids with associated bright red blood per rectum which
he had intermittently and attributed to hemorrhoids for some
time, but over the last two weeks he has had increasing
bright and dark red blood per rectum for about three times
per day; sometimes pure blood and sometimes in stool. No
melena, and no hematemesis. He also complains of some rectal
discomfort when having bowel movements and some crampy lower
abdominal pain radiating to the rest of the abdomen and
sometimes relieved with bowel movements.
He notes that he was constipated a few days ago, but now
having more loose stools and diarrhea. He has also had three
syncopal events over the last three days. The last one
occurred in the morning on the day of admission, and he had
some yellow-green emesis. No fevers, chills, or night
sweats. No changes in his weight. No travel history. No
unusual food intake.
He came into to the Emergency Department where his hematocrit
was noted to be 12%. His heart rate was 122, and his blood
pressure was 121/75. He had an nasogastric lavage which was
negative in the Emergency Room.
PHYSICAL EXAMINATION ON PRESENTATION: On examination,
temperature was 97.2 degrees Fahrenheit, heart rate was 122,
blood pressure was 121/75, respiratory rate was 16, and
oxygen saturation was 100% on room air. In general, he was a
pale-appearing white male sitting in bed, in no acute
distress. Head, eyes, ears, nose, and throat examination
revealed sclerae were white. The mucous membranes were
moist. Neck examination revealed no adenopathy.
Cardiovascular examination revealed a regular rhythm,
tachycardic. A soft 1/6 systolic murmur at the left sternal
border. Chest was clear to auscultation bilaterally. The
abdomen was soft, nontender, and nondistended. Normal active
bowel sounds. Extremities were without edema. Rectal
examination revealed no masses or hemorrhoids palpated. No
stool for guaiac. Neurologic examination revealed alert and
oriented times three.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 18.5, hematocrit was
12.2%, and platelets were 310. RDW was 17.1. Mean cell
volume was 62. Differential with 84% neutrophils, 10%
lymphocytes, and 5% monocytes. Prothrombin time was 13.1,
INR was 1.1, and partial thromboplastin time was 19.8.
Sodium was 139, potassium was 4.1, chloride was 107,
bicarbonate was 23, blood urea nitrogen was 16, and
creatinine was 0.8.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL ISSUES: The patient with a history of
internal and external hemorrhoids who presented with
recurrent bright red blood per rectum and syncopal episodes.
Noted to have a hematocrit on admission of 12.2. His
hematocrit on [**2157-5-15**] was 41% He was transfused to keep
his hematocrit at greater than 24% and received a total of 6
units of packed red blood cells.
He had an esophagogastroduodenoscopy and colonoscopy which
was only significant for internal hemorrhoids with a stigmata
of recent bleeding.
His hematocrit after 6 units of packed red blood cells bumped
appropriately from 12.2% to 30%. He remained hemodynamically
stable but was admitted initially to the Medical Intensive
Care Unit for a severely decreased hematocrit on admission.
He left the Medical Intensive Care Unit on the same day (on
[**7-24**]) and received an additional one unit of packed red
blood cells after leaving the Intensive Care Unit.
He has had multiple banding procedures in the past, and
engaged in anal intercourse, but denies putting any foreign
bodies in the anal canal.
After being transferred from the Medical Intensive Care Unit
to the floor on [**7-24**], his hematocrit remained in the low
20s to 30s and remained stable on the floor.
2. NEUROLOGIC ISSUES: The patient complained of pulsating
posterior headaches since [**Month (only) 547**] of this year after hitting
his head. Neurology was consulted and suggested the patient
had a post-tussive headache or migraine headache. He was
started on Imitrex which subsequently relieved his headache
and Zoloft for depression.
3. URINARY RETENTION ISSUES: After having an internal
hemorrhoidectomy on [**8-2**], the patient had some urinary
retention and was noted to have a residual of 800 cc after
anesthesia. He had a Foley catheter in for 24 hours after
surgery, and after pulling the Foley catheter the patient
voided on his own prior to going home.
4. PAIN ISSUES: The patient had some rectal pain after
surgery which was controlled postoperatively on Percocet.
The patient was sent home on Percocet for control of pain.
CONDITION AT DISCHARGE: Condition on discharge was stable.
CODE STATUS: The patient is a full code.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed secondary to internal
hemorrhoids.
2. Status post internal hemorrhoidectomy.
MEDICATIONS ON DISCHARGE:
1. Dibucaine one application topically as needed (for
rectal pain).
2. Zoloft 50 mg by mouth once per day.
3. Imitrex 25 mg by mouth q.2h. as needed (for headaches);
may be repeated every two hours up to a total of 100 mg; do
not exceed 200 mg to 300 mg per day.
4. Colace 100 mg by mouth twice per day.
5. Iron 325 mg by mouth once per day.
6. Ambien 5 mg by mouth q.h.s. (for insomnia).
7. Nicotine patch 21-mg transdermally once per day.
8. Percocet 5/325 one to two tablets by mouth q.4-6h. as
needed (for pain).
9. Flovent 110-mcg inhaler 2 puffs inhaled twice per day.
10. [**Last Name (un) **] baths three times per day.
11. Metamucil one tablespoon with a glass of water twice per
day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 3314**] in two
weeks.
2. The patient was also to follow up with his primary care
physician (Dr. [**Last Name (STitle) 2539**] in two to four weeks.
3. The patient was instructed to call if he noted a marked
increase in bleeding, or dizziness upon standing, or
shortness of breath.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 5819**]
MEDQUIST36
D: [**2158-8-3**] 16:53
T: [**2158-8-12**] 04:57
JOB#: [**Job Number 41794**]
|
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81,025
| 162,484
|
37197
|
Discharge summary
|
report
|
Admission Date: [**2168-12-20**] Discharge Date: [**2168-12-24**]
Date of Birth: [**2125-1-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
CHIEF COMPLAINT: BACTEREMIA
REASON FOR MICU ADMISSION: HYPOTENSION
Major Surgical or Invasive Procedure:
Removal of right tunneled HD line
Placement of new right tunneled HD line
History of Present Illness:
-- per admitting MICU resident --
Mr [**Known lastname 1024**] is a 43 year old man with past medical history
significant for EtOH cirrhosis, c/b severe esophagitis, ESRD due
to Hepatorenal syndrome, presenting with bacteremia from
dialysis unit.
.
Patient had blood cultures obtained on [**12-17**] for low grade temps
(99 at HD). Patient had remained asymptomatic with exception of
some tenderness at catheter site. Denies any drainage or oozing
from catheter. Today, while at his dialysis unit ([**Doctor Last Name **] at
[**Location (un) 5028**], RI, T/Th/Sat), ~4L were diuresed and blood cultures
returned positive for MRSA ([**12-20**] collected on [**12-17**]). HD line was
also noted to be loose but with good flow. Patient received a
dose of Vancomycin and Gentamycin and given appearance of
tunneled line, he was referred to [**Hospital1 18**] for removal of the
central line.
.
In the ED, vital signs were initially: 97.9 115 82/44 16 100.
Renal and IR teams were consulted and line was removed and sent
for culture. Lactate was noted to be 5.5, WBC 12.6. New cultures
were obtained and patient was admitted to MICU for further
management.
At time of Transfer, HR 89 79/41 16 100% RA.
Past Medical History:
(#) MRSA bacteremia [**10-22**] treated with vancomycin
(#) EtOH abuse with h/o seziures ? during intoxication
(#) EtOH Liver disease-- acute EtOH hepatitis in [**8-26**] (was not
started on corticosteroids due to GI bleed, UTI and [**Last Name (un) **]); was
started on pentoxyphyline to prevent HRS with a planned 4 week
course from [**2168-9-26**] (last day [**2168-10-24**]); negative hepatitis A, B
and C serologies.
(#) Hemodialysis dependent-- since last admission, dx
multifactorial with ATN +/- NSAIDs +/- HRS; HD through tunneled
line TuThSat
(#) Gastroesophageal Reflux Disease
(#) Seizures in setting of heavy alcohol consumption, seen by a
neurologist who did not feel that it was a primary seizure
disorder (first [**12-26**])
(#) MVA [**3-/2153**] - Right femur fracture with [**Male First Name (un) **] placement, pelvic
fracture
(#) Asthma
Social History:
Has never smoked. Drank [**11-22**] Vodka daily until recently, but
denies drinking in the past 4 months (last drink first week of
[**Month (only) 359**]). Never has used IV drugs. Lives with girlfriend, [**Name (NI) 5627**]
[**Name (NI) 83758**] [**Telephone/Fax (1) 83759**]. Has 2 children, daughter 17, son, 16
who live with their mother who the patient is still very close
to. Pt formerly worked at Mass Electric.
Family History:
Mother - Deceased [**12-20**] alcoholic liver disease
Father - Deceased [**12-20**] [**Name2 (NI) 499**] cancer, diagnosed in his 40s. No
other family history of [**Name2 (NI) 499**] cancer.
Physical Exam:
VS: 98/96.2 73-92 82-101/34-69 14 98-100% RA
GEN: NAD, AAOx3
HEENT: scleral icterus, OP clear, MMM
RESP: CTA with diminished BS at bases bilaterally
CV: RRR c [**12-24**] SM @ LUSB
ABD: soft, distended, umbilical hernia, + fluid wave,
non-tender, +BS
EXT: 2+ edema bilaterally, WWP. No peripheral stigmata of SBE.
NEURO: Grossly intact.
Pertinent Results:
[**2168-12-20**] 12:51PM BLOOD WBC-12.1* RBC-2.47* Hgb-8.1* Hct-26.8*
MCV-109*# MCH-32.9* MCHC-30.3*# RDW-22.5* Plt Ct-104*
[**2168-12-20**] 12:51PM BLOOD Neuts-68 Bands-4 Lymphs-17* Monos-7 Eos-3
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2168-12-20**] 12:51PM BLOOD Glucose-117* UreaN-13 Creat-3.6* Na-141
K-3.8 Cl-100 HCO3-27 AnGap-18
[**2168-12-21**] 01:53AM BLOOD calTIBC-65* Hapto-<5* Ferritn-879*
TRF-50*
[**2168-12-24**] 05:35AM BLOOD WBC-9.0 RBC-2.41* Hgb-8.0* Hct-24.8*
MCV-103* MCH-33.2* MCHC-32.2 RDW-22.0* Plt Ct-119*
[**2168-12-24**] 05:35AM BLOOD Glucose-88 UreaN-17 Creat-4.2*# Na-136
K-3.9 Cl-98 HCO3-29 AnGap-13
WOUND CULTURE (Final [**2168-12-22**]):
STAPH AUREUS COAG +. >15 colonies.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- 16 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
CXR [**12-20**]: Hemodialysis catheter in stable and standard position
from a
right internal jugular approach. New left pleural effusion.
.
TTE [**12-21**]: The left atrium is mildly dilated. The right atrium is
moderately dilated. 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) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
.
RUE U/S: No evidence of DVT in the right upper extremity.
Brief Hospital Course:
43 year old man with EtOH cirrhosis c/b ESRD on HD, with new
catheter infection and MRSA bactermia, in stable condition.
.
# BACTEREMIA / HYPOTENSION / SEPSIS - Pt reports he had low
grade temps 99 at HD on [**12-17**], and tenderness at R IJ tunneled HD
line site along the tunnel. Blood Cx was drawn on [**12-17**] which
grew MRSA 2 out of 2 sets, and HD line catheter tip grew out
MRSA with identical antibiogram, suggesting this to be the
source. The line was also noted to be loose but with good flow.
Patient received a dose of Vancomycin and Gentamycin at HD on
[**12-20**] with about 4L UF. Patient with known stable hypotension,
noted to be as low as 60/40 on his hepatologists office. Noted
to have a lactate of 5.5 on admission; although his impaired
liver function may account for elevated lactate, in setting of
bacteremia it was felt this warranted MICU admission. On
admission to [**Hospital1 18**] his tunneled HD line was removed and was
admitted to the ICU for further management. He remained
hemodynamically stable with baseline low blood pressure SBP
80-90's and tachycardia 100's. He was mentating and did not
show evidence of decompensation. He also underwent a diagnostic
paracentesis that was negative (60 WBC). Patient was called out
to floor after 24 hours in ICU. He remained HDS (within his
baseline of SBP 60s-90s) and had no change in mental status.
Infectious disease consult was called for management of high
grade MRSA bacteremia. TTE was performed and showed no evidence
of endocarditis. Given his murmur on exam and recurrent
bacteremia, ID recommended TEE. This was deferred to an
outpatient setting and patient was discharged on vancomycin with
HD, with the plan for 2 weeks of abx if no e/o endocarditis on
TEE, or 6 weeks otherwise.
.
# END STAGE LIVER DISEASE - MELD Score 34 on admission, 25 on
discharge. Patient being evaluated for liver transplant,
however only 4 months sober. Continued lactulose, titrated to
[**2-21**] BM per day and Rifaximin. His mental status remained at
baseline.
# Anemia - Patient was transfused 2u pRBC while in the MICU, and
required 1 additional unit with HD while on the floor. Hct
stabilized thereafter. Patient was guaiac negative on exam with
no evidence of active bleeding.
.
# END STAGE RENAL DISEASE - Last HD session on day of
admission. His tunneled line was pulled on the day of
admission. He had it replaced by IR after a 48 hour line
holiday with no evidence of growth on blood cultures.
Medications on Admission:
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule
MIDODRINE - 7.5 mg Tablet TID
PANTOPRAZOLE - 40 mg Tablet [**Hospital1 **]
RIFAXIMIN [XIFAXAN] - 400 mg Tablet
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 bottle* Refills:*2*
6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous 3 times a week: with hemodialysis. Ongoing till
dictated by ID.
Disp:*12 gram* Refills:*0*
7. Outpatient Lab Work
Dx: MRSA bactermia
Weekly labs to be drawn while on vancomycin starting [**2168-12-29**]
CBC, vanco trough.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient
antibiotics should be directed to the infectious disease R.Ns.
at ([**Telephone/Fax (1) 1354**]
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
9. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ml PO
three times a day as needed for confusion or constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
MRSA bateremia
HD line sepsis
Alcoholic hepatitis
ESRD on HD
Discharge Condition:
stable. MS A+OX3, ambulatory
Discharge Instructions:
You were admitted to [**Hospital1 18**] because they found that bacteria were
growing in your blood at dialysis. Your exsisting hemodialysis
line was removed. Bactermia grew off of the old line making this
the likely source of infection. Echocardiogram was done which
did not show infection on her heart valve. An ultrasound of your
right arm was done which did not show clot in that area. A new
dialysis line was placed and you received 2 days of dialysis
before leaving. You will resume your normal dialysis schedule
after discharge. You will continue to receive IV antibiotics
(vancomycin) at dialysis.
.
Please follow up with your doctors as detailed below. You will
need labs drawn weekly while on vancomycin.
.
The following changes were made to your medication regimen:
STARTED Vancomycin to be given with dialysis.
STARTED Sarna lotion for itching
CONTINUE the rest of your medications as prior to
hospitalization.
Followup Instructions:
Liver: Some one from the liver center will call to arrange
follow up with [**Last Name (LF) **], [**First Name3 (LF) **] H. MD. If you are not contact[**Name (NI) **] by
Wednesday call ([**Telephone/Fax (1) 1582**].
.
Infectious disease: Someone from this department will call you
to arrange follow up. If you do not get contact[**Name (NI) **] please call
Infectious disease clinic at ([**Telephone/Fax (1) 4170**].
.
PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 50168**]. Call to schedule follow up
within 1 month.
.
Existing appointments:
Provider: [**Name10 (NameIs) 454**],SIX [**Name10 (NameIs) 454**] Phone:[**Telephone/Fax (1) 446**]
Date/Time:[**2169-1-3**] 12:30
Provider: [**Name10 (NameIs) 703**] [**Location 704**] [**Location 705**] / IOUS RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-1-3**] 2:00
Completed by:[**2168-12-25**]
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[
"54.91",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9977, 9983
|
6031, 8530
|
384, 460
|
10088, 10119
|
3589, 6008
|
11090, 12020
|
3023, 3216
|
8751, 9954
|
10004, 10067
|
8556, 8728
|
10143, 11067
|
3231, 3570
|
295, 346
|
488, 1690
|
1712, 2570
|
2586, 3007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,726
| 188,434
|
27486
|
Discharge summary
|
report
|
Admission Date: [**2188-11-4**] Discharge Date: [**2188-11-28**]
Date of Birth: [**2116-10-30**] Sex: F
Service: MEDICINE
Allergies:
Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
CVL, a-line
History of Present Illness:
patient is a 71 y/o F with PMH of ESRD on HD, recent broncial
hemorrhage, respiratory failure with trach, hx of multiple GI
bleeds, nonresponsive at baseline presenting from [**Hospital **] rehab
with coffee ground emesis and fever.
The son reports that patient has been vomitting over the past
month, nonbloody until this morning. She was brought in from
rehab for evaluation of this. patient is unable to give review
of systems. Per the notes from [**Hospital 100**] rehab: at 8pm [**11-3**] she was
febrile to 101.2, she was diaphoretic and clammy, was given
250cc NS BPs were 80s/40s. stable overnight until 545 AM, when
she had hypotension to 88/32 again, was diaphoretic. Aspiration
of Gtube feeds showed 500cc of coffee ground fluid.
Per interview with the son, she is alert and speaks when not
infected and her electrolytes are normal. She has been having
emesis 3-4 times a day for the past month. This is been slowly
improving with change in admisteration of aluminum hydroxide
(daily instead of TID). Her Ca has also been high the past few
days. Her emesis also appeared more brown the past day instead
of the color of tube fees.
In the ED, her vitals were Tmax 101.4, BP: 116-149/60-70 (left
arm), HR 60-80, 96% on 100% BiPAP. Gtube aspirated 300-400cc of
coffee ground material. She was lavaged 7-800cc water which was
persistently coffee ground. Access was very difficult given her
vasculopathy; IJ was attempted but unable to thread and
eventually a 3inch 18 guage angiocath was placed. She has a 20
guage in her left arm. She was given 10mg IM morphine,
vancomycin 1gm IV, zosyn 4.5 mgIV, Ativan 1m, 2L NS, protonix
80mg IV once. She was put in BIPAP for reasons unclear, but
possibly in the setting of morphine and ativan.
Also of note her pressure should be checked from her left arm.
Past Medical History:
1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]
Social History:
# Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. Son [**Name (NI) **] is her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use.
Family History:
Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.
Physical Exam:
vitals: T100.2 BP 93/39 P83 RR 19-28 98-100% on CPAP 50%
gen: resting, nad
pulm: diminished BS, no w/r/r
cv: hrrr, no m/r/g
abd: diffuse TTP, firm. hypoactive BS.
extr: multiple amputated toes, gangrene. No edema.
Pertinent Results:
[**2188-11-4**] CT ABDOMEN WITH INTRAVENOUS CONTRAST: The left lower
lobe is collapsed. There
are bilateral small pleural effusions. There is trace
pericardial fluid,
likely physiologic.
There are several segments of a bowel wall thickening, mucosal
enhancement,
and adjacent mesenteric edema, particularly at the distal ileum.
Some of
these bowel loops demonstrate pneumatosis.
The patient is post-resection of the right and the transverse
colon, with
ileocolic anastomosis. Small amount of perihepatic free fluid is
present.
Gallbladder is distended and contains numerous gallstones.
Kidneys are
atrophic. Pancreas and spleen are unremarkable. Gastrostomy tube
is in place.
There is no free air in the abdomen.
CT PELVIS WITH INTRAVENOUS CONTRAST: There is diverticulosis of
the sigmoid
colon without evidence of acute diverticulitis. The uterus is
atrophic. There
is a small amount of free fluid in the pelvis. The rectal wall
is thickened,
though may be in part due to nondistention.
Extensive vascular calcifications are noted in the abdomen and
pelvis. The
celiac axis and SMA are patent proximally, though there is
stenosis at the
origin of both vessels due to extensive atherosclerotic
calcification of the
abdominal aorta, which is normal in caliber. [**Female First Name (un) 899**] is not clearly
enhancing,
possibly secondary to atheroscleortic changes.
BONE WINDOWS: Demonstrate no concerning lytic or sclerotic
lesions.
IMPRESSION:
1. Findings highly concerning for mesenteric ischemia and
ischemic bowel in
the SMA territory.
2. Small amount of ascites.
3. Bilateral small pleural effusion, left lower lobe collapse.
4. Cholelithiasis; gallbladder distention can be related to the
fasting
state.
.
[**2188-11-9**] CT chest/abd/pelvis
FINDINGS:
The right brachiocephalic vein is markedly attenuated. The right
common
jugular vein appears to be normal caliber. However, there is a
clot in the
common jugular vein, series 2, image 127, which is eccentrically
positioned
and occupies approximately 50% of the lumen. The takeoff of the
right
subclavian vein is not well seen; however, an attenuated right
subclavian vein
is identified as it courses through the axilla. A left internal
jugular
central line is identified. The left brachiocephalic vein, left
internal
jugular, and left subclavian vein appear to be normal caliber.
There are
diffuse atherosclerotic changes of the arterial vessels without
evidence of
significant thrombus. The superior vena cava is slightly
attenuated in
caliber. The central line coursing through the SVC terminates at
the
SVC/right atrial junction.
There is no significant pericardial effusion. There are moderate
bilateral
pleural effusions with subjacent atelectasis, which appear to be
increased in
size from prior study dated [**2188-11-4**]. Shotty
mediastinal adenopathy
is noted. The tracheobronchial anatomy appears normal. There is
tracheostomy
tube identified. Esophagus appears unremarkable.
There is a distended gallbladder, which measures high normal in
diameter, at
4.9 cm, but is slightly decreased in diameter since the prior
study. Multiple
calcified dependent gallstones are identified. There is mild
amount of
perihepatic and perisplenic fluid. There is no focal lesion
identified in the
spleen or liver. There is no intrahepatic ductal dilatation.
There are
atrophic kidneys without evidence of hydronephrosis. The
pancreas appears
unremarkable.
There are atherosclerotic changes in the abdominal aorta, most
prominent at
series 2, image 60.
Patient is status post partial colonic resection and ileocolic
anastomosis. There are fluid filled loops of large and small
bowel with
air/fluid levels but no evidence of bowel wall thickening,
pneumotosis,
or acute transition point. There is free fluid in the right
lower quadrant as
well as the pouch of [**Location (un) **]. A gastrostomy tube is identified.
There is no
evidence of intraperitoneal free air. There is diverticulosis of
the sigmoid
colon. A right femoral venous line is identified.
There are mild degenerative changes in the thoracolumbar spine.
IMPRESSION:
1. Attenuated appearance of the right brachiocephalic vein with
poorly
delineated inflow from the right subclavian vein, possibly
representing
stenosis. Eccentric clot in a normal caliber common right
jugular vein.
Patent left brachiocephalic vein and SVC, with a left- sided
central venous
catheter coursing to the SVC/right atrial junction.
2. Ascites.
3. Increased bilateral effusions and bilateral lower lobe
atelectasis.
4. Findings suggestive of ileus, with no evidence of obstruction
or
pneumotosis.
5. Distended gallbladder with cholelithiasis.
The study and the report were reviewed by the staff radiologist.
.
CT Torso [**2188-11-25**]
CT TORSO WITH CONTRAST
INDICATION: 72-year-old woman with mesenteric ischemia, renal
failure, and
septic shock, please evaluate chest, abdomen and pelvis for
possible source of
infection and in light of clinical concern for SVC syndrome.
TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and
pelvis were
obtained with hand injection of intravenous contrast via the
left femoral
central line. Early and late arterial images were obtained.
Coronal and
sagittal reformats were performed.
COMPARISON: [**2188-11-9**].
CT CHEST: The tracheostomy is in expected location. There is no
significant
axillary or hilar adenopathy. There are multiple small shotty
mediastinal
nodes. There are large bilateral pleural effusions, not
appreciably changed.
There is adjacent atelectasis. There are no pulmonary nodules.
There is a
central line in the left internal jugular vein. There is again
posterior non-
occlusive thrombus in the right internal jugular, which is not
completely
imaged. There is a highly stenotic but patent right
brachiocephalic vein,
which is diminutive but patent distally. The distal right
subclavian vein is
diminutive but patent. There is no evidence of SVC thrombosis,
although it is
somewhat attenuated in caliber. There are diffuse vascular
calcifications.
There is cardiomegaly without pericardial effusion.
CT ABDOMEN: The study is somewhat limited as the patient's arms
were down
causing streak artifact. There is trace perihepatic and
perisplenic fluid,
less than on prior study. There is focal atrophy in segments IV
A and B of the
liver that may represent prior insult. There is no intra- or
extra- hepatic
biliary ductal dilatation. The gallbladder is distended
containing gallstones.
The pancreas and adrenals are normal. The spleen is somewhat
nodular. The
kidneys are atrophic.
The patient had prior partial colonic resection and ileocolic
anastomosis.
There is a gastrostomy tube in place. The intra- abdominal small
and large
bowel is otherwise normal. There is no free air or adenopathy.
There is diffuse anasarca.
CT PELVIS: There is sigmoid diverticulosis. There is a rectal
tube. There
is a left femoral line. There is trace free fluid in the pelvis.
The skin nodules in the anterior abdominal wall are likely due
to sub-
cutaneous injections.
The abdominal aorta is atherosclerotic as are the iliac
arteries.
There is complete or near complete occlusion of the left
external iliac
artery, with epigastric arterial collaterals. There is complete
SFA thrombosis
on the right, with some flow in the profunda femoris.
IMPRESSION:
1. Posterior non- occlusive thrombus in right internal jugular,
again seen but
incompletely imaged. Distal right subclavian and brachiocephalic
veins
diminutive but patent. No evidence of SVC syndrome.
2. No evidence of intra-abdominal abscess
3. Slight interval decrease in ascites.
4. Bilateral effusions and atelectasis are not significantly
changed.
5. Severe atherosclerotic disease as described above.
Brief Hospital Course:
On admission tot he hospital the patient was placed on broad
spectrum antibiotic with vancomycin, flagyl, levofloxacin,
zosyn, and gentamicin for coverage of GI flora, given her bowel
ischemia. oral vancomycin was also added for empitric coverage
of C.Diff colitis, given her recent history of C.Diff. She was
placed on a norepinephrine drip for hypotension. CVVH was
intiated given her hypotension. Initial Abdomenal CT showed
extensive atherosclerotic disease and calcification of her SMA,
[**Female First Name (un) 899**], and celiac axis, along with bowel distension and
pneumatosis of her bowel wall. After being hospitalized for 10
days she developed a vent associated pneumonia and was placed on
meropenem. Chest CT revealed occlusion of the right subclavian,
and brachiocephalic veins. As a result, the patient had
increased facial plethora and edema of the subcutaneous tissues
surrounding her neck. She continued to be hypotensive throughout
her hospitalization and vasopressin was added on [**2188-11-21**]. A
yeast infection was detected [**11-19**] and she was given fluconazole
IV for two days. The patient's CVVH line became infected and it
was replaced over a wire. She was placed on vancomycin and the
line was replaced. The replacement line became infected two
days later. Repeat CT Torso on [**11-25**] showed no radiographic
evidence of bowel ischemia, however the patient persisted with
intense abdominal pain with palpation. By [**11-27**] the patient
continued to be dependent on two vasopressors to maintain her
blood pressure. She was vent dependent, and on CVVH. She was
developing increased respiratory and metabolic acidosis. On
[**11-27**], after family discussion, the patient was made CMO. her
antibiotics and vasopressors were stopped. Per her son's
request, the CVVH was continued. The patient passed away at
9:40am on [**11-28**], of septic shock secondary to mesenteric
ischemia.
Medications on Admission:
Tylenol, alumnium hydroxide 45ML per gtube, B12 1', colace,
Fluticasone proprionate, Folic acid, Heparin 2500 q12h,
dilauded 0.75mg PO at dialysis, Levothyroxine 200', Lidoderm 5%
2 patch once a dat topically, Nystatin 5mL QID, albterol q6h
nebs, Dulcolax 10PRN, Iartroprium q6hours, Zofran 4 TID
Discharge Disposition:
Expired
Discharge Diagnosis:
mesenteric ischemia
septic shock
Discharge Condition:
expired
|
[
"V42.0",
"038.8",
"995.92",
"427.31",
"496",
"V44.1",
"E879.8",
"507.0",
"785.52",
"511.9",
"588.89",
"459.2",
"585.6",
"518.81",
"112.1",
"V45.11",
"008.45",
"V44.0",
"557.0",
"403.91",
"V49.72",
"482.1",
"999.31",
"276.0",
"276.2",
"997.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.33",
"39.95",
"93.90",
"38.93",
"38.91",
"38.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13568, 13577
|
11290, 13220
|
361, 374
|
13653, 13663
|
3528, 11267
|
3145, 3278
|
13598, 13632
|
13246, 13545
|
3293, 3509
|
300, 323
|
402, 2210
|
2232, 2888
|
2904, 3129
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,992
| 123,291
|
24189+57393
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-4-18**] Discharge Date: [**2124-8-3**]
Date of Birth: [**2084-2-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vicodin / Accolate
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
1. Rigid bronchoscopy, Flexible bronchoscopy, Tracheal and
bilateral bronchial stent placement (Y- stent)[**4-18**]
2. Multiple Flex bronchs with therapeutic aspiration [**2042-4-18**]
3. Rigid bronch, Flex bronch, therapeutic aspiration, foreign
body removal (Y stent) [**4-26**]
4. Tracheobronchplasty [**2124-5-3**]
5. Mult Flex Bronch with therepeutic aspiration
6. Flex bronch, Foreign body removal (granulation tissue and
sloughed
tissue from left mainstem bronchus, Bronchoalveolar lavage(LL
lobe)
7. Multiple flex brochoscopies with therepeutic aspirations
History of Present Illness:
40 year-old man with a history of HTN, stroke, DM, and
tracheobronchomalacia presents for placement of Y-stent for
prolonged history of severe shortness of breath. Symptoms
started in [**8-/2119**] when patient describes not feeling well and
being diagnosed with bilobar PNA and treated with antibiotics.
He then became extremely SOB and emergently returned to the
hopsital where he was intubated and diagnosed with asthma/COPD.
He was treated with steroids of which his blood sugars were
extremely elevated (1400) and he subsequently had CVA with mild
speech defecit and renal insuddiciency. Patient was in coma for
9 days. In [**2-/2124**], patient was worked-up by pulmonologist and
diagnosed with TBM. He presents now for Y-stent placement
Past Medical History:
PMH:
1. Tracheobronchomalacia
2. Hypertension
3. Diabetes
4. Stroke, details unknown.
5. Asthma
6. GERD
PSH:
Amputation R hand fingertips (crush accident), subclavicular
port
Social History:
Married
Physical Exam:
Pleasant well-appearing male in NAD
HEENT: no LAD, nl oropharynx, short neck
CV: RRR
LUNGS: CTAB
ABD: +BS, soft NT/ND
EXT: no edema, s/p R fingertip amputations, L middle toe ulcer
Neuro: grossly intact
Pertinent Results:
CBC:
[**2124-4-18**] WBC-4.7 Hgb-13.6 Hct-39.6 Plt Ct-175
[**2124-5-1**] WBC-7.5 Hgb-9.9 Hct-28.6 Plt Ct-250
[**2124-5-3**] WBC-22.2 Hgb-11.7 Hct-34.3 Plt Ct-327
[**2124-5-4**] WBC-30.0 Hgb-11.4 Hct-35.8 Plt Ct-394
[**2124-5-5**] WBC-13.6 Hgb-9.7 Hct-29.2 Plt Ct-241
[**2124-5-10**] WBC-6.5 Hgb-8.4 Hct-24.9 Plt Ct-195
[**2124-5-13**] WBC-17.8 Hgb-8.5 Hct-26.9 Plt Ct-249
[**2124-5-26**] WBC-4.5 Hgb-8.0 Hct-25.1 Plt Ct-238
[**2124-5-29**] WBC-3.2 Hgb-6.8 Hct-21.2 Plt Ct-230
[**2124-6-9**] WBC-6.9 Hgb-8.6 Hct-26.7 Plt Ct-301
[**2124-6-10**] Hct-20.7
[**2124-6-13**] WBC-6.4 Hgb-9.0 Hct-27.8 Plt Ct-321
[**2124-6-17**] WBC-10.0 Hgb-9.4 Hct-29.7 Plt Ct-363
[**2124-7-4**] WBC-13.1 Hgb-9.1 Hct-26.7 Plt Ct-187
[**2124-7-6**] Hct-23.5
[**2124-7-7**] Hct-26.4
[**2124-7-15**] WBC-9.2 Hgb-9.5 Hct-29.0 Plt Ct-451
CHEMISTRY:
[**2124-4-18**] Gluc-157 Na-142 K-4.8 Cl-104 HCO3-32 BUN-26 Creat-1.0
[**2124-4-22**] Gluc-258 Na-137 K-3.9 Cl-99 HCO3-30 BUN-24 Creat-1.1
[**2124-4-24**] Gluc-304 Na-139 K-4.5 Cl-100 HCO3-24 BUN-15 Creat-1.1
[**2124-4-25**] Gluc-101 Na-140 K-3.5 Cl-102 HCO3-27 BUN-17 Creat-1.1
[**2124-4-26**] Gluc-343 Na-137 K-4.5 Cl-102 HCO3-28 BUN-14 Creat-1.0
[**2124-5-4**] Gluc-481 Na-137 K-3.5 Cl-106 HCO3-15 BUN-17 Creat-1.2
[**2124-5-7**] Gluc-92 Na-139 K-4.4 Cl-111 HCO3-23 BUN-14 Creat-1.1
[**2124-5-14**] Gluc-165 Na-141 K-4.2 Cl-100 HCO3-33 BUN-38 Creat-1.5
[**2124-5-29**] Gluc-105 Na-139 K-4.6 Cl-107 HCO3-27 BUN-46 Creat-1.4
[**2124-6-2**] Gluc-186 Na-141 K-4.3 Cl-108 HCO3-22 BUN-44 Creat-1.1
[**2124-6-10**] Gluc-318 Na-136 K-4.8 Cl-103 HCO3-24 BUN-30 Creat-1.3
[**2124-6-21**] Gluc-219 Na-136 K-4.7 Cl-96 HCO3-31 BUN-47 Creat-0.7
[**2124-6-28**] Gluc-102 Na-139 K-4.4 Cl-101 HCO3-30 BUN-29 Creat-0.6
[**2124-7-2**] Gluc-56 Na-139 K-4.7 Cl-99 HCO3-33 BUN-25 Creat-0.8
[**2124-7-5**] Gluc-242 Na-136 K-4.7 Cl-97 HCO3-32 BUN-30 Creat-0.9
[**2124-7-15**] Gluc-123 Na-147 K-3.6 Cl-110 HCO3-25 BUN-21 Creat-0.7
COAGS:
[**2124-4-18**] PT-11.5 PTT-21.5 INR(PT)-0.9
[**2124-5-6**] PT-12.3 PTT-25.0 INR(PT)-1.0
[**2124-5-18**] PT-12.2 PTT-23.7 INR(PT)-1.0
[**2124-6-20**] PT-12.7 PTT-20.7 INR(PT)-1.1
[**2124-7-12**] PT-13.6 PTT-25.1 INR(PT)-1.2
BLOOD GAS:
[**2124-5-2**] pH-7.48 pCO2-36 pO2-78 HCO3-28 Base XS-3
[**2124-5-3**] pH-7.30 pCO2-49 pO2-112 HCO3-25 Base XS-2
[**2124-5-10**] pH-7.45 pCO2-44 pO2-76 HCO3-32 Base XS-5
[**2124-5-16**] pH-7.36 pCO2-59 pO2-112 HCO3-35 Base XS-6
[**2124-5-25**] pH-7.36 pCO2-51 pO2-107 HCO3-30 Base XS-1
[**2124-6-9**] pH-7.29 pCO2-58 pO2-78 HCO3-29 Base XS-0
[**2124-6-20**] pH-7.41 pCO2-54 pO2-146 HCO3-35 Base XS-8
[**2124-7-8**] pH-7.32 pCO2-73 pO2-255 HCO3-39 Base XS-8
[**2124-7-12**] pH-7.43 pCO2-42 pO2-111 HCO3-29 Base XS-2
[**2124-7-15**] pH-7.43 pCO2-42 pO2-75 HCO3-29 Base XS-2
URINE:
[**2124-4-22**] Bld-NEG Nit-NEG Prot-TR Glu-1000 Ket-15 Bili-NEG pH-5.0
Leuks-NEG
[**2124-6-9**] Bld-LG Nit-NEG Prot-30 Glu-NEG Ket-NEGBili-NEG pH-9.0
Leuks-NEG
[**2124-7-11**] Bld-MOD Nit-NEG Prot-30 Glu-NEG Ket-50 Bili-NEG pH-8.0
Leuks-NEG
[**2124-6-17**] RBC-[**2-5**] WBC-0 Bacteri-RARE Yeast-NONE Epi-0
[**2124-7-11**] RBC-[**2-5**] WBC-[**2-5**] Bacteri-FEW Yeast-NONE Epi-0-2
Brief Hospital Course:
[**4-19**] Y-stent placed, breathing much improved
5/19 L 2nd toes with large ulcer and necrotic tissue, DVT ruled
out. Vascular and podiatric consults agree significant PVD, but
not acutely limb threatening
[**4-21**] Desaturation to 84%, moved to CCU. Bronch & agressive
pulmonary toliet. Rt internal carotic stenosis <40%, Left
internal carotic stenosis 40-59%. Pre-op Cardio clearance recc
Dob Echo & beta blocker. Started on IV Vanco/Zosyn for septic
picture/pneumonia
[**4-22**] BAL: strep pneumo, Coag neg staph Bcx
Continued to receive therapeutic bronchoscopies daily.
[**4-26**] Y-Stent removed. granulation tissue L maintem distal to
stent. CPAP used post-op for stable resp distress
[**4-27**] Cr 1.7
[**4-28**] Echo: EF 70%
5/29 Transfered to MICU for mgt of PNA/sepsis until surgery.
Tolerating continued CPAP
[**5-1**] Intubated after tiring out, unable to clear secretions,
unable to maintain oxygenation. TF started, ran until surgery.
[**Last Name (un) **] stim test showed adrenal insuff. Hydrocort and flucort
started
[**5-3**] Tracheoplastia via R thoracotomy and open tracheostomy. Very
long procedure due to difficult dissection, TSICU postop.
[**5-4**] requiring paralysis to make ventilation for efficient.
worsening septic shock. Levophed started. Vanco continued. TF
restarted.
[**5-5**] off pressors, Cr 1.2. Oral intubation secondary to
cuff-leak at tracheostomy
Continued to receive therapeutic bronchoscopies daily.
[**5-7**] Paralytics weaned. remained sedated on assist control
ventilation. diureses initiated.
TF to goal
Bronch w/ severe edema of supraglottic area. Copious secretions
requiring daily to [**Hospital1 **] bronch's. 80-85% occlusion of both right
and left main stem d/t sutures.
[**5-12**] taken back to the OR for balloon dilation and clean out of
necrotic tissue.
Paralyzed and sedated post op for ventilation management.
temp spike on on vanco;zosyn and fluc added.
Cont'd support management-unable to wean paralytics.
[**5-17**] paralytics weaned. cont'd serial bronchs for secretion
management. cont triple ivab. conts to require high vent
support- 24 peep.
no longer [**Last Name (un) 1815**] Tf swithced to TPN.
[**5-31**] abx changed- Vanco, [**Last Name (un) **], Zosyn, Diflucan. Multilobad PNA.
Post-pyloric dobhoff placed
[**6-1**] TPN d/c'd, TF started
7/1-9 sedation/ paralytics weaned. pt noted to be following
commands w/bilat UE but not LE.
[**6-10**] neuro consult for LE paresis
[**6-10**] Cord edema C3-T1, lesion C7-T1 susp for infection
(cryptococcus)
steroids started. response likely to suggest transverse
myelitis.
[**6-17**] BCx: Coag neg Stap oxacillin resistant. Cefoxatine, Cipro,
Gent, Vanco, Caspo.
[**6-21**] Steroids d/c'd.
[**6-22**] Trach collar trials. Gent d/c'd. Continue
Ceftaz/Cipro/Vanco/Caspo x 21 days.
[**6-24**] MRI C/T/L spine: resulution of edema
[**6-27**] d/c Ceftaz. Trach mask trials continue.
[**6-28**] excellent progress, 24H trach mask. some movement of RLE
[**6-29**] negative swallow eval
[**6-30**] off insulin drip, neg video swallow. started PO's. TF
continued
[**7-3**] BAL: GNR
[**7-4**] Febrile, PICC d/c'd. Vanco started
[**7-5**] BCx Gm+ Cocci. Meropenem started
[**7-6**] Pseudomonas PNA, back on vent
8/8 TF on hold for post pyloric tube placement, unsuccessful.
BAL: budding yeast
[**7-11**] Vanco d/c'd.
[**7-13**] trach mask
[**7-16**] vent, LLL pneumonia. BAL sent
[**7-17**] PEG placed; started on promote w/fiber
[**7-19**] Uncomplicated bronchoscopic aspiration of secretions
[**7-21**] Uncomplicated bronchoscopic aspiration of secretions
[**7-24**] Uncomplicated bronchoscopic aspiration of secretions
[**7-24**] Psychiatry consult: Anxiety/Depression due to current
medical situation; increase Zoloft and Xanax, minimize Ativan;
f/up recommended in rehab
[**7-25**] CT airway: showing small area of air behind R mainstem
bronchus of uncertain etiology but doesn't seem to be
significant;
[**7-25**] Trach tube changed for #9 cuffed, fenestrated tube
[**7-27**] Patient on trach collar during day requiring occas vent
support overnight.
Throughout, [**Last Name (un) **] Diabetes service consulted for DMI and
difficult to control BS, insulin changed accordingly requiring
insulin drip for much of hospitalization.
Wound care consult for B/L plantar/heel ulcers.
Medications on Admission:
Insulin NPH/Regular (sliding scale)
Prilosec 20mg"
Lisinopril 20mg'
Tegretol 20mg'''
Zoloft 100mg'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours) as needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO PRN (as needed) as needed for Phos less than 2.5.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
10. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
16. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1) Intravenous Q8H (every 8 hours) for 7 days.
19. Sertraline 50 mg Tablet Sig: 1 1/2 tabs Tablet PO at
bedtime.
20. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
21. Lorazepam 0.5 mg IV Q4H:PRN
22. Potassium Chloride 40 mEq / 100 ml SW IV PRN K < 4.0
23. Magnesium Sulfate 3 gm / 250 ml NS IV PRN Mg=<1.6
24. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN 1.6 < Mg <2.0
25. Calcium Gluconate 2 gm / 100 ml NS IV PRN iCa <1.12
26. Morphine Sulfate 2-4 mg IV Q2H:PRN
27. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1)
Intravenous twice a day for 7 days.
28. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Tracheobronchomalacia
2. Hypertension
3. Diabetes
4. Stroke, details unknown.
5. Asthma
6. GERD
severe tracheobronchomalacia s/p tracheoplasty
severe tracheobronchomalacia s/p tracheoplasty
Discharge Condition:
fair/severely deconditioned
Discharge Instructions:
cont pul hygiene-wean vent as [**Last Name (un) 1815**], bronch's prn, rehab,
nutritional support
Followup Instructions:
Call Dr.[**Name (NI) 1816**] office for any care related questions
[**Telephone/Fax (1) 170**] and you have a follow up appointment on [**8-10**] 3:30pm in the [**Hospital Ward Name 23**] Clinical Center [**Location (un) **].
Completed by:[**2124-8-2**] Name: [**Known lastname 11127**] [**Known lastname 201**],[**Known firstname **] D Unit No: [**Numeric Identifier 11128**]
Admission Date: [**2124-4-18**] Discharge Date: [**2124-8-3**]
Date of Birth: [**2084-2-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vicodin / Accolate
Attending:[**Last Name (NamePattern1) 10570**]
Addendum:
antibiotics are to be completed on [**2124-8-7**].pt has been on trach
collar during day 8-12hrs and restes on vent overnoc CPCP 50% TV
350, 8peep, 8PSV.
*** his follow up appointment has been changed to [**2124-8-22**] at 3:30pm [**Hospital Ward Name **] clinical center [**Location (un) **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours) as needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Potassium & Sodium Phosphates [**Telephone/Fax (3) 11129**] mg Packet Sig: One
(1) Packet PO PRN (as needed) as needed for Phos less than 2.5.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
10. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
16. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1) Intravenous Q8H (every 8 hours) for 7 days: end date
[**2124-8-7**].
19. Sertraline 50 mg Tablet Sig: 1 1/2 tabs Tablet PO at
bedtime.
20. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
21. Lorazepam 0.5 mg IV Q4H:PRN
22. Potassium Chloride 40 mEq / 100 ml SW IV PRN K < 4.0
23. Magnesium Sulfate 3 gm / 250 ml NS IV PRN Mg=<1.6
24. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN 1.6 < Mg <2.0
25. Calcium Gluconate 2 gm / 100 ml NS IV PRN iCa <1.12
26. Morphine Sulfate 2-4 mg IV Q2H:PRN
27. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1)
Intravenous twice a day for 7 days: end date [**2124-8-7**].
28. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Instructions:
Continue w/ pul rehab and physical rehab. Currently trach collar
during day and CPAP 50% 350 peep 8, PSV 8.
Followup Instructions:
Call Dr.[**Name (NI) 3722**] office for any care related questions
[**Telephone/Fax (1) 1477**]. you have a follow up appointment with Dr. [**Last Name (STitle) 384**]
[**2124-8-22**] at 3:30pm in the [**Hospital Ward Name **] Clinical center 9 th floor.
[**First Name4 (NamePattern1) 904**] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(1) 1370**]
Completed by:[**2124-8-3**]
|
[
"995.92",
"482.1",
"996.79",
"519.1",
"785.52",
"464.51",
"336.1",
"117.5",
"707.14",
"250.01",
"482.30",
"112.4",
"038.8",
"440.23",
"321.0",
"518.84",
"701.5",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"31.1",
"33.48",
"33.91",
"38.93",
"96.05",
"93.90",
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"43.11",
"96.04",
"98.15",
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"99.15",
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icd9pcs
|
[
[
[]
]
] |
15874, 15944
|
5370, 9668
|
312, 879
|
12406, 12436
|
2118, 5347
|
16100, 16528
|
13544, 15851
|
12188, 12385
|
9694, 9795
|
15968, 16077
|
1895, 2099
|
253, 274
|
907, 1655
|
1677, 1855
|
1871, 1880
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,217
| 167,867
|
10946
|
Discharge summary
|
report
|
Admission Date: [**2128-7-17**] Discharge Date: [**2128-7-22**]
Date of Birth: [**2048-1-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
80yo F with PVD (s/p R EIA stent), HTN, DMII, Lung CA, who
c/o 2-3 days +n/v and general malaise. She initially went to
OSH and was found to be in high-grade AVB. Of note, the pt was
recently started on a new CCB (x 2 weeks; cardizem from
nifedipine). At OSH, pt rec'd calcium gluconate (unclear dose).
In [**Name (NI) **], pt was given isoproteronal gtt at 1mcg/min then 2mcg/min.
Initial response was an increased sinus rate to 120 with
consistent 2:1 block. As dose was increased, pt developed atrial
flutter with variable block (rates around 40bpm). Throughout her
ED stay, the patient maintained SBP in 180s, mental status was
waxing and [**Doctor Last Name 688**] but pt was able to follow commands and answer
appropriately to most questions with occasional confusion.
Past Medical History:
--DMII
--HTN (poorly controlled, OSH records indicate SBP 190s)
--PVD, s/p right external iliac artery stent, endarterectomy of
the EIA, CFA, PFA with bovine patch angioplasty and iliac and
femoral angiography([**3-22**])
--Lung ca s/p R lower lobe resection (no chemo; [**11-14**])
--COPD
--dCHF (recent admission [**Date range (1) 35545**])
--L pleural effusion (noted on [**6-19**] hosp)
--h/o AFib/flutter (found post-op from R EIA stent)
Social History:
quit tob 10yrs ago; 50PY hx; lives with husband
Family History:
non contributary
Physical Exam:
AF 170-180/50-60 30-50 16 96% on 2L
Gen: NAD, oriented x [**3-19**], waxing and [**Doctor Last Name 688**]
HEENT: PERRL, EOMI, MMM
Neck: JVP 10-12cm
CV: RRR
Chest: rales about 1/2 up b/l
Abd: soft, obese, NT, + BS
Extr: 1+ pitting on LLE, trace on RLE
Neuro: mild resting tremor b/l; moves all 4 extr, follows
commands
Pertinent Results:
[**2128-7-17**] 09:10PM GLUCOSE-154* UREA N-57* CREAT-2.3*#
SODIUM-138 POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19
[**2128-7-17**] 09:10PM CK(CPK)-71
[**2128-7-17**] 09:10PM cTropnT-0.04*
[**2128-7-17**] 09:10PM CK-MB-NotDone proBNP-[**Numeric Identifier 35546**]*
[**2128-7-17**] 09:10PM CALCIUM-9.6 PHOSPHATE-4.4 MAGNESIUM-2.7*
[**2128-7-17**] 09:10PM WBC-12.5* RBC-3.31* HGB-9.4* HCT-27.9* MCV-84
MCH-28.3 MCHC-33.7 RDW-16.9*
[**2128-7-17**] 09:10PM NEUTS-85.7* LYMPHS-9.1* MONOS-4.6 EOS-0.5
BASOS-0.1
[**2128-7-17**] 09:10PM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+
[**2128-7-17**] 09:10PM PLT COUNT-380
[**2128-7-17**] 09:10PM PT-37.2* PTT-46.8* INR(PT)-4.1*
.
EKG [**2128-7-17**]: 2:1 AVB, rate 60; sl LAD
.
EKG [**2128-7-20**]: A-V paced rhythm Since previous tracing of [**2128-7-18**],
Atrium now paced with A-V pacing
.
CXR [**2128-7-17**]: mild vasc engorgement, raised R hemidiaphragm (old)
.
CXR [**2128-7-20**]: Temporary pacer lead has been removed. Standard
transvenous right atrial and ventricular pacer leads follow
their expected courses in the left pectoral pacemaker. No
pneumothorax or mediastinal widening is present. Minimal left
pleural effusion precedes placement of the new leads.
Atelectasis or scarring is present in medial aspect of the right
lung, either middle or lower lobe. Lungs are otherwise clear
aside from mild [**Month/Day/Year 1106**] congestion. There is no edema. Heart is
borderline enlarged, but unchanged
.
Left Foot and Ankle [**2128-7-22**]: degenerative changes on the medial
and lateral malleoli, however, there is no evidence of a
fracture.
.
TTE ([**6-19**]): EF 65-70%, sLVH, 1+ MR, 1+ TR, 1+ AR
.
ETT-MIBI ([**3-22**]): EF 60%; 1. Normal myocardial perfusion. 2.
Normal left ventricular cavity size and systolic function.
Brief Hospital Course:
Hospital [**Last Name (un) **]: 80yo F with hx of PVD, DM, HTN, Lung CA s/p
resection and COPD presents to OSH with symptomatic AVB (mental
status changes and ARF) now s/p PPM placement.
.
# Rhythm/AV Block: The etiology of the AV Block is unclear at
this moment, however it is most likely related to the recent
addition of CCB. The location of block is also not perfectly
elucidated but it appears to be at level of AV node as
isoproterenol resulted in increased rate. Vagal manuevers were
attempted but could not be succesfully peformed given her change
in mental status and inability to cooperate. As she had new ARF
and MS changes, the pt was deemed to have some end organ effects
of bradycardia with a poor perfusion state. Therefore a
temporary pacer wire was placed under fluoro in the L femoral
position for VVI pacing at 60bpm. Initially the setting was as
follows: paced at low of 0.5mA with sensitivity 3.0mV. However,
she was not captuing all of the time. She was admitted to and
monitored in the CCU where she was found to still require
pacing, even after the CCB wore off. She was therefore taken to
the EP lab where a permanent pacemaker was placed on [**7-19**]. She
received vancomycin prophylactically around the device placment.
She was also given an additional day of clindamycin as well.
Post pace make placement, the temporary pacing wires were
removed. A CXR confirmed proper placement of the pacemaker and
its leads and the pacemaker was interrogated demonstrating
appropriate capture. The patient should f/u in the device
clinic on [**2128-7-28**].
Of note, the pt had been on coumadin 3mg QHS after developing
atrial fibrillation post-op in [**3-22**] and on admission this was
reversed given supratherapeutic INR. She was restarted on
coumadin at 5mg QHS the day after the pacemaker was placed. INR
should be followed closely and coumadin levels should be
adjusted to achieve a goal INR of [**3-19**].
.
# PUMP: The pt has elements of diastolic CHF by recent TTE,
likely from long-standing poorly controlled HTN. BP control was
initially achieved with nitro gtt and then this was weaned off
as outpt meds were restarted, including lisinopril (at same
dose), diltiazem (at higher dose), and lasix (at lower dose).
She was also started on a low dose beta blocker for additional
blood pressure control. Her final regimen at time of dischage
included diltiazem CR 360mg once daily, Lisinopril 40mg once
daily, Metoprolol 12.5mg [**Hospital1 **] and lasix 40mg once daily. Given
her history of COPD, the effect of the low dose beta blocker
should be monitored closely.
.
# ARF: The pt has a baseline Cr of 1.0-1.5, which was elevated
up to 2.3 on admission. This was attibuted to poor perfusion
state from her bradycardia. Urine lytes on admission consistent
with pre-renal azotemia. (FeUrea 31% (FeNa less useful in
patient on lasix)). Her ACEI and diuretic were initially held
on admission due to the ARF and creatinine and urine output
followed closely. After placement of the PPM, her Cr has been
trending down. Her ACEI was titrated back up to her outpt dose
and her lasix was similarly titrated back on. However at time
of discharge her lasix dose was still lower than previous (40mg
as opposed to 80mg once daily on admission). Her renal function
and urine output shouuld be followed closely in rehab with
routine chemistries. Should she develop some amount of fluid
retention, her lasix dose can be returned to her former outpt
dose of 80mg once daily assuming her renal function is able to
tolerate it.
.
# Anemia: HCT was 27.9 on admission which then dropped to 24
after pacer placement (moderate procedural blood loss). Her
previous medical records indicate a baseline in mid-low 30's (on
admission in [**3-22**]). She was subsequently transfused 2 U PRBCs
from [**Date range (1) 26325**] (lasix 40 mg iv between units) with some response.
Her pacemaker site appeared to be without significant hematoma
and she remained guaiac negative.
.
# + UA: on [**7-19**] wih WBC, RBC, small leuk. As the pt had a foley
catheter in place at the time of the finding, she was started on
Bactrim DS one tab [**Hospital1 **] for a total of 10day course for
complicated UTI on [**7-19**]. Culture grew pan-sensitive e.coli. She
should complete ten day course of Bactrim (last dose [**2128-7-28**])
given this occurred in the setting of a foley catheter.
.
# Urinary retention: Her foley catheter was removed after her UA
and urine culture returned positive for a UTI. However she was
found to be retaining 500cc of urine (as demonstrated by US on
Post Void Residual) and so the foley was replaced. This urine
retention was attributed to her chronic use of narcotics
(fentanyl patch) and resultant atony. The foley catheter should
remain in place until either she demonstrates the ability to
urinate or an outpt urological appointment can be arranged by
her PCP.
.
# Foot pain: The pt complained of left foot pain on HD #3.
There was no evidence of trauma, no swelling, and the pt had
good ROM. The pt has known chronic pain from neuropathy,
however her pain medications were held in the setting of ARF.
As the pain was consistent with her chronic nephropathy. She was
restarted on both her fentanyl patch (which may have contributed
to her urinary retention as above) and neurontin. Plain X-rays
of the left foot and ankle were performed which demonstrated
degenerative changes on the medial and lateral malleoli,
however, there was no evidence of a fracture.
.
# COPD: The pt has a diagnosis of COPD and a hx of tob use but
is not on any routine nebulizers or inhalers. She was started
on low dose beta blocker for additional blood pressure control
as well as for additional PVD and CAD ppx. She was not noted to
have any pulmonary side effects of this medication, however this
should be monitored routinely with regular physical examinations
and treatment with nebulizers if necessary.
.
# DMII: she was maintained on ISS while in house and restarted
on glipizide on discharge.
.
# PVD: recent R EIA stent. She was kept on aspirin and restarted
on coumadin after the pacer was placed.
.
# PPx: The pt was maintained on DVT ppx with heparin sub Q
during this admission.
Medications on Admission:
Diltiazem CD 180
Lasix 80 daily
Lisinopril 40 daily
Lipitor 40 daily
Glipizide 2.5 [**Hospital1 **]
Neurontin 300 qhs
Fentanyl 25 mcg q72hr
Coumadin 3 daily
FE 325
Colace
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
5. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for prn, yeast infection.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Diltiazem HCl 180 mg Capsule, Sust. Release 24HR Sig: Two
(2) Capsule, Sust. Release 24HR PO once a day.
13. Glipizide 2.5 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO twice a day.
14. Iron 325 (65) mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary: Bradycardia (high degree AV block)
Secondary: Diabetes, peripheral [**Location (un) 1106**] disease, hypertension,
COPD
Discharge Condition:
Stable, pacemaker functioning normally.
Discharge Instructions:
Your care will continue to be managed at rehab facility.
Please follow up with all of your doctors. Please make sure the
patient follows up at device clinic as outlined below.
Please take all of your medications. Note the following changes
have been made in you medications.
1. You have been stated on Aspirin 325mg once daily.
2. You have also been started on a new blood pressure
medication called Metoprolol (Lopressor). Please take one half
of a 25mg tablet (12.5mg) twice a day.
3. Your diltiazem dose has been increased to 360mg once daily.
4. Your furosemide (lasix) dose been decreased to 40mg once
daily
5. Please continue to take the Bactim DS one tablet twice
daily. This is an antibiotic to treat your urinary tract
infection and should continue for an additional 7 days (for a
total of 10 day [**Last Name (un) 10128**]).
6. Please continue your Warfain (Coumain) at 5mg once daily.
We have increased this dose during your hospitalization. You
should continue to have the levels of you INR checked to adjust
your warfarin dose as necessary.
7. Please continue the remainder of your medications including
your lisinopril at 40mg once daily and your lipito at 40mg once
daily at night.
The steri strips and dressing over the pace maker site should
remain on until your follow up appointment at device clinic.
Please keep the dressing and area dry. Please do NOT lift your
arms above your head for two months.
If you develop any chest pain, palpitations, shortness of
breath, dizziness, lightheadedness, abdominal pain, nausea,
vomiting, diarrhea or other concerning health issues, please
call you physician or come directly to the ED.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2128-7-28**]
1:30
Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2128-8-9**] 12:15
Please call your primary care doctor, Dr. [**Last Name (STitle) **], for a follow
up appointment within one month of discharge. Dr.[**Name (NI) 23247**]
office can be contact[**Name (NI) **] at [**Telephone/Fax (1) 17753**]. If you don't pass the
voiding trial for urination without the foley, please have Dr.
[**Last Name (STitle) **] assist in referring you to a urologist.
Please check her chemistries to assess for renal function in [**3-19**]
days. On admission she was found to have acute renal failure
from which she is recovering and some medications changes have
been made during this admission which may affect her renal
function.
Please check her INR in two days time (Sat) to adjust her
coumadin dose. She had previously been on 3mg QHS but this dose
was increased to 5mg QHS for the last two days of the admission.
Her goal INR is between 2 and 3.
|
[
"788.20",
"397.0",
"V10.11",
"427.32",
"996.64",
"584.9",
"355.8",
"496",
"443.9",
"599.0",
"398.91",
"402.91",
"426.12",
"396.3",
"285.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"37.83",
"99.04",
"37.72",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
11826, 11910
|
3900, 10118
|
322, 344
|
12083, 12125
|
2073, 3877
|
13837, 14999
|
1700, 1718
|
10340, 11803
|
11931, 12062
|
10144, 10317
|
12149, 13814
|
1733, 2054
|
275, 284
|
375, 1152
|
1174, 1619
|
1635, 1684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,782
| 199,834
|
50255
|
Discharge summary
|
report
|
Admission Date: [**2121-11-14**] Discharge Date: [**2121-12-4**]
Date of Birth: [**2041-10-30**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Exploratory laparotomy.
2. Lysis of adhesions to portion of small bowel.
3. Replacement of jejunostomy tube.
History of Present Illness:
80-y.o. male p/w sharp constant epigastric abdominal pain with
radiation to the back and R shoulder since 4:30pm the day before
admission after eating peanuts. Pain radiates to back,
associated with nausea, dry heaving without emesis, and
abdominal distention. Passing flatus yesterday but not on day
of admission. Last BM day before admission. Denies
fever/chills.
Past Medical History:
Past Medical History:
1. Esophageal adenocarcinoma in situ s/p esophagogastrectomy
with pull up 11/04 c/b 50 day hospital course for psuedomonal
PNA, pleural effusions, trach, J-tube
2. Afib s/p pacemaker on coumadin
3. Echo: EF > 55%; mild pulm HTN
4. Prostate Cancer
5. HTN
6. OSA
7. Hypothyroid
8. MI
9. Appy
10. Hypertrophic cardiomyopathy s/p EtOH ablation
[**21**]. Trach
12. Left vocal cord paralysis
13. Subglottic stenosis
14. OSA
15. ^Lipids
Social History:
He is married,. He is a retired truck driver. He does not drink
alcohol and he has never smoked cigarettes.
Family History:
father w/[**Name2 (NI) 499**] cancer and his mother having breast cancer.
Physical Exam:
99.2 97.9 76 128/52 20 95RA
AOX3, NAD, raspy voice
RRR
fine crackles bilaterally, good air movement
abd soft, appropriately tender, nondistended, minimally
tympanetic\
Midline incision c/d/i. No drainage. No erythema or edema
bilateral upper extremity edema, chronic
Pertinent Results:
Admission labs:
[**2121-11-14**] 06:25AM BLOOD WBC-13.4* RBC-4.90 Hgb-14.2 Hct-42.4
MCV-87 MCH-28.9 MCHC-33.4 RDW-15.8* Plt Ct-232
[**2121-11-14**] 06:25AM BLOOD PT-25.0* PTT-25.5 INR(PT)-2.4*
[**2121-11-14**] 06:25AM BLOOD Glucose-177* UreaN-29* Creat-1.3* Na-143
K-4.0 Cl-110* HCO3-15* AnGap-22*
[**2121-11-14**] 06:25AM BLOOD ALT-204* AST-454* AlkPhos-342*
TotBili-2.4* DirBili-1.9* IndBili-0.5
[**2121-11-14**] 12:48PM BLOOD Calcium-8.3* Phos-3.7 Mg-1.3*
Discharge Labs:
[**2121-12-3**] 07:28AM BLOOD WBC-9.0 RBC-2.63* Hgb-7.6* Hct-23.4*
MCV-89 MCH-29.0 MCHC-32.7 RDW-20.6* Plt Ct-465*
[**2121-12-4**] 07:20AM BLOOD Glucose-66* UreaN-22* Creat-1.0 Na-140
K-4.3 Cl-107 HCO3-26 AnGap-11
[**2121-12-4**] 07:20AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.2
Brief Hospital Course:
Mr [**Known lastname 1726**] was admitted to surgical service and taken to the OR
on [**2121-11-14**]. He tolerated his procedure (see operative note for
full details). He was transferred to the post anesthesia care
unit for recovery and then to the intensive care unit. He was on
a mechanical ventilator, with IVF , a foley and monitoring with
central line pressures and with ABGs. He received several
boluses of IVF and albumin and repletions of his electrolytes.
On [**2121-11-16**] he had a chest xray which showed As compared to the
previous radiograph, there was increase in density of the right
hemithorax.
He continued to receive IVF boluses and his J tube was taken off
of suction and placed to gravity. He was placed in two point
restraints secondary to non-violent behavior such as tube
pulling. He was weaned off pressors and extubated on [**2121-11-16**].
He was reintubated on [**11-18**] after increased respiratory distress
to RR 28-29. He received lasix on [**11-19**]. His cxr on [**11-20**]
showed:
1. Worsening right upper lobe opacity either represents
consolidation or
fissural fluid.
2. Moderately large bilateral pleural effusions, increased since
[**2121-11-19**].
He was started on Ampicillin IV. He received another dose of
furosemide 20 mg IV on [**11-20**]. He remained intubated until [**11-20**]
when he was weaned off the vent. He was started on TPN on [**11-21**]
for nutritional support. He was transferred to the floor on
[**2121-11-22**], started on zosyn, and kept NPO. His pain was controlled
with IV dilaudid. His blood sugars managed with an insulin
sliding scale. His NGT was continued on suction. He continued
HSQ for DVT prophylaxis and pantoprazole for GI prophylaxis.
On [**2121-11-23**] his electrolytes were repleted. His NGT continued and
he received TPN.
On [**2121-11-24**], he continued his TPN, his NGT removed, and his diet
advanced to sips. His foley was discontinued at midnight and he
voided.
On [**2121-11-25**] his J tube was clamped and flushed with sterile water
TID. he received Albuterol nebulizers for wheezing and increased
work of breathing. He continued his TPN. His CXR on [**2121-11-25**]
showed:
Severe cardiomegaly has worsened since [**11-22**], moderate right
pleural
effusion is unchanged and previous mild pulmonary edema has
decreased.
His insulin sliding scale was also adjusted to optimize blood
sugar control.
On [**2121-11-26**], he continued his TPN. Pulmonology was consulted who
recommended thoracocentesis. His Chest CT on [**2121-11-26**] showed:
1. Large dependent bilateral pleural effusions and resulting
atelectasis,
with a right fissural component which may or may not be
loculated.
2. Mild pulmonary edema.
3. Cardiomegaly, coronary artery calcification, and pulmonary
arterial
enlargement.
On [**2121-11-27**] he continued his TPN, received a dose of lasix for
increased work of breathing, and also received a transfusion of
1 uPRBC to continue to optimize his respiratory status. A
thoracocentesis was attempted on [**2121-11-27**] however unsuccessful as
as there was no clear window on ultrasound.
On [**2121-11-28**], he started tube feedings and continued his TPN as his
tube feedings were progressively increased.
On [**2121-11-29**] He continued his TPN and continued to advance his tube
feeds. His zosyn was discontinued. His zosyn was discontinued
after completion of the fourteen day course.
On [**2121-11-30**], his TPN was changed from half strength to full
strength fibersource. His foley was replaced as the patient was
incontinent over the past several days and was developing skin
irritation.
On [**2121-12-1**] and [**2121-12-2**], his central line was discontinued and
his diet advanced to regular, pureed per speech and swallow
consult. His respiratory conditions progressively improved until
he was on minimal O2 supplementation by nasal cannula or room
air.
His chest x ray showed:
Severe cardiomegaly and large right pleural effusion are
unchanged. What
appears to be increasing consolidation in the right upper lobe
and persistent
severe consolidation in the right lower lobe is instead fissural
pleural
effusion and mild basal atelectasis posterior to a moderate
layering pleural
effusion, respectively.
His tube feeds were cycled and optimized by the nutrition
service. He chronic left upper extremity swelling improved after
elevation above the level of the heart with a stockinette.
His tube feeds were adjusted on [**2121-12-4**] and his home meds
including coumadin started. He was discharged to rehab in stable
condition with a foley that should be discontinued at rehab.
Medications on Admission:
Current Medications: Metoprolol 25", Captopril 6.25", ASA 81,
Warfarin, Atorvastatin 20', Lorazepam 0.5', Finasteride 5',
Flomax 0.4', Silver Sulfadiazine 1 % Topical Cream [**Hospital1 **] PRN,
Ranitidine 300', Prilosec 40", Imodium A-D 2', Atrovent 0.06 % 2
puffs each nostril TID, Astelin 137 mcg 2 puffs each nostril
[**Hospital1 **], Promote with Fiber 1 can per J-tube at lunch, 2 cans at
bedtime, Folic Acid
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. insulin regular human 100 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED): per sliding scale.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q4H (every 4
hours) as needed for dyspnea, wheeze.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syrine
syringe Injection TID (3 times a day).
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**11-23**] weeks. Please call
his office to make this appointment.
|
[
"427.31",
"511.9",
"478.30",
"244.9",
"041.04",
"425.4",
"V10.46",
"428.30",
"933.1",
"E915",
"038.8",
"557.9",
"327.23",
"486",
"272.4",
"412",
"287.5",
"428.0",
"401.9",
"041.3",
"V43.65",
"789.59",
"995.91",
"276.2",
"560.2",
"V58.61",
"V10.03",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.81",
"45.02",
"96.6",
"99.15",
"97.03",
"33.24",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8801, 8873
|
2619, 7233
|
320, 445
|
8941, 8941
|
1845, 1845
|
9095, 9221
|
1463, 1538
|
7698, 8778
|
8894, 8920
|
7259, 7259
|
2322, 2596
|
1553, 1826
|
266, 282
|
7280, 7675
|
473, 845
|
1861, 2305
|
8956, 9072
|
889, 1320
|
1336, 1447
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,719
| 154,383
|
47191
|
Discharge summary
|
report
|
Admission Date: [**2120-3-25**] Discharge Date: [**2120-4-1**]
Date of Birth: [**2057-11-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Briefly, 62 yoF with h/o metastatic breast CA and prior hypoxic
episodes, often occuring in association with anxiety (prior
work-up with CTA and PE all negative), who presented with
vertigo and O2 sat in 60s on home O2 monitor in the setting of
recent paracentesis and first cycle of CMF chemotherapy. At
baseline, the pt intermittently uses oxygen at home. She is able
to ambulate and climb stairs with minimal dyspnea.
In the ED, initial vitals were T 100.2, P 120, R 18, 111/75 with
a difficult to obtain O2 sat. While in the ED, the pt was noted
to desaturate to the 70s while on room air and required a NRB to
maintaine sats in the mid-90s. As per ICU Admission Note, the
pt's oncologist, Dr. [**Last Name (STitle) 19**], was reportedly contact[**Name (NI) **] and advised
against further acute work-up for PE given the pt's recent
negative CTA and similar presentations in the past. The patient
was admitted to the [**Hospital Unit Name 153**] for acute management of hypoxia.
While in the ICU, the patient underwent an echo and repeat CXR.
She was rehydrated with IVF, stabilized, and transferred to the
floor.
ROS: The pt denies any fevers or chills. No frank cough, wheeze
or shortness of breath. Denies chest pain. Endorses some
low-level, diffuse abdominal pain, which has been somewhat
long-standing. Newer is some loose stool; she cannot recall
exactly when this began but has treated with Immodium on several
occasions with excellent effect. No urinary symptoms.
Past Medical History:
metastatic breast cancer
-involvement of the peritoneal cavity, bone, lymph nodes, and
skin
-s/p lumpectomy and XRT
-chemotherapy most recently with CMF (started [**2120-3-22**])
-prior therapy including tamoxifen, Femara, Herceptin,
carboplatin, xyotax (experimental), gemcytobine, Xeloda,
doxorubicin, and Taxol
osteoporosis
osteoarthritis
s/p myomectomy for fibroids
s/p appendectomy
rheumatic fever as child
Social History:
She denies tobacco use. No alcohol. No drug use. Lives at home
with her husband.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Gen: Chronically ill appearing adult female, no acute distress.
HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. Flat neck veins. No
tenderness with palpation.
Chest: Slightly decreased breath sounds at bases bilaterally.
Otherwise CTAB anterior and posterior.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Soft, moderate diffuse tenderness. No R/G.
Non-distended. +BS, no HSM.
Extremity: Positive clubbing in fingers. Warm, without edema. 2+
DP pulses bilat.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Positioning: Oxygen saturation checked x two with patient in
recumbant versus upright position. When lying down, pt with
oxygen saturations in high 90s on 3L NC. When seated upright,
sats drop to high 80s.
Pertinent Results:
Admission labs:
[**2120-3-25**] 05:40PM WBC-3.7* RBC-3.52* HGB-10.8* HCT-33.0* MCV-94
MCH-30.7 MCHC-32.8 RDW-17.8*
[**2120-3-25**] 05:40PM NEUTS-78.4* LYMPHS-18.8 MONOS-1.6* EOS-0.8
BASOS-0.4
[**2120-3-25**] 05:40PM GLUCOSE-101 UREA N-22* CREAT-0.5 SODIUM-137
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-11
[**3-26**] CXR: FINDINGS: In comparison with study of [**3-25**], there is
continued opacification in the retrocardiac region with
obliteration of the left hemidiaphragm. This is consistent with
substantial volume loss involving the left lower lobe. Some
pleural fluid may also be present. Central catheter remains in
place. Diffuse sclerotic metastases are again seen.
[**3-26**] echo: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic root is moderately dilated at
the sinus level. The ascending aorta is markedly dilated The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Markedly dilated ascending aorta. Moderately dilated
aortic root. Moderate aortic regurgitation. No atrial septal
defect or patent foramen ovale visualized on color Doppler
imaging, although interatrial septum was obscured by the large
aorta.
Compared with the prior study (images reviewed) of [**2118-9-7**],
aortic root and ascending aorta are larger (although root was
undermeasured on prior study).
Brief Hospital Course:
62 yoF presents with hypoxia in setting of mild transient
vertigo.
.
# Hypoxia: Pt's history of recurrent hypoxic episodes in the
setting of ASD was concerning for dynamic intracardiac shunting
(i.e., Platypnea-orthodeoxia syndrome). It is possible that
factors such as the pt's volume status (orthostasis with
systemic hypotension in the upright position) or mild
auto-PEEPing the setting of tachypnea may alter the degree of
shunting which occurs. It is also possible that the anxiety the
patient has experienced in relation to prior episodes may in
fact be a manifestation of hypoxia. Other considerations would
still include pulmonary embolus, interstitial lung disease, CHF
or pneumonia, however these appear less likely explainations
given the reproducibility of symptoms. She had an echo that was
unable to visualize an ASD or PFO and did not demonstrated any
elevated R atrial pressures or pulmonary hypertension.
Ultimately, she reintubated for another episode of hypoxia and
extubated at the request of her husband/ HCP who felt that she
would have wanted to be CMO at this stage of her disease. She
was transferred to floor from ICU and died in [**12-19**] days. Family
was notified
.
# Tachycardia/elevated BUN: In setting of recent paracentesis
and poor PO intake, patient was likely dry. She was given IVNS
boluses in the ICU.
.
# Anemia: Consistent with recent baseline. Normal MCV with
elevated RDW. Suspected a strong component of AOCD. No recent
w/u undertaken.
.
# Breast cancer: S/p recent initiation of CMF chemotherapy. We
talked with oncology (Dr. [**Last Name (STitle) 19**] and alerted him to pt's
admission. Appears acutely stable from an oncologic perspective.
She was scheduled for weekly paracentesis, and this was
performed with IR while inpatient.
.
# Pain: The patient reported abdominal pain, related to
abdominal distention and paracentesis. At home, she controls
the pain with Tylenol. While inpatient, she was managed on
morphine 0.5-1.0mg IV q4hrs prn pain. She developed nausea in
association with morphine, and this was managed with compazine.
Ultimately, she was placed on a morphine drip after extubation.
.
# GI bleed: On [**3-28**], the patient had an episode of hematemesis,
was tachycardic to 130s, and had a large melanotic stool. She
was transferred back to the MICU and was transiently intubate
and then extubated as described above.
Medications on Admission:
Tylenol prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxia
Secondary diagnosis
Metastatic Breast Cancer
Discharge Condition:
Pt died
Discharge Instructions:
Pt was made CMO and died in hospital
Followup Instructions:
Pt died in hospital
|
[
"198.3",
"733.00",
"198.2",
"276.1",
"799.02",
"V10.3",
"789.59",
"197.6",
"745.5",
"285.22",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"45.13",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7607, 7616
|
5154, 7545
|
279, 285
|
7714, 7724
|
3247, 3247
|
7809, 7831
|
2343, 2361
|
7637, 7693
|
7571, 7584
|
7748, 7786
|
2391, 3228
|
232, 241
|
313, 1793
|
3264, 5131
|
1815, 2229
|
2245, 2327
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,924
| 161,076
|
14156
|
Discharge summary
|
report
|
Admission Date: [**2165-6-24**] Discharge Date: [**2165-7-3**]
Date of Birth: [**2099-8-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior/Posterior lumbar fusion with instrumentation L5-S1
Thoracentesis
History of Present Illness:
65F with DM1, CAD s/p stent [**2161**], MR valvuloplasty (with current
moderate to severe MR) EF 55%, PAD s/p peripheral bypass, hx TIA
on ASA & plavix, s/p PPM placement, s/p lumbar fusion ([**6-25**] &
[**2165-6-26**]) who presents from ortho service after 2 days of
progressive hypoxia. patient noticed to be hypoxic in the PACU
following the lumbar fusion, and was given LV lasix without good
result. She had a CXR that revealed a RLL process and was
started on Vancomycin and Ciprofloxacin. She was given inhalers
and further lasix in the setting of hypoxia, although did not
respond. She was transitioned from nasal cannula to NRB with
oxygen saturations in the low 90s and her tachypnea increased to
>25 and was transferred to the MICU.
.
Patient denies any chest pain, lightheadeness, dizziness,
abdominal pain.
Past Medical History:
HTN,
DMII,
TIA,
HYPERCHOL,
COPD,
PVD,
ASYSTOLIC ARREST [**1-28**],
MITRAL V DZ S/P Valvoplasty
Chronic low back pain
Social History:
non smoker
no alcohol
Family History:
non contributary
Physical Exam:
Vitals - T:98.9 BP:120/106 HR:83 RR:25 02 sat: 95%
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: clear
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Imaging:
CXR: [**2165-6-29**]
FINDINGS: Left-sided dual chamber cardiac pacemaker is again
seen, unchanged. The patient is status post sternotomy, with
sternotomy sutures unchanged as well. Imaging is degraded by
motion; however, overall the right-sided pleural
effusion/consolidation appears minimally changed when compared
to the prior examination. There is persistent retrocardiac
opacity. No evidence of pneumothorax.
[**2165-7-2**] 07:13AM BLOOD WBC-12.3* RBC-2.88* Hgb-8.9* Hct-25.8*
MCV-90 MCH-30.9 MCHC-34.4 RDW-14.2 Plt Ct-423
[**2165-7-1**] 07:30AM BLOOD WBC-11.1* RBC-2.96* Hgb-9.1* Hct-26.8*
MCV-91 MCH-30.8 MCHC-34.0 RDW-14.1 Plt Ct-349
[**2165-6-30**] 03:56AM BLOOD WBC-12.0* RBC-3.00* Hgb-9.4* Hct-26.8*
MCV-89 MCH-31.3 MCHC-35.0 RDW-14.3 Plt Ct-299
[**2165-6-29**] 06:25AM BLOOD WBC-15.6* RBC-3.12* Hgb-9.7* Hct-28.5*
MCV-92 MCH-31.1 MCHC-34.0 RDW-14.1 Plt Ct-253
[**2165-6-28**] 07:20AM BLOOD WBC-16.8* RBC-3.07* Hgb-9.5* Hct-27.9*
MCV-91 MCH-30.9 MCHC-34.0 RDW-14.3 Plt Ct-218
[**2165-6-26**] 04:06AM BLOOD WBC-20.2* RBC-3.54* Hgb-11.0* Hct-31.7*
MCV-89 MCH-31.1 MCHC-34.8 RDW-14.4 Plt Ct-226
[**2165-7-2**] 07:13AM BLOOD Glucose-127* UreaN-17 Creat-0.5 Na-137
K-3.2* Cl-99 HCO3-28 AnGap-13
[**2165-6-30**] 03:56AM BLOOD Glucose-215* UreaN-27* Creat-0.5 Na-141
K-3.1* Cl-102 HCO3-28 AnGap-14
[**2165-6-29**] 09:13PM BLOOD Glucose-210* UreaN-27* Creat-0.6 Na-138
K-3.3 Cl-99 HCO3-25 AnGap-17
[**2165-6-28**] 06:00PM BLOOD Glucose-265* UreaN-25* Creat-0.7 Na-139
K-3.0* Cl-101 HCO3-26 AnGap-15
[**2165-6-27**] 04:12PM BLOOD Glucose-167* UreaN-24* Creat-0.5 Na-142
K-2.9* Cl-106 HCO3-25 AnGap-14
[**2165-7-2**] 07:13AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0
[**2165-6-28**] 07:20AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.0
Brief Hospital Course:
Ms. [**Known lastname 27462**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
circufrential fusion L5-S1. She was informed and consented for
the procedure and elected to proceed. Please see Operative Note
for procedure in detail.
Post-operatively she was administered antibiotics and pain
medication. Due to the dural tear intra-op, she remained flat
in bed for 48 hours. She subsequently developed a pneumonia
with low O2 saturation. She was transfered to the MICU where a
thoracentesis was preformed. Transudative fluid 800cc was
drained and sent for culture. All cultures have been negative
to date. She was placed on Vancomycin and Cefepime and a PICC
line placed for a 10 day course of antibiotics.
She was transfered out of the MICU to the floor where she was
able to work with physical therapy. Her O2 saturation remained
high and she was discharged in stable condition. She will
follow up in clinic in 10 days.
Medications on Admission:
See list
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
17. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
18. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed.
19. Vancomycin 1000 mg IV Q 12H
20. 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.
21. CefePIME 2 gm IV Q8H
22. Antibiotics
Please continue Vancomycin and Cefepime for 10 days. End date
is [**2165-7-13**].
23. Medication
Lantus 8 units SQ [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Stenosis and spondylolisthesis L5-S1
Pneumonia
Post-op fever
Post-op hypoxia
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Out of bed w/ assist
Lumbar corset for ambulation; may be out of bed to chair
without.
Treatment Frequency:
Plesae continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
Completed by:[**2165-7-3**]
|
[
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"V45.01",
"401.9",
"496",
"722.52",
"424.0",
"E849.7",
"997.09",
"507.0",
"518.81",
"486",
"738.4",
"E878.8",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.06",
"34.91",
"81.62",
"38.93",
"84.51",
"03.59",
"84.52",
"81.08"
] |
icd9pcs
|
[
[
[]
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] |
6788, 6860
|
3753, 4748
|
289, 365
|
6980, 6986
|
1997, 3730
|
7449, 7563
|
1415, 1433
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4807, 6765
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6881, 6959
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4774, 4784
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7010, 7217
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1448, 1978
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7235, 7334
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232, 251
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393, 1218
|
7355, 7426
|
1240, 1359
|
1375, 1399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,980
| 124,899
|
38158
|
Discharge summary
|
report
|
Admission Date: [**2189-8-6**] Discharge Date: [**2189-8-14**]
Date of Birth: [**2126-5-23**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Sesame Oil
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Shortness of breath and recurrent pericardial effusion
Major Surgical or Invasive Procedure:
Bilateral Thoracentesis at OSH
R thoracentesis at [**Hospital1 18**]
History of Present Illness:
63 yo F h/o HTN, PAF underwent PVI on [**7-21**] with pericardial
effusion and pericardial drain post-procedure for cardiac
tamponade, admitted from OSH for recurrent pericardial effusion.
She reports that she was feeling fine after her discharge [**7-24**].
She started having dry cough and central rib pain on Wed [**7-29**].
for pain. On sunday she reports worsening in her symptoms and
SOB, DOE, air hunger, fever/chills and sweats. She took herself
to the ED and was admitted to [**Hospital3 417**] Hospital on [**8-2**].
.
She was in afib without RVR on admission. Her OSH course
included initiation of Ceftriaxone and Levofloxacin for
pneumonia (consolidation b/l lower lung on chest xray). She was
also found to have b/l pleural effusions and underwent b/l
thoracentesis (8/16 L sided, [**8-5**] R sided) which was positive
for RBCs [**Numeric Identifier 18085**], WBC 144, 62 LO, 29 Mac, tot prot 3.8, pleural
alb 2.4, LDH 232, gucose 113, amylase 15. Her c/o of abd pain
and amylase 240, lipase 121 prompted a CT abd which showed
cystic liver, pleural effusions and negative for pancreatitis.
Pericardial effusion was detected on CT chest on [**8-2**] and was
followed with TTE on [**8-3**] . There was a suspicion for worsening
pericardial effusion on TTE today (slight RA invagination, ?RV
invagination) at OSH. She was given 1.5L IVF bolus and 1uFFP
prior to transfer to [**Hospital1 18**].
Medications held since [**8-5**]: coumadin, amiodarone, diltiazem and
metoprolol.
Blood cultures on [**8-5**] show gram positive cocci in clusters,
w/o speciation or susceptibilities.
Lab prior to transfer [**8-6**]: Na= 132, Hct=31, Dig=1.1, trop=0.02,
CPK=37, Cr=0.8, INR=2.0
.
On arrival to floor vitals: 128/82 93 25 100%5L
non-rebreather.
Pt reported some anxiety but no discomfort or SOB. +chest pain
in full supine position. She had 1 episode of vomiting yesterday
and some nausea this morning. She denies any diarrhea. Last BM
this AM. Foley cath in place.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. S/he denies exertional buttock or calf pain. All
of the other review of systems were negative.
Past Medical History:
Hypertension
Lacunar infarct: non-embolic per CT scan done in [**2188-12-19**]
Osteoarthritis
Infertility surgery
Breast biopsy,lumpectomy (benign)
C cection
Cholecystectomy
Knee arthroscopy
Exploratory lapartomy/appendectomy
Social History:
Married. Works part time as a physical therapist.
ETOH: Denies
Tobacco: Denies
Illicit drugs: none
Family History:
Father died of an MI in his 60s. Mother died of renal
failure in her 80s. Brother with diabetes. 2nd Brother had
diabetes and died of lung cancer. One sister who has
palpitations.
Physical Exam:
Tm/c: 97.6 Tm: 98.1 BP: 97/65-126/84 HR: 70-129 RR: 18
O2Sa: 96% RA
I: 420 O: 500
GENERAL: appears comfortable. Oriented x3. Mood, affect
appropriate. .
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink,
NECK: Supple normal JVP, no HJR
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular rhythm, tachycardic, normal S1, S2.
No m/r/g. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA on upper and mid
lobes bilaterally, decreased breath sounds at left base.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace pitting edema of lower extremities, no
clubbing/cyanosis. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Large
ecchymoses on left leg and smaller ecchymoses on left forearm.
PULSES: Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2
Pertinent Results:
[**2189-8-14**] 09:20AM BLOOD WBC-6.0 RBC-4.19* Hgb-11.9* Hct-38.0
MCV-91 MCH-28.5 MCHC-31.5 RDW-14.2 Plt Ct-443*
[**2189-8-9**] 03:59AM BLOOD WBC-9.1 RBC-3.83* Hgb-11.2* Hct-34.9*
MCV-91 MCH-29.3 MCHC-32.2 RDW-14.1 Plt Ct-538*
[**2189-8-6**] 07:06PM BLOOD WBC-10.2 RBC-3.29* Hgb-10.2* Hct-30.1*
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.2 Plt Ct-437#
[**2189-8-14**] 09:20AM BLOOD PT-26.2* INR(PT)-2.5*
[**2189-8-13**] 07:15AM BLOOD PT-22.1* PTT-28.2 INR(PT)-2.1*
[**2189-8-12**] 07:25AM BLOOD PT-19.3* PTT-25.3 INR(PT)-1.8*
[**2189-8-11**] 05:19AM BLOOD PT-16.5* PTT-24.8 INR(PT)-1.5*
[**2189-8-6**] 07:06PM BLOOD PT-19.7* PTT-28.8 INR(PT)-1.8*
[**2189-8-14**] 09:20AM BLOOD Glucose-118* UreaN-14 Creat-0.8 Na-139
K-3.5 Cl-100 HCO3-31 AnGap-12
[**2189-8-6**] 07:06PM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-136
K-3.9 Cl-99 HCO3-32 AnGap-9
[**2189-8-9**] 04:39PM BLOOD LD(LDH)-292*
[**2189-8-9**] 06:24PM BLOOD pH-7.51* Comment-PLEURAL FL
[**2189-8-10**] 01:26PM PLEURAL WBC-1250* RBC-[**Numeric Identifier 85119**]* Polys-2*
Lymphs-46* Monos-0 Meso-16* Macro-35* Other-1*
[**2189-8-9**] 05:29PM PLEURAL WBC-1000* RBC-[**Numeric Identifier 28056**]* Hct,Fl-2.5*
Polys-2* Lymphs-85* Monos-7* Meso-5* Other-1*
[**2189-8-10**] 01:26PM PLEURAL TotProt-3.5 Glucose-106 LD(LDH)-293
Albumin-2.0
[**2189-8-9**] 05:29PM PLEURAL TotProt-3.8 Glucose-116 Creat-0.6
LD(LDH)-230 Amylase-21 Albumin-2.2
[**2189-8-10**] 1:26 pm PLEURAL FLUID
GRAM STAIN (Final [**2189-8-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2189-8-13**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2189-8-9**] 5:29 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2189-8-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2189-8-12**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2189-8-10**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2189-8-10**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
Ms. [**Known lastname 20296**] is a 63yo female recently admitted to [**Hospital1 18**] for
pericardial effusion s/p drain after attempted PVI and
subsequent hypotensive episode. She was restarted on digoxin and
amiodarone at discharge. She represented to OSH w complaints of
dry cough, chest discomfort, subjective fever/chills, and found
to be in afib w/o rvr, pericardial effusion, and b/l pleural
effusions s/p thoracentesis. She was transferred here for
management of pericardial effusion with suspicion for tamponade
physiology. Currently hemodynamically stable.
.
# Pericardial effusion: Discharged [**7-24**] for treatment of
pericardial effusion s/p drain placement. Pt stable at time of
discharge with resolution of symptoms. Represented to OSH 1 wk
later for SOB, cough and fever. Symptomatology of cough, chest
pain, and fever likely [**1-20**] inflammatory reaction to prior
effusion on [**7-21**] with development of pericarditis. Transferred
from OSH for management of potential pericardial tamponade on
ECHO. Repeat in house ECHO at bedside on admission and again on
[**2189-8-7**] showed small to moderate effusion w/o tamponade
physiology. No pulsus on exam. Chest CT [**2189-8-9**] showed small
pericardial effusion. Patient never showed signs of tamponade
physiology or hemodynamic compromise. Started on colchicine and
indomethacin. Will be discharged on both with follow up with Dr.
[**Last Name (STitle) **] for reevaluation and adjustment of medications.
.
#Pleural effusions: Underwent b/l thoracentesis at OSH both
showing large RBC component. Thoracentesis on [**2189-8-9**] removed 1
liter of serousangionous fluid from the left side, thoracentesis
on [**2189-8-10**] on the right side and removed 800cc. Pleural fluid
analysis from both taps were similar. Large about of RBCs,
exudative by lights criteria, negative for malignant cells and
gram stain. Etiologies include infection, CHF, malignancy,
rheumatologic, or inflammatory secondary to pericarditis.
Afebrile, no leukocytosis, does have persistent non productive
cough, was initially treated with antibiotics that were
continued from the outside hospital, but were later
discontinued. Aggressive diuresis was undertaken for possible
improvement of effusions. No sign of systolic HF on ECHO, few
crackles on exam, negative 7.7 liters including thoracentesis
for LOS. ESR was elevated at 37, [**Doctor First Name **] negative, rheumatologic
could explain persistence of effusions however less likely due
to timing close to pericardial effusion. Malignancy was unlikely
with no malignant cells on pleural fluid cytology. Likely
inflammatory reaction to pericardial drainage in combination
with elevated INRs previously, causing pericardial and pleural
inflammation and resultant effusions; likely a post cardiac
injury syndrome. Also component of atelectasis as patient had
pleuritic chest pain with deep inspiration secondary to
pericarditis and broken sternum/ribs from previous CPR. Patient
was put on a 5 day taper of prednisone, started on colchicine
initially 0.6mg [**Hospital1 **] that was decreased to daily, and started on
indomethacin 25mg TID to decrease inflammation. After
thoracentesis her oxygenation status slowly improved, along with
her pleuritic chest pain. At discharge patient was 95% on room
air and comfortable. She was also started on Lasix 20mg PO daily
and 20meq KCl daily for some residual swelling in her lower
extremities and maintenance of fluid balance. Stable at time of
discharge.
.
# Pneumonia: Patient transferred on ticarcillin after receiving
levaquin 750mg IV since [**2189-8-2**] and ceftriaxone for unknown
period of time. Received 2 doses of cefepime at [**Hospital1 18**].
Antibiotics d/c'd [**2189-8-9**] because of no evidence of PNA at this
time. Afebrile, no leukocytosis, nonproductive cough likely [**1-20**]
pericarditis.
.
# Afib: New diagnosis of afib in 6/[**2188**]. found to be in afib w/o
RVR on admission to OSH and on admission here. Pt asymptomatic -
occasionally detects palpitations when tachycardic but
asymptomatic when rate controlled. Coumadin initially held as
possible small bleeding component to pleural effusions. Rate
controlled with digoxin and metoprolol 25mg [**Hospital1 **]. Also given
amiodarone 200mg [**Hospital1 **]. Coumadin was restarted at 2mg and INR was
2.5 at discharge. Patient to follow up at coumadin clinic.
.
#Diarrhea: Multiple episodes of diarrhea. Likely secondary to
colchicine, however C. Diff possible after antibiotics, but
negative X2. Lowered colchicine to once daily, Symptoms improved
on decreased colchicine dose.
.
# HTN: Blood pressure was well controlled throughout her
hospitalization with metoprolol 25mg as tolerated by her BP.
Cont metoprolol as outpatient for HTN.
Medications on Admission:
From OSH:
tylenol 650mg prn
mylanta
colace
milk of magnesia 10ml prn
guaifenisen
Digoxin 0.25mg daily
metoprolol tartrate 50mg [**Hospital1 **]
omeprazole 40mg
Zofran 4mg q6 prn
Ticarcillin/clavulanate 3.1g
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
6. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*45 Capsule(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1
doses.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lab Work
Check INR for Coumadin and Potassium [**Last Name (LF) 766**], [**8-17**] at [**Hospital 61**] in [**Location (un) **]. Please fax results to Dr.[**Name (NI) 29750**] office
at [**Telephone/Fax (1) 3341**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Post-Cardiac Injury Syndrome
Afib w/o RVR
Pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent for short distances
Discharge Instructions:
Dear Mrs. [**Known lastname 20296**],
You were initially admitted to the Cardiac Care Unit from [**Hospital 6451**] hospital because of concern over increased fluid
around your heart. In the CCU, it appeared that the fluid around
your heart was minimal. You also had fluid in your lungs. The
fluid was removed from both sides to help your breathing. After
the fluid removal, your breathing started to improve. It
appears that the most likely cause of the fluid collection was
an inflammatory reaction from the procedure you had (Your
pulmonary vein isolation). It can come back, but its not likely
given that the inflammation should continue to improve.
We did some changes to your medications. We started you on some
NEW medications:
* Colchicine 0.6 mg, which will help you with the inflammation.
You should take it until you see Dr [**Last Name (STitle) **] and then you both
will dicide when to stop it
* Indomethacin: this medications is like aspirin/ibuprofen, but
has stronger anti-inflammatory effect. You should take it until
you see Dr. [**Last Name (STitle) **]
* Furosemide 20 mg PO/NG DAILY. This is a "water pill", which
will help you get rid of fluid. You will need it to prevent the
fluid from building up.
* We started you on a potassium pill, that most likely you will
need as long as you continue the furosemide (mentioned above).
Changes to your medications:
* We decreased your metoprolol to Metoprolol Succinate 50 mg
Tablet Sustained Release 24 hr once a day
* Coumadin 2 mg Daily; you will need to have your INR checked
next week (see attached sheet)
Followup Instructions:
Check INR for Coumadin [**Last Name (LF) 766**], [**8-17**] at [**Hospital3 **] in
[**Location (un) **]. Please fax results to Dr.[**Name (NI) 29750**] office at
[**Telephone/Fax (1) 3341**].
Dr. [**Last Name (STitle) **]: Thursday [**2189-8-20**] at 11:00 AM at [**Hospital Ward Name 23**] Center [**Location (un) **]
in [**Location (un) 86**] - Phone:[**Telephone/Fax (1) 62**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Date/Time:[**2189-9-21**] 10:00
|
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"787.91",
"511.89",
"V58.61",
"401.9",
"428.0",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
12640, 12695
|
6445, 11204
|
346, 417
|
12797, 12797
|
4223, 5817
|
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|
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|
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|
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|
14350, 14548
|
252, 308
|
445, 2724
|
6154, 6422
|
12812, 12943
|
2746, 2974
|
2990, 3091
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,418
| 152,251
|
36146
|
Discharge summary
|
report
|
Admission Date: [**2149-11-19**] Discharge Date: [**2150-1-15**]
Date of Birth: [**2087-9-21**] Sex: M
Service: SURGERY
Allergies:
Ampicillin / Piperacillin Sodium/Tazobactam
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Hepatorenal Syndrome
Major Surgical or Invasive Procedure:
Two colonoscopies, one with biopsy
Upper endoscopy
Transesophageal echocardiography
[**2149-12-29**] liver and kidney transplant with roux en y
hepaticojejunostomy
[**2150-1-9**] nasointestinal tube
History of Present Illness:
62 y.o. male with alcoholic cirrhosis, medflighted to the
[**Hospital6 1708**] on [**10-24**] from [**Hospital3 22439**]
for hemoperitoneum of unclear etiology. Upon exploratory
laparotomy, patient was noted to be bleeding from segments 4, 5,
6 and 8. A cholecystectomy was performed as well as an open
liver biopsy given the nodular appearance of his liver, felt to
be consistent with cirrhosis. The operation was successful and
patient's post-operative course was likewise uncomplicated.
He was transferred to the medicine service at [**Hospital1 **] where discussion was held concerning transplant given
the extent of his liver disease, based on the liver biopsy which
showed cirrhosis with moderate activity. Hepatitis serologies
showed immunization against hepatitis A and B with no hepatitis
C and the etiology was felt to be alcoholic cirrhosis. His
hospital course was later significant for discovery of a portal
vein occlusion on US on [**11-5**] and encephalopathy despite
Lactulose/Rifaximin, guaiac negative stools and negative
infectious work-up. Additionally, his creatinine began to worsen
and the renal team was consulted at the onset of the elevation
and suspected hepatorenal syndrome in light of the patient's
liver disease, an undetectable urine sodium and normal renal
ultrasound. He was started on Midodrine and Octreotide on [**11-3**]
with delay in the progression of his renal failure, though it
eventually increased to 5.2 (from baseline 0.8) at the time of
transfer. Patient was also noted to have mental status changes
felt to be secondary to uremia and for this reason, an HD line
was placed for impending HD. Since liver transplantation was
being considered, the decision was made to transfer the patient
to [**Hospital1 18**] for further evaluation and thus patient was
Past Medical History:
Alcoholic Cirrhosis
s/p repair of liver laceration
Hepatorenal syndrome
Social History:
Patient reports heavy alcoholism, but stopped
approximately 4 months ago. He reports stopping tobacco use 1
month ago, but prior to that smoked as much as 1.5 ppd. He
denies
illicit drug use, has no tattoos or piercing and denies a
history
of blood transfusions. Unmarried, lives in [**Hospital1 6687**].
Family History:
NC
Physical Exam:
Vitals: T - 96.1, BP - 114/73, HR - 73, RR - 23, O2 - 93% 2L
General: Awake, alert, NAD
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: Supple, no LAD
Chest/CV: S1, S2 nl, no m/r/g appreciated
Lungs: CTAB anteriorly
Abd: Markedly distended and tense with ascites, midline incision
well-approximated and closed with staples, no signs of
infection, + BS
Ext: No c/c; 2+ bilateral pitting edema of LEs; left PICC in
place and right tunneled line in place without signs of
infection
Neuro: Awake and oriented x 3; No asterixis
Skin: No lesions
Pertinent Results:
[**2149-11-20**] 01:10AM BLOOD WBC-9.1 RBC-3.18* Hgb-10.8* Hct-30.9*
MCV-97 MCH-34.0* MCHC-34.9 RDW-16.3* Plt Ct-115*
[**2149-11-20**] 01:10AM BLOOD Plt Ct-115*
[**2149-11-20**] 02:31AM BLOOD PT-16.7* PTT-38.9* INR(PT)-1.5*
[**2149-11-20**] 01:10AM BLOOD Glucose-100 UreaN-90* Creat-5.2* Na-130*
K-3.9 Cl-98 HCO3-20* AnGap-16
[**2149-11-20**] 01:10AM BLOOD ALT-13 AST-32 LD(LDH)-251* AlkPhos-56
TotBili-1.4
[**2149-11-20**] 01:10AM BLOOD Albumin-2.9* Calcium-8.0* Phos-6.5*
Mg-2.9*
[**2149-11-21**] 06:30AM BLOOD calTIBC-118* Ferritn-581* TRF-91*
[**2149-11-30**] 06:45AM BLOOD PTH-194*
[**2149-11-21**] 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2149-11-21**] 06:30AM BLOOD PSA-0.6 AFP-1.4
[**2149-11-21**] 06:30AM BLOOD HIV Ab-NEGATIVE
[**2149-11-21**] 06:30AM BLOOD HCV Ab-NEGATIVE
[**2149-11-21**] 06:30AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2149-11-21**] 06:30AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test
[**2149-11-21**] 06:30AM BLOOD CA [**60**]-9 -Test
[**2150-1-15**] wbc 6.2, h/h 9.3/27.3, plt 264, sodium 142, potassium
4.4, chloride 113, co2 22, bun 28, creat 1.1, gluc 105, calcium
7.9, mag 1.5, phos 2.1, ast 16, alt 30, alk phos 195, t.bili
0.8, prograf trough 5.9
Abd CTA ([**11-21**]): CT ABDOMEN WITH CONTRAST: There is bibasilar
atelectasis. There are bilateral small pleural effusions, left
greater than right. The visualized heart is unremarkable. There
is a dual-chamber central venous line with one tip terminating
in the cavoatrial junction and the other tip terminating low in
the right atrium near the IVC-right atrial junction. The liver
is shrunken and nodular consistent with cirrhosis. No arterially
enhancing lesions are identified. There are two tiny sub-7 mm
hypodense lesion in the left and right lobes of the liver which
is too small to characterize, but likely simple cysts. There is
abundant ascites. There is no pathologic adenopathy. The
gallbladder is not seen. The pancreas is normal. The spleen is
normal size although measures 13.8 cm in the longest diameter.
The stomach is normal. There is a small hiatal hernia. The
adrenal glands and kidneys are normal. The small bowel loops are
normal.
Colonoscopy ([**11-25**]):
No clear cecal landmarks could be identified.
Findings:
Mucosa: Normal mucosa was noted.
Impression: Normal mucosa in the colon
Otherwise normal colonoscopy to cecum
Recommendations: CT colonography for evaluation of the right
colon and cecum
EGD ([**11-25**]):
Tortuous esophagus
Blood in the stomach body
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
CT colongraphy ([**11-25**]):
Possible flat lesion (vs adherent stool) within the mid to
distal
one third of the transverse colon. Please corelate with
colonoscopy and if
area not reached consider re-endoscopy. Please note discussion
in body of
report. Otherwise, no significant polyp or mass identified
greater than 1 cm.
Colonoscopy ([**11-27**]):
A single sessile 8 mm polyp of benign appearance was found in
the transverse colon. A single-piece polypectomy was performed
using a hot snare. The polyp was completely removed.
Impression: Polyp in the transverse colon (polypectomy)
Otherwise normal colonoscopy to cecum
Recommendations: Follow-up biopsy results
Biopsy of polyp ([**11-27**]):
Fragments of adenoma.
TEE ([**11-28**]):
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast. The result of the rest injection study is
consistent with the presence of pulmonary arteriovenous shunting
(one single bubble in 20 cardiac cycles seen in left atrium).
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta seen
up to 45cm from the incisor. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. There is no pericardial effusion.
Impression: possible pulmonary arteriovenous shunt. Normal
biventricular function. No significant valvular disease.
Head CT ([**12-1**]):
There is a 10 mm focus of intraparenchymal hemorrhage within the
right parietal lobe. There are also hypodense lesions in the
left frontal
lobe, which most likely represent small vessel ischemic change.
The [**Doctor Last Name 352**]-
white matter differentiation is well preserved. The ventricles
and sulci are normal in size and configuration. No shift of
midline structures is noted. The visualized part of the
paranasal sinuses and mastoid air cells are clear.
Repeat Head CT ([**12-1**]):
There has been no interval change since two hours ago. 10 mm
right
parietal hemorrhage is unchanged.
Brief Hospital Course:
At [**Hospital6 **] he underwent an exploratory laparotomy
and was found to be bleeding from multiple segments of his
liver. He underwent a liver biopsy (given the nodular
appearance of the liver and no previous dx of cirrhosis) and
cholecystectomy. The liver biopsy showed cirrhosis with
moderative activity. His hospital course was complicated by a
portal vein occulsion on US on [**11-5**] and encephalopathy
initially unresponsive to lacutlose and rifaximin. He also
experience ARF and was thought to have hepatorenal syndrome
therefore he was started on midodrine and octreotide on [**11-3**].
Cr continued to rise and a tunneled hemodialysis line was
placed.
.
He was transferred to [**Hospital1 18**] on [**11-19**] for consideration and
workup for liver transplantation. He underwent an extensive
workup including 2 colonoscopies with a biopsy of a polyp found
to be an adenoma in the transverse colon. Dialysis was
initiated. He was evaluated by the renal transplant team who
felt he would need a combined liver and kidney transplantation.
He was listed for transplant with a MELD of 28.
.
On [**11-30**], he was found to have acute change in mental status. A
diagnostic paracentesis showed no evidence of SBP. Head CT
showed a 1 cm acute Rt-parietal hemorrhage. 2 units of FFP and
1 units of platlets were transfused. Neurosurgery recommended
reversing his coagulopathy with Factor-IX. The patient was then
found to have eye deviation to the left and intermittent upper
extrem jerking. Neurology thought he was having a
non-convulsive status and ativan was given x 1. Repeat head CT
showed no change. He was transferred to the MICU for further
care. Chronic ischemic changes were seen on MRI from [**2144**].
.
In the MICU he was started on keppra and he underwent an EEG
which showed no seizure activity. Mental status change was
partially attributed to hepatic encephalopathy and increased
doses of lactulose and rifaximin were given. Neurology
recommended a MRI/MRA. This demonstrated four lesions in the
brain parenchyma, as seen on the FLAIR sequence, one of which
had blood products within and corresponded to the previously
noted small intraparenchymal hematoma in the right parietal
lobe. Two lesions, noted in the left frontal lobe, were
heterogeneous in appearance with a central hypointense area,
surrounded by thicker rind of FLAIR hyperintensity. No
surrounding edema or mass effect was noted. A small 5 mm
homogeneous
hyperintense lesion in the right inferior frontal lobe. The
exact nature of
these lesions was not clear from the present study. Assessment
was somehwat
limited due to lack of IV contrast.
He did not appear to have residual deficits on his neuro exam.
Plts were kept >75. The keppra was stopped on [**12-4**].
He experienced lower GI bleeding on [**12-2**] with Hct drop so 4
units PRBC, 4 units FFP, and 1 unit of plt were given. An
octreotide drip was started. Hct stablized and he had no further
bleeding, so it was thought it was secondary to the polyp. Zosyn
had been started empirically for SBP initally, however the
diagnostic para showed no sign of infection and the patient
developed a maculopapular rash on his legs so this was stopped.
The abdominal erythema around his healing incision had
increased, so vancomycin was started for possible cellulitis.
Dermatology evaluated the drug rash and ordered triamcinolone
cream [**Hospital1 **] on the rash. Derm felt the drug rash was benign and
recommended vancomycin for the abdominal cellulitis. This was
continued for 7 days.
A postpyloric feeding tube was placed for malnutrition.
On [**2149-12-29**] a liver and kidney became available. He underwent
transplant of both organs and required hepaticojejunostomy for a
bile leak. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative
reports for complete details. Induction immunosuppression was
given per protocol. CVVHD was continued intraop. Two JPs were
placed around the liver and one near the kidney. A ureteral
stent was also placed. Urine was produced immediately and CVVHD
was stopped. He was transferred to the SICU immediately
following surgery intubated where vasopressin was weaned off and
levophed was increased.
On pod 1 ([**12-30**]), he had a temp of 103. He was pan-cultured with
only the urine showing some growth of yeast. A f/u urine culture
was negative. His IV lines were exchanged and the HD line
removed. He received blood products to maintain hemostasis per
guidelines. LFTs trended down. A liver duplex was ordered. This
was a difficult evaluation of the hepatic artery, with normal
waveforms (good systolic upstroke), but decreased velocities,
particularly in the left and right hepatic arteries. No definite
evidence of arterial stenosis.
Creatinine trended up to 4.9. Albumin and lasix had been given
to increase urine output. Prograf was started on pod 0 at 2mg
[**Hospital1 **]. Trough prograf level increased to 9.0. Renal US was
unremarkable. IV Vanco and levaquin were stopped on pod 6.
Creatinine started to trend down around pod 8. Urine output was
appropriate. JP drain output was high initially, but diminished.
On [**12-31**], the patient extubated himself. He was kept extubated
on a face tent. Trophic tube feeds were started. He was
transferred out of the SICU on [**1-4**] to [**Hospital Ward Name 121**] 10 where mental
status was confused, but gradually improved. He pulled out his
feeding tube on [**1-8**]. This was replaced on [**1-9**]. Tube feeds were
adjusted per nutrition. Kcals were insuffient for needs. Nutren
2.0 was ordered to provide 2400 kcal and 96 grams of protein. He
experienced diarrhea when feedings were cycled so, continuous
feedings were resumed. He required a 1:1 sitter briefly to
prevent further inadvertant removal of the feeding tube. The 1:1
sitter was stopped as his mental status improved. Stools were
sent for c.diff. This was pending. Diearrhea was felt to be
related to the increased due to the higher rate when cycling was
briefly attempted.
Diet was advanced and tolerated, but intake was poor due to poor
appetite and mental status (flat affect/decreased energy). PT
worked with him and recommended rehab.
On [**1-9**], he experienced hypotension while ambulating. This
responded to fluid bolus and po lasix was stopped. Hct was
stable, but had trended down to 25 on [**1-11**]. Two units of PRBC
were transfused with a hct increase to 31.
The JP drains were removed as output decreased. The Roux tube
was capped after cholangiogram on [**1-5**] that showed Roux tube
located in the jejunum, no opacification of biliary tree was
likely due to partial withdrawal of the tube into jejunum.
Abdomen was soft and non-distended. The incision was clean, dry
and intact.
Vital signs remained stable. Immunosuppression continued with
cellcept 1 gram [**Hospital1 **], tapering prednisone and prograf based on
trough levels. Prograf level goal is 10. His levels had been
ranging between [**11-20**], but decreased on [**1-15**] to 5.9. Prograf was
increased to 3mg [**Hospital1 **]. He may have had increased levels due to
some diarrhea that he experienced on [**1-13**] and [**1-14**] that resolved
with resuming continuous tube feeds vs. cycled tube feeds.
[**Last Name (un) **] was consulted for assist with management of hyperglycemia
(due to the steroids) that started immediately postop in the
SICU when he required an insulin drip. This was switched to a
sliding scale and later Lantus insulin was added. Glucoses
immproved.
He will be discharged to [**Hospital 671**] Rehab. Labs will be drawn every
Monday and Thursday with results called that day to the
Transplant Center [**Telephone/Fax (1) 673**].
Medications on Admission:
Medications On Transfer:
Folate 1 mg PO QD
SC Heparin
Lactulose 30 mL QID
Midodrine 7.5 mg PO TID
Ocreotide 50 mcg SC BID
Prilosec 40 mg PO QD
Rifaximin 400 mg PO TID
Sevelamer 800 mg PO TID w/ meals
Thiamine 100 mg PO QD
Reglan 10 mg PO Q6 PRN
Zofran 1 mg by infusion Q6 PRN
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow taper per Transplant Office.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
13. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day: see printed scale.
14. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
15. Outpatient Lab Work
labs every Monday and Thursday with same day results called to
the [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**]
cbc, chem 10, ast, alt, alk phos, t.bili, albumin and trough
prograf level.
Discharge Disposition:
Extended Care
Facility:
radius specialty hosp
Discharge Diagnosis:
Acute renal failure secondary to hepatorenal syndrome
Cirrhosis, ESLD
Failure to thrive
R parietal bleed
abdominal cellulitis
anemia
Acute renal failure secondary to hepatorenal syndrome
Cirrhosis, ESLD
Failure to thrive
R parietal bleed
abdominal cellulitis
anemia
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
abdominal pain, incision or capped Roux tube site
redness/bleeding/drainage, diarrhea, decreased urine output,
weight gain of 3 pounds in a day or jaundice
No heavy lifting
[**Month (only) 116**] shower
Continue tube feedings
Followup Instructions:
Please follow up with your primary doctor, Dr. [**First Name (STitle) 2429**]
([**Telephone/Fax (1) 22442**]) within the next month.
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2150-1-22**]
9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2150-1-22**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2150-1-29**]
9:30
Completed by:[**2150-1-15**]
|
[
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"693.0",
"458.9",
"572.2",
"263.8",
"584.9",
"E930.8",
"682.2",
"303.93",
"789.59",
"518.0",
"276.8",
"211.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.91",
"99.05",
"00.93",
"87.54",
"45.13",
"39.95",
"50.59",
"50.4",
"56.74",
"88.72",
"99.07",
"45.23",
"51.37",
"96.71",
"55.69",
"45.42",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
17734, 17782
|
8233, 15953
|
325, 526
|
18093, 18100
|
3386, 8210
|
18516, 19100
|
2794, 2798
|
16279, 17711
|
17803, 18072
|
15979, 15979
|
18124, 18493
|
2813, 3367
|
265, 287
|
554, 2359
|
16004, 16256
|
2381, 2454
|
2470, 2778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,340
| 169,427
|
30908
|
Discharge summary
|
report
|
Admission Date: [**2180-6-28**] Discharge Date: [**2180-6-29**]
Date of Birth: [**2114-7-16**] Sex: F
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing / Gemcitabine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
65F with metastatic pancreatic CA to lungs, liver present with
melena.
She was seen in heme/onc clinic today to start C2D1 of PTK/Taxol
protocol and was noted to become unresponsive during a meeting
with Dr. [**Last Name (STitle) **]. She had been having declining functional status
over the past couple of weeks with chemotherapy having
refractory symptoms of nausea and pain, followed by palliative
care service. After developing unresponsiveness in clinic, she
was administered IVF through port and given narcan. She was
noted to have coffee grounds emesis. VS were noted: BP 118/68, p
90 rr 16, O2 96%. She was transferred to ED by ambulance.
In the ED, initial vitals demonstrated HR 130, bp 95/45. 2
additional PIVs were placed. She was infused 3L NS, and 1U pRBCs
were started and the patient was transferred up to the medical
ICU. Hct was noted to drop to 25.9 from a baseline of roughly
33.
Past Medical History:
Oncologic History:
Pancreatic Cancer: Pt developed abdominal pain in [**6-7**], and CT
scan showed multiple nodules in her lungs, most of which were
located in a perivascular distribution. There was also a
hypoattenuating lesion in the dome of the right lobe of the
liver, which measured about 9 mm x 12 mm; but most importantly,
there was identified in the uncinate process of the pancreas at
2.7 x 3.6 cm hypoattenuating mass that was highly suspicious for
an adenocarcinoma. This mass was found to encase the SMA and
was also associated with occlusion of SMV as it passes through
the mass. The patient was also incidentally found to have AAA.
On [**2179-6-3**], she also had a CA-19.9 evaluated,which was
elevated to 12,654. The patient was initiated on weekly
gemcitabine therapy (from [**Date range (1) 73037**]/07)and for unclear reasons
had episodes of neurological disturbances which required
admission to the hospital. On a subsequent instance, the
patient was readmitted with intermittent fevers for ten days as
well as altered mental status and was recently discharged after
a workup demonstrated no neurological abnormalities. She was
taken off gemcitibine and is currently on CapeOx regimen with
oxaliplatin and capecitabine (second cycle on [**11-3**])
.
OTHER PAST MEDICAL HISTORY:
-hyperlipidemia
-AAA
-Depression
Social History:
The patient smoked for several years but has quit recently and
she also is a recovering alcoholic.
Family History:
Her mother died of lung cancer, although she was a smoker. She
also suffered from stroke and required a triple vessel CABG.
She has 3 children, all of whom are healthy.
Physical Exam:
VS: Temp: 97.4 BP: 93/59 HR: 81 RR: 15 O2sat: 100 RA
GEN: awake, alert, slight in appearance, responds verbally to
questions A+Ox3
HEENT: PERRL, EOMI, MM dry
RESP: CTAB
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, no
ascites
EXT: no c/c/e
Pertinent Results:
[**2180-6-28**] 10:00AM BLOOD WBC-14.3*# RBC-2.64*# Hgb-8.2*#
Hct-25.9*# MCV-98 MCH-31.3 MCHC-31.9 RDW-14.2 Plt Ct-390#
[**2180-6-28**] 01:42PM BLOOD WBC-11.2* RBC-2.33* Hgb-7.2* Hct-22.4*
MCV-96 MCH-31.0 MCHC-32.2 RDW-14.6 Plt Ct-216
[**2180-6-28**] 05:12PM BLOOD WBC-16.7* RBC-3.31*# Hgb-10.6*#
Hct-30.5*# MCV-92 MCH-31.9 MCHC-34.6 RDW-14.7 Plt Ct-219
[**2180-6-28**] 09:05AM BLOOD Neuts-92.4* Bands-0 Lymphs-6.7*
Monos-0.7* Eos-0.1 Baso-0.1
[**2180-6-28**] 10:00AM BLOOD Neuts-79.3* Bands-0 Lymphs-19.7
Monos-0.7* Eos-0.1 Baso-0.2
[**2180-6-28**] 11:36AM BLOOD PT-15.3* PTT-23.9 INR(PT)-1.3*
[**2180-6-28**] 11:45AM BLOOD PT-16.6* PTT-24.4 INR(PT)-1.5*
[**2180-6-28**] 01:42PM BLOOD PT-15.9* PTT-25.2 INR(PT)-1.4*
[**2180-6-28**] 10:00AM BLOOD Glucose-292* UreaN-15 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-16* AnGap-21*
[**2180-6-28**] 01:42PM BLOOD Glucose-218* UreaN-13 Creat-0.5 Na-139
K-3.8 Cl-108 HCO3-22 AnGap-13
[**2180-6-28**] 09:05AM BLOOD ALT-24 AST-26 LD(LDH)-209 AlkPhos-426*
Amylase-23 TotBili-0.8 DirBili-0.4* IndBili-0.4
[**2180-6-28**] 01:42PM BLOOD Calcium-7.2* Phos-3.2 Mg-1.6
[**2180-6-28**] 11:21AM BLOOD Hgb-7.4* calcHCT-22
Brief Hospital Course:
#. CMO status: A family meeting was held with several members
including the patient's children with the medical team including
Dr. [**Last Name (STitle) **], [**Doctor Last Name 12879**] and [**Doctor Last Name **]. The decision was made to
pursue no further blood draws, no transfusions, and to treat the
patient with the goal for comfort. The patient expired quietly
and comfortably in the presence of her family on [**2180-6-29**].
# Upper GIB: Significant blood loss with hct drop from baseline
33 to 22. Now s/p urgent EGD revealing infiltrating tumor into
duodenum with question obstruction. No active bleeding was
identified on EGD raising clinical suspicion for bleed distal to
the mass vs spontaneous resolution. Now transfused to hct 30,
bumped from 22 after 2U pRBCs. No further intervention as
above.
# Pancreatic CA: Metastatic CA with tumor eroding into duodenum
- comfort care
Medications on Admission:
AMYLASE-LIPASE-PROTEASE [PANCREASE] - 20,000 unit-[**Unit Number **],500
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by
mouth three times a day
DIPHENOXYLATE-ATROPINE [LOMOTIL] - 2.5 mg-0.025 mg Tablet - 1
Tablet(s) by mouth 1 tablet every 6-8 hours as needed for
diarrhea
HYDROMORPHONE [DILAUDID] - 4 mg Tablet - [**2-3**] Tablet(s) by mouth
q3h as needed for pain
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [**2-2**] Tablet(s) by mouth
q8hrs
as needed for nausea, anxiety, insomnia
ONDANSETRON HCL [ZOFRAN] - 8 mg Tablet - 1 Tablet(s) by mouth
q8hrs as needed for nausea - No Substitution
OXYCODONE - 5 mg Tablet - 2 Tablet(s) by mouth q 2 hrs as needed
for pain
OXYCODONE [OXYCONTIN] - (Dose adjustment - no new Rx) - 30 mg
Tablet Sustained Release 12 hr - 1 Tablet Sustained Release 12
hr(s) by mouth three times a day
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth once one
hour prior to contrast
SCALP PROSTHESIS - - apply as directed daily as directed
Chemotherapy induced alopecia
SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s)
by mouth once a day - No Substitution
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
pancreatic ca
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2180-7-4**]
|
[
"V66.7",
"578.1",
"285.1",
"441.4",
"197.0",
"197.7",
"157.8",
"311",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6564, 6573
|
4393, 5294
|
310, 315
|
6630, 6639
|
3226, 4370
|
6695, 6858
|
2735, 2906
|
6535, 6541
|
6594, 6609
|
5320, 6512
|
6663, 6672
|
2921, 3207
|
262, 272
|
343, 1245
|
2568, 2602
|
2618, 2719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,327
| 177,168
|
46259
|
Discharge summary
|
report
|
Admission Date: [**2174-1-29**] Discharge Date: [**2174-3-1**]
Date of Birth: [**2094-12-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Meperidine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
[**2174-1-29**] Cerebral Angiogram with coiling of L supraclinoid ICA
aneurysm
[**2174-1-29**] Right fronatl External ventricular drain
[**2174-2-1**] Cerebral angiogram
[**2174-2-6**] Right frontal External ventricular drain re-placed
[**2174-2-8**] Left frontal external ventricular drain placement
[**2174-2-25**] Left frontal VP shunt
[**2174-2-28**] PEG
History of Present Illness:
HPI: 79yo F w/ h/o HTN found down this AM w/ altered mental
status and unwitnessed fall. Was found by husband on floor, with
urinary incontinence noted. Last seen normal on evening of
[**1-29**].
Was evaluated on [**1-29**] in ED for nausea, vomiting, and headache
and was stable and discharged at that time. On arrival to ED
patient is non-vocal and is unable to provide history.
Past Medical History:
HTN, HLD
Social History:
Social Hx: per OMR no tobacco, occasional alcohol
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
GCS 8 E: 2 V:1 Motor 5
O: T: 100.5 BP: 126/85 HR: 90 R 14 O2Sats 100% RA
Neuro: lethargic, non-vocal, not following commands, EO to
noxious, pupils 2->1.5 bilaterally, +corneal, +gag, moving all
extremities spontaneously w/ strength, localizing noxious
stimuli, toes upgoing bilaterally, no clonus
ON DISCHARGE
Patient is generally lethargic, but opens eyes to voice. PERRL 3
to 2mm bilaterally EOM I.
Moves all extremities spontaneously.
Cranial incision closed with nyelon sutures.
Pertinent Results:
[**1-30**] CTA:
1. Head CT shows diffuse subarachnoid hemorrhage and
hydrocephalus.
2. CT angiography demonstrates a 6-mm aneurysm arising from the
left internal carotid artery C6 segment, pointing superiorly
with a 4-mm neck. No other aneurysms are seen.
[**1-30**] Cerebral Angio:
Successful embolization of the supraclinoid left internal
carotid artery
aneurysm.
[**1-30**] CT C-spine: No fractures
[**1-31**] CT head: Interval increase in the amount of blood in the
occipital horns of the lateral ventricle, the third ventricle
and the fourth ventricle with a small amount of blood adjacent
to the catheter opening in the right frontal [**Doctor Last Name 534**].
[**2-1**] CTA Head: IMPRESSION:
1. Stable diffuse subarachnoid hemorrhage involving both
hemispheres with
redistribution and resolution of the intraventricular component.
2. Evolution of scattered infarcts in the left fetal origin PCA
vascular
territory and left frontal lobe which are most likely embolic in
nature.
3. Diffuse narrowing of left PCA and bilateral distal A2 and M3,
M4 branches. In conjunction with the more recent CT performed at
the time of this report, this finding appears largely related to
technical issues, though an actual component of peripheral
vasospasm appears to be present.
4. Further decrease of the ventricular size with stable position
of right
frontal ventriculostomy catheter.
[**2-2**] ECHO: IMPRESSION: Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
[**2-2**] CTA Head: IMPRESSION:
1. Evolving scattered infarcts, involving the left PCA territory
as well as small lacunar area in the left frontal corona
radiata.
2. Mild spasm involving the left PCA and bilateral anterior and
middle
cerebral artery terminal branches.
3. Unchanged appearance of extensive subarachnoid hemorrhage
with relatively small intraventricular component.
4. Stable size and configuration of ventricles.
[**2-2**] Angio- / Cerebral
FINDINGS: Left common carotid artery arteriogram shows filling
of the left
internal carotid artery along the cervical, petrous, cavernous
and
supraclinoid portion. The previously coiled supraclinoid
aneurysm stays
obliterated. The MCA is normal in caliber along with the
internal carotid
artery and the fetal PCA. The anterior cerebral artery is
smaller in caliber consistent with a right dominant A1.
Right common carotid artery arteriogram again demonstrates that
the right
internal carotid artery fills well along the cervical, petrous,
cavernous and supraclinoid portion. The anterior and middle
cerebral arteries fill well. The anterior cerebral artery is
seen to be dominant and supplies both hemispheres.
IMPRESSION: [**Known firstname 6739**] [**Known lastname **] underwent cerebral angiography which
revealed no
evidence of vasospasm. The previously coiled aneurysm continues
to stay
obliterated.
[**2174-2-4**] LENIES
CONCLUSION: No evidence of DVT in right or left lower extremity.
[**2174-2-8**] CT BRAIN:
IMPRESSION: New focus of air in the frontal [**Doctor Last Name 534**] of the right
lateral
ventricle with otherwise stable exam.
[**2174-2-8**] CT BRAIN:
Diffuse subarachnoid hemorrhage is largely stable from prior
exam.
Ventriculostomy catheter has been removed. Intraventricular
hemorrhage has
significantly progressed from study obtained 11 hours prior, now
extending
into and filling the right lateral, third and fourth ventricles.
In addition, the ventricles appear increased in size. For
example, frontal horns of the lateral ventricles currently
measure 4.2 cm in diameter, previously 3.6 cm (2:11). The third
ventricle measures 1.4 cm, previously 1.1 cm (2:12). A locule of
gas involving the frontal [**Doctor Last Name 534**] of the right lateral ventricle is
unchanged (2:12). Focal hyperattenuation with surrounding
hypodensity along the previous ventriculostomy tract, likely
represents hemorrhage with surrounding edema (2:13). Small
subgaleal hematoma, soft tissue edema and a burr hole overlying
the right frontal area is unchanged, likely post-procedural.
[**2174-2-9**] CT BRAIN:
IMPRESSION:
1. Similar extent of diffuse subarachnoid hemorrhage and
right-predominant
intraventricular hemorrhage.
2. Interval placement of left frontal approach shunt catheter
with significant improvement in degree of lateral
ventriculomegaly, more on the left.
3. No new hemorrhage, major infarct, or increased mass effect.
[**2174-2-11**] CT Head:
IMPRESSION:
1. Interval increase in dilatation of the occipital [**Doctor Last Name 534**] of the
left lateral ventricle with increase in the amount of blood
pooling in this region.
2. Persistence of subarachnoid hemorrhage, and persistence of
blood products in the right ventricle as well at the right
frontal lobe.
3. Persistence of hypodensity in the left occipital lobe
consistent with a
chronic infarction.
[**2174-2-12**] CXR
REASON FOR EXAMINATION: Ventilation-acquired pneumonia in a
patient with
subarachnoid hemorrhage.
AP radiograph of the chest was compared to [**2174-2-8**].
The ET tube tip is 3.5 cm above the carina. The Dobbhoff tube
tip is in the stomach. Heart size is normal. Mediastinum is
stable. The PICC line tip is at the level of mid SVC. Right
lower lobe opacity has progressed consistent with either
atelectasis or infectious process. Upper lungs are essentially
clear. No appreciable pleural effusion or pneumothorax is seen
[**2174-2-12**] LEFT SHOULDER
REASON FOR EXAMINATION: Trauma, shoulder swelling.
Two limited views of the left shoulder were reviewed.
There is chronic widening of the left acromioclavicular joint,
8.6 mm. There is no acute fracture or dislocation.
Radiology Report CT Chest, ABD & PELVIS WITH CONTRAST Study Date
of [**2174-2-18**] 1:47 PM
IMPRESSION:
1. Mild dependent bibasilar atelectasis. Ground glass opacity at
the right
lung base may represent aspiration in the appropriate clinical
setting. No
consolidative pneumonia.
2. 7-mm ground-glass nodule at the right apex. If the patient
has no risk
factors for malignancy, followup with dedicated chest CT is
recommended at
6-12 months. If the patient has risk factors for malignancy
(e.g. smoking),
dedicated chest CT is recommended in [**4-12**] months.
3. No evidence of infection in the abdomen or pelvis.
4. Massive amount of stool in the rectum.
5. Nonobstructing stone in the left kidney.
Head CT [**2174-2-19**]:
IMPRESSION:
1. Interval increase in dilatation of the ventricular system,
consistent with progressive hydrocephalus.
2. Interval decrease in quantity of multi-compartmental
intracranial
hemorrhage, as described above.
3. No new intracranial hemorrhage, acute large vascular
territorial
infarction, or central herniation.
Head CTA [**2174-2-21**]:
IMPRESSION:
1. Slight decrease in ventricular size which remains still
dilated.
2. CT angiography shows unchanged appearance of the vascular
structures
compared with [**2174-2-6**], but minimal diffuse vasospasm is seen
compared to the CT of [**2174-2-1**]. No occlusion is seen
Head CT [**2174-2-23**]:
1. Moderate ventricular dilation, minimally increased since the
recent CTA
study. Correlate with catheter function and position.
Intraventricular
hemorrhage as before. No new areas of hemorrhage identified.
2. Left frontal lucent calvarial lesion is unchanged since
[**2174-1-29**] and since the MR [**First Name (Titles) 767**] [**2164-12-13**] and
likely benign.
Head CT [**2174-2-28**]
1.Decreased amount of air in the ventricles and in the left
frontal lobe
surrounding the catheter .
2. No evidence of new hemorrhage or other acute intracranial
process.
Brief Hospital Course:
Ms. [**Known lastname **] was found to have a left superclinoid aneurysm and
obstructive hydrocephalus. A right frontal EVD was placed
emergently and the patient subsequently went to the angio suite
for coiling of her aneurysm. Post coiling the patient was
placed on a heparin drip for 12 hours and transported intubated
to the ICU.
ICU course:
[**1-31**] Patient remained stable, on examination she was moving all
four extremities spontaneously. Her EVD stopped working for a
period of time, a CT was obtained that showed a Clot at the end
of her EVD. She recieved 2mg of IT TPA which desolved the clot
and she started to drain normally.
[**2-1**] TCD w increased velocities on left dista MCA, minimal
respons to commands with no motor weakness. Pressing to SBP 140
[**2-2**] Cerebral angiogram negative for vasospasm, ECHO with EF>55
and normal biventricular function
[**2-3**] febrile to 102, blood/urine/CSF cultures sent. Off
pressors now, Dilantin changed to Keppra and ASA started
On [**2-4**], The evd was at 15 and open. The patient had a fever
spike to 102 and was cultured by icu team. A picc line was
placed.
On [**2-5**], The EVD was raised drain to 20. Transcranial doppler
studies were consistent with mild vasospasm in the left MCA,
borderline vasospasm in the Right MCA. lower extremity
ultrasound of the bilateral lower extremity was performed and
were negative.
On [**2-6**], The EVD stopped draining CSF. TPA 2mg was instilled
to the EVD catheter. The Aspirin and keppra ws discontinued. A
ChestXRay was performed which was suggestive of mid/upper lung
emphysema. The Hematocrit was 26 and the patient was transfused
with 1 unit of PRBCs.
On [**2-6**], A CTA of the Head was performed and showed NO vasospasm.
The EVD stopped draining at 1100 and TPA not given due to small
hemorhage noted along the EVD tract. The EVD removed and large
clot noted in the distal end of the EVD catheter and replaced in
same tract without difficulty. The EVD was raised to 20 and
open.
She remained stable and the EVD catheter stopped functioning.
It was left open at 10 cm if H20. It was then intermittently
functioning for a day or so and her vetricular size remained
stable as did her clinical exam. She had the right frontal EVD
removed on [**2-8**]. It was noted some hours afterwards that her
clinical exam had changed. CT imaging demonstrated large new
intraventricular hemorrhage. She was re-intubated and a left
sided External Ventricular drain was placed. Follow up imaging
diplayed worsening hemorrhage. Her drian remains functional and
her exam stabilized. On [**2-10**], patient had low grade fevers with
episodes of tachycardia and tachypnea. She was tranfused with
PRBCs for low hct. Cultures were sent. She continued to spike
and patient was more lethargic on examination. Sputum culture
was positive and she was placed on vanc/zoysn for presumed VAP.
On [**2-11**] a CT of the head was performed which was stable, her EVD
was raised to 20 and she was started on salt tabs for
hyponatremia. On the weekend of the 8th she fever spiked to
102.8 / her abx were switched to Nafcillin for RLL PNA. She
remains intubated at present.
A re-clamping trial occured on the 9th and she failed within 5
hours. Her drain was re-opened. On [**2-15**] she appeared more
lethargic in the AM but seemed to perk up late morning. Early
afternoon, she once again appeared lethargic. She was noted to
be tachpenic and working to breathe, she was afebrile. Her EVD
was dropped to 15cm. An ABG was sent which showed a PO2 of 66. A
repeat NA was 127 and 3% saline was started at 20 cc/hr.
Patient had persistant fevers on [**2-17**] and [**2-18**] despite
antibiotics. An ID consult was consulted for further
recommednations. A CT of the chest , abdomen, and pelvis was
performed and consistent with Mild dependent bibasilar
atelectasis. Ground glass opacity at the right lung base may
represent aspiration, but no
consolidative pneumonia, 7-mm ground-glass nodule at the right
apex. If the patient has no risk factors for malignancy,
followup with dedicated chest CT is recommended at 6-12 months.
If the patient has risk factors for malignancy (e.g. smoking),
dedicated chest CT is recommended in [**4-12**] months. No evidence of
infection in the abdomen or pelvis and a non-obstructing stone
in the left kidney.
Patient was started on Cipro on [**2-20**] for a UTI, her Dilantin was
found to be supertheraptic, and put on hold, she had an EEG that
was negative initially but then some subclinical seizures were
noted on EEG on [**2-21**] into [**2-22**] and she was started on Keppra.
Speech therapy came by for an initial evaluation and recommended
a video swallow when patient is able to travel out of the ICU.
On [**2-23**], her exam remained unchanged, EEG [**Location (un) 1131**] from [**2-22**] into
[**2-23**] was improved but showed rare seizure activity. Her Keppra
was increased to 500mg [**Hospital1 **]. There was no further seizure
activity noted. Her exam remained unchanged. On [**2-24**] CSF was
sent and showed no sign of infection. On [**2-25**], she underwent a
surgical placement of a L VP shunt. She received one unit of FFP
and platelets in the OR intraop. There were no complications and
her VP shunt was programmed to 1.0.
She underwent a PEG placement on [**2-28**] without complications. A
CT of the head was performed that showed persistant enlarged
ventricles. Her shunt settings were dialed down to .5.
Patient was medically stable and screened for rehab and
discharged to [**Hospital 100**] rehab on [**3-1**].
Medications on Admission:
Lipitor 10,
Diovan 160,
vit D3 1000u,
MVI,
ranitidine 150
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO HS (at
bedtime).
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. potassium chloride 20 mEq Packet Sig: One (1) Packet PO PRN
(as needed).
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth care.
6. methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day): Please monitor Na level and wean off if NA
consistantly above 130.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day.
11. insulin regular hum U-500 conc Injection
12. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. 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.
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
SAH
L supraclinoid ICA aneurysm
Interventricular hemorrhage
Hydrocephalus
Fever
Urinary tract infection / complicated
Left Thalamic Lacunar Infarct
Anemia requiring transfusion
Hyponatremia
Altred mental status
Ventilator aquired Pneumonia
protien/calorie malnutrition
Dysphagia
Seizures
Lethargy
Aphasia
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Generally non verbal except with family
Discharge Instructions:
What to report to office:
?????? Changes in vision (loss of vision, blurring, double
vision, half vision)
?????? Slurring of speech or difficulty finding correct words to
use
?????? Severe headache or worsening headache not controlled by
pain medication
?????? A sudden change in the ability to move or use your arm or
leg or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow
or green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please have a CT of the head performed here at [**Hospital1 18**] for our
review, you will not be seen in our office at this time.
Your sutures on your head should be removed on [**2-8**]. This can
be done by a practitioner at your rehab facility.
Please follow-up with Dr [**First Name (STitle) **] in 4wks with a MRI/MRA ([**Doctor Last Name **]
protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Please follow up with your primary care physician regarding the
CT of the Chest/Abdomen/and pelvis findings which included a
7-mm ground-glass nodule at the right apex. If you have no risk
factors for malignancy, followup with dedicated chest CT is
recommended at 6-12 months. If you have risk factors for
malignancy (e.g. smoking), dedicated chest CT is recommended in
[**4-12**] months.
Completed by:[**2174-3-1**]
|
[
"997.31",
"276.1",
"997.02",
"434.91",
"430",
"331.4",
"348.5",
"599.0",
"482.41",
"780.39",
"263.9",
"276.0",
"285.9",
"999.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"02.34",
"43.11",
"39.76",
"02.22",
"96.6",
"38.93",
"96.71",
"02.39"
] |
icd9pcs
|
[
[
[]
]
] |
16465, 16531
|
9351, 14922
|
284, 645
|
16880, 17039
|
1726, 2142
|
18042, 18890
|
1174, 1182
|
15031, 16442
|
16552, 16859
|
14948, 15008
|
17063, 17063
|
17089, 18019
|
1212, 1707
|
234, 246
|
673, 1057
|
6178, 9328
|
1079, 1090
|
1106, 1158
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,723
| 167,718
|
16672
|
Discharge summary
|
report
|
Admission Date: [**2174-7-10**] Discharge Date: [**2174-7-27**]
Date of Birth: [**2106-10-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Transfer from surgery for thrombocytopenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 year old male from NH with a past medical history significant
for hepatitis C, recent prolonged hospital course for Group B
Strep endocarditis with porcine MVR [**4-9**], and laryngeal cancer
admitted to surgery for intervention of L foot nonhealing ulcer
with pain x 3 months. The patient was admitted for intervention
[**2174-6-26**] but Dr. [**Last Name (STitle) 3124**] was forced to reschedule. On this
admission, the patient was found to be thrombocytopenic with
elevation of INR to 1.5, new findings per OMR and PCP. [**Name10 (NameIs) **] note,
the patient had been started on levofloxacin and Lasix
approximateley 6 days prior to presentation for presumed
pneumonia and pleural effusion, respectively. In addition, the
patient has had a PICC line in place with heparin flushes for
approximately 4 months per report. [**Name8 (MD) **] RN at nursing home, there
have been no changes in diet or new supplements. The patient is
confused but otherwise has no complaints.
Past Medical History:
Laryngeal cancer
h/o endocarditis with Group B strep with peripheral emboli to LE
[**4-9**]
CAD s/p CABG LAD/RCA and MVR [**5-10**]
Ischemic L foot ulcer
Hepatitis C
HTN
Hypercholesterolemia
Meningitis
Chronic back pain
Social History:
Roscommon NH resident for past 4+ months. Separated from wife,
had been living with girlfriend before being transferred to a
nursing home. Has a daughter in town and a son in [**Name (NI) 9012**] who
are involved in their father's care. 40+ year tobacco history.
Former cocaine.
Family History:
Non-contributory
Physical Exam:
VS: Tm 98.0 Tc 98.0 BP 146/78 (132-146/78-80) HR 85 (79-85) RR
18 O2sat 94% RA
General: Drowsy but arouses to voice, NAD
HEENT: PERRLA, EOMI, MMM, no mucosal petechiae
Heart: RRR, loud S1, normal S2, +S3, systolic murmur
Lungs: Decreased bs left base, dullness left [**12-7**]
Abdomen: +bs, soft, NTND, +hepatomegaly, liver edge smooth, no
splenomegaly
Extremities: Dopplerable DP/PT pulses bilaterally; left foot 5cm
x 3cm dorsal medial shallow ulcer, fibrinous very mild serous
discharge, no pus
Neuro: Oriented to person, year
Pertinent Results:
[**2174-7-10**] 07:40PM WBC-4.6 RBC-3.90* HGB-11.9* HCT-33.5* MCV-86
MCH-30.6 MCHC-35.6* RDW-17.6*
[**2174-7-10**] 07:40PM PLT COUNT-68*#
[**2174-7-10**] 07:40PM GLUCOSE-112* UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
[**2174-7-10**] 07:40PM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-2.1
[**2174-7-10**] 07:40PM PT-15.0* PTT-24.3 INR(PT)-1.4*
.
ART EXT (REST ONLY) [**2174-5-12**]
IMPRESSION:
1. Severe arterial insufficiency at the level of the left
superficial femoral
artery with probable outflow disease.
2. Outflow disease in the right lower extremity.
.
CHEST (PORTABLE AP) [**2174-7-10**]
Tip of the right PICC line projects over the mid third of the
superior vena cava. Small-to-moderate left pleural effusion and
severe left lower lobe atelectasis have worsened. The patient
has had median sternotomy, coronary bypass grafting and mitral
valve replacement. The heart size is top normal. There is no
pulmonary edema, or indication of pneumothorax.
.
CHEST (PORTABLE AP) [**2174-5-20**]
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs: The patient has had median sternotomy, mitral valve
replacement, and coronary bypass grafting. Heart is mildly
enlarged. Mild interstitial abnormality present is probably
edema. Opacification at the base of the left lung is probably a
combination of atelectasis and small-to-moderate left pleural
effusion. No pneumothorax. Tip of the right PIC catheter
projects over the
upper third of the SVC. No pneumothorax.
.
ECG [**2174-7-11**]
Sinus rhythm
Marked right axis deviation
Right bundle branch block
Inferior infarct - age undetermined
Nonspecific lateral T wave changes
Since previous tracing, QRS and T wave changes in lead V4 - ?
lead placement
.
Abdominal/Pelvic US [**2174-7-13**]: 1.Geographic heterogeneous liver
consistent with fatty infiltration. More advanced forms of
liver disease such as fibrosis/cirrhosis cannot be excluded.
2.Gallbladder sludge without evidence of acute cholecystitis.
Patent hepatic vasculature.
.
Liver/Gallbladder US [**2174-7-13**]: 1. Geographic heterogeneous liver
consistent with fatty infiltration. More advanced forms of
liver disease such as fibrosis/cirrhosis cannot be excluded. 2.
Gallbladder sludge without evidence of acute cholecystitis.
Patent hepatic vasculature.
.
CT Thorax: [**2174-7-14**] 1)Multiple right-sided pulmonary emboli to
the lobar arteries. 2) Elevation of left hemidiaphragm with
either atelectasis or pneumonia in the left lower lobe and
lingula and a small non-loculated appearing left pleural
effusion. Findings could all be due to atelectasis from prior
cardiac surgery with a chronic elevation of the left
hemidiaphragm. A sniff test could be performed to assess for
left diaphragmatic paralysis if indicated. 3) Enlarged liver
with attenuation of the intrahepatic branches of the portal
veins. Heterogeneous perfusion could be due to nutmeg liver
(passive cardiac congestion) or cirrhosis. This study was not
tailored to assess for focalhepatic masses.
4) Sigmoid diverticulosis. Slight colonic wall thickening in
the sigmoid most likely due to chronic diverticular disease.
Superimposed low protein state from liver failure is also
possible.
.
Bilateral LE US ([**2174-7-15**]):Thrombus in relation to the right
common femoral vein extending down into the upper portion of the
right superficial femoral vein.
.
Right UE US ([**2174-7-15**]):Partially occlusive thrombus within the
right subclavian vein. Patient refused evaluation of the right
internal jugular vein.
.
CT Head ([**2174-7-16**]): 1. No evidence of intracranial hemorrhage.
2. Periventricular changes consistent with chronic
microvascular infarctions. 3. Extraaxial spaces are prominant
for a patient of this age; this can be associated with chronic
alcohol or benzodiazopene exposure.
.
RUQ Ultraound ([**2174-7-17**])
1. Patent hepatic vasculature. 2. Trace ascites with
pericholecystic fluid and gallbladder wall edema and sludge that
is worse compared to the previous exam. No gallstones are seen.
The gallbladder was not distended. This appearance may be seen
in the setting of liver disease. Clinical correlation
recommended.
.
CT Head ([**2174-7-18**]): No acute intracranial pathology including no
signs of intracranial hemorrhage.
.
Chest X-ray ([**2174-7-18**]): There has been prior median sternotomy,
coronary bypass surgery and mitral valve replacement. The
cardiac silhouette is enlarged and has slightly increased
compared to the previous radiograph. There is vascular
engorgement and perihilar haziness. Moderate left pleural
effusion has likely slightly increased in size even allowing for
slight differences in patient positioning. There is a new area
of patchy consolidation in the right lower lobe, which may be
due to aspiration or evolving pneumonia in the appropriate
clinical setting.
.
Repeat Chest X-ray ([**2174-7-19**]): The NGT is now present with its
tip in unremarkable position in the proximal stomach. There is
persistent collapse/consolidation/effusion at the left base.
Persistent patchy streaking infiltrates are slightly more
prominent in the right upper lobe and at the right lung base.
The visualized lung fields are otherwise clear. No overt CHF.
.
MR [**Name13 (STitle) 430**] ([**2174-7-19**]): Study significantly limited by patient's
motion demonstrating no acute ischemic event or intracranial
arterial occlusion. Generalized atrophy and small vessel
chronic ischemic changes in the deep/periventricular white
matter.
.
MR Abdomen: No abscess is visualized within the liver. No
abnormal collections are visualized within the abdomen and
pelvis.
.
TEE ([**2174-7-21**]): No echocardiographic evidence of endocarditis.
Normally-functioning mitral bioprosthesis.
.
_______________________WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2174-7-27**] 04:45AM 4.3 4.10* 12.4* 38.7* 95 30.3 32.1 21.7*
143*
__________________Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2174-7-27**] 04:45AM 98 15 0.7 147* 3.6 114* 21* 16
_______________________ALT AST LD(LDH) AlkPhos TotBili
[**2174-7-27**] 04:45AM 193* 49* 385* 152* 1.0
[**2174-7-26**] 04:25AM 227* 66* 399* 166* 1.2
[**2174-7-25**] 05:15AM 260* 61* 349* 162* 1.3
[**2174-7-24**] 03:24AM 305* 78*1 530* 151* 1.1
1 HEMOLYSIS FALSELY ELEVATES AST
[**2174-7-23**] 03:25AM 352* 41* 272* 144* 1.0
[**2174-7-22**] 05:40AM 455*1 63* 307* 137* 1.1
1 VERIFIED BY DILUTION
[**2174-7-21**] 05:45AM 527* 101* 293* 140* 1.1
[**2174-7-20**] 05:50AM 733* 181* 331* 164* 1.5
[**2174-7-19**] 04:00PM 864* 252*1 579*1 180*2 1.6*
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
2 HEMOLYSIS FALSELY DECREASES THIS RESULT
[**2174-7-18**] 05:45AM 1113*1 488* 434* 205* 1.6*
1 VERIFIED BY DILUTION
[**2174-7-17**] 06:30AM 1082*1 679* 923* 169* 1.9*
ADDED TSH,B12 AT 0937 ON 13-08-06
1 VERIFIED BY DILUTION
[**2174-7-16**] 06:25AM 823*1 484* 681* 171* 1.8*
1 VERIFIED BY DILUTION
[**2174-7-15**] 05:15AM 593* 256* 511* 210* 47 1.5 0.8* 0.7
Brief Hospital Course:
A/P: 67 yoM with PVD, hepatitis C, recent endocarditis admitted
to surgery [**2174-7-10**] for revascularization of L foot ulcer,
transferred to medicine [**2174-7-12**] for new onset thrombocytopenia.
While here, he was found to have multiple right sided PE's, gram
negative rod bacteremia, elevated liver enzymes, thrombi in his
right subclavian and right superficial femoral veins, and acute
mental status changes. See brief hospital course by problem
below.
.
1. Thrombocytopenia
The patient was transferred to medicine due to a decreased
platelet count. Per OMR, his platelet count had been 255 on
[**6-27**], but decreased to 68 on [**7-10**]. Multiple etiologies were
considered for this thrombocytopenia. Heparin-induced
thrombocytopenia was considered as the patient had had heparin
flushes in his PICC line. This was eventually ruled out due a
negative HIT antibody test and repeat antibody test and a
negative serotonin-release assay. DIC or TTP was also considered
due to thrombocytopenia, elevated d-dimer, multiple PE's found
on CT scan (see more details below), some schistocytes on
peripheral blood smear, and in the setting of bacteremia (see
details below). However, a normal fibrinogen and no evidence of
sepsis made this diagnosis less likely. It was also thought
that the thrombocytopenia may have been due to sepsis itself,
given the gram negative rod bacteremia, but again his
thrombocytopenia persisted even in the absence of acute symptoms
of sepsis. Drug-induced thrombocytopenia was considered to be
most likely, with possible drugs including levofloxacin, Lasix,
and eventually cefepime. The patient was initially switched to
argatroban due to concerns about HIT, but was then switched to
lepirudin due to concerns about elevated LFT's. He was placed
back on heparin when the antibody and serotonin assay results
came back negative. His platelets improved throughout his stay,
with a trend beginning [**7-10**] of 68--> 49 and 41-->
42-->52-->59-->72--> 81-->
76-->69-->72-->95-->100-->107-->148-->127-->143 on discharge.
.
2. Pulmonary Embolism
The patient was found to have multiple right-sided PE's on a CT
scan performed on [**2174-7-14**]. Ultra-sounds showed a clot in the
right subclavian and right superficial femoral veins. The
patient had been off of heparin since his transfer to medicine
due to thrombocytopenia and possible HIT. The hematology
service was consulted and followed the patient for most of his
stay. He was started on Argatroban 0.25 mcg/kg/min IV on [**2174-7-14**]
which was changed to Lepirudin 0.025-0.15 mg/kg/hr IV later that
day given elevated LFT's. His anti-coagulation was changed to
heparin on [**2174-7-19**] due to negative HIT antibody tests. The
heparin was stopped and changed to Lovenox on [**2174-7-26**] for
outpatient coagulation. Warfarin was not given due to an
elevated INR, likely secondary to liver dysfunction.
.
3. Gram negative rod bacteremia
The patient had an elevated WBC count of 14.0 on [**7-13**] and had a
PICC line in place for four months, so blood cultures were drawn
on [**7-13**]. He was found to have gram negative rods in blood
cultures drawn from PICC line and appeared to have negative
cultures in blood drawn from peripheral sites. Follow-up
cultures were drawn on [**7-14**], with positive cultures again drawn
from the PICC line. The PICC line was removed on [**7-14**]; all
cultures drawn since then have been negative. Four colonies
were present in the positive cultures; one was Klebsiella,
pan-sensitive and the other three were non-lactose fermenting
non-pseudomonas gram negative rods which were sent to the [**Hospital1 47193**] for identification. The gram negative rod from the
culture on [**7-13**] was pan-sensitive; one gram-negative rod from
[**7-14**] was resistant to cefepime but sensitive to levofloxacin.
These non-lactose fermenters are environmental bacteria known as
"water bugs," they do not usually cause human disease. The
contaminated PICC line was considered to be the likely source of
the infection with colonization of the PICC entrance site,
although the tip cultures were negative. ID was consulted and
were initially concerned about a bowel etiology given multiple
organisms. Following the ID of the bacteria, a bowel source
seemed unlikely given the nature of the pathogens, although
these pathogens can rarely be due to a bowel source. A CT scan
showed evidence of chronic diverticulosis but not evidence of
acute bowel perforations. The bacteria was also concerning for
endocarditis given his recent mitral valve replacement, a TTE
and TEE showed no evidence of endocarditis. Urine cultures and
fungal blood cultures were both negative. He was initially
started on cefepime 2 mg IV Q8H with metronidazole 500 mg IV Q8H
added to cover possible GI bacterial. When the sensitivities
of the bacteria returned, he was switched to levofloxacin 500 mg
IV Q24H. The medications were changed to PO on [**2174-7-22**]. The
patient completed his course of flagyl and will finish
levofloxacin in 7 days after discharge.
.
4. Elevated liver function tests
On transfer, the patient was found to have elevated liver
function tests, which worsened during most of his stay before
improving in the last week of his admission. The liver team was
consulted. The etiology of the liver dysfunction was unclear.
Drug-induced liver dysfunction in the setting of bacteremia was
felt to be most likely, and indeed the liver function tests
improved when the patient was taken off some potentially liver
toxic drugs including argatroban, lepirudin, and cefepime.
Other possible etiologies included bacteremia, congestion from
cardiac backup (patient's ejection fraction is 30%), or abscess.
Multiple imaging studies showed no evidence of liver abscess or
acute obstruction. The peak ALT level was 1113; on discharge was
193.
.
5. Mental status changes
The patient had confusion and some disorientation since
admission, which had been worse than baseline since 2-3 weeks
prior to admission per nursing home report. His mental status
declined during his admission until [**7-18**], when he was
transferred to the MICU for brief hypoxia and worsening mental
status. The patient had been give Ativan prior to an MRI scan,
and it was felt that this may have contributed to the acute
worsening of his mental status. His mental status improved
after his return from the MICU, but he has remained somewhat
disoriented. Multiple etiologies for his continued confusion
were considered. An MRI scan of his head showed no evidence of
stroke or other acute changes. Encephalopathy was felt to be a
likely etiology, and lactulose and Rifaximin were started.
Sepsis was also considered, but his confusion persisted beyond
his bacteremia. On discharge, he is oriented to person and
place (knows he is in a hospital in [**Location (un) 86**]), but reports the
year is 6000, which has been his standard answer during
admission. This appears to be close to his baseline. His
attention and mental status wax and wane, getting worse when it
gets dark.
.
6. HTN.
The patient's blood pressure values were high throughout his
admission, even though he is on multiple blood pressure
medications. His highest values occurred on [**7-18**] before
transfer to the MICU, with high systolic values in 170's and
high diastolic values in 120's. These values decreased after his
return from the MICU, although high systolic BP's remained in
the 150s, and high diastolic values in the 100's. The patient
had intermittently refused to take his PO medications, so he was
temporarily switched to IV metoprolol and his clonidine was
changed to a weekly patch. He then began to take his PO
medications broken up and served in pudding, although he has
remained on the clonidine patch. He received two doses of 10 mg
IV hydralazine, once in the MICU and once on [**7-26**] for elevated
BP. His metoprolol dose was increased from 100 mg TID to 125 mg
TID on [**7-21**] and then to 150 mg TID on [**7-24**]. His quinapril dose
was increased from 30 mg to 40 mg PO QD on [**7-20**]. Hydralazine 10
mg PO Q6H was added on [**7-26**] for consistently high blood
pressure. Outpatient follow-up is recommended for evaluation of
high blood pressure refractory to treatment.
.
7. Fluid Status
The patient had decreased urine output during his stay, which
improved with hydration. He remained hypovolemic, with decreased
urine output responsive to fluid boluses. His decreased urine
output was at first concerning for early sepsis, but his blood
pressure remained elevated and he responded well to fluid. There
was then concern about fluid overload given increased effusions
found on chest x-ray and the patient's known CHF with ejection
fraction 30%, so IV fluids were stopped. The patient had low PO
intake, however, and he began to look hypovolemic with high
sodium levels. He was given 1000 ml D5 1/2NS at 100 ml/hr for
dehydration on [**7-26**] and 2L on [**7-27**] to correct his free-water
deficit. His renal function remained normal throughout his stay.
A foley catheter was placed to aid in monitoring fluid output.
The patient was discharged with foley in place; a voiding trial
should be attempted as soon as possible.
.
8. Hypoxia
The patient was transiently hypoxemic on [**7-18**] with O2
saturations falling to 85%, improving with oxygen face mask. He
was transferred to the MICU on [**7-18**] for hypoxemia and worsening
mental status. He was returned to the floor when his oxygen
saturation stabilized. Since then he has had normal oxygen
saturations on room air.
.
9. Low bicarbonate.
An ABG on [**7-16**] showed low bicarbonate. Likely etiologies were
chronic respiratory alkalosis vs mixed acute respiratory
alkalosis and metabolic acidosis. This was monitored throughout
and resolved.
.
10. Left Foot Ulcer
The patient has had a non-healing ulcer on his left foot for the
past three months. He was initially admitted for a
revascularization procedure on this foot. Surgery was postponed
indefinitely due to the patient's multiple medical problems.
The ulcer has been stable during this admission and is no longer
and open wound. Vascular surgery followed him and provided
recommendations for wound care. The patient should follow up
with vascular surgery regarding future surgical plans.
.
11. Coronary Artery Disease.
The patient has standing CAD, status post CABG. Multiple EKG's
during his admission showed no new changes. He was continued on
his outpatient medications of metoprolol, atorvastatin, and
Imdur. His aspirin was decreased from 325 mg to 81 mg QD due to
decreased platelets.
.
12. Left pleural effusion.
The patient had decreased breath sounds on his left lower lobe
throughout his stay. Chest x-rays showed a left pleural
effusion, which was also found to be present on [**5-10**]. Likely
etiologies included cardiac-related vs. pneumonia vs.
atelectasis. This remained stable during his admission.
.
13. Anemia.
The patient has baseline anemia, with hematocrits around 38 and
red blood cells normocytic. This remained stable throughout his
admission At baseline. Folate studies were performed and were
normal, Vitamin B12 levels were found to be high, indicating no
deficiencies. He was found to have a low TIBC and a low
transferrin which indicated a likely etiology of anemia of
chronic disease.
.
14. Depression.
The patient has depression and takes citalopram as an
outpatient. This was continued in-house until the liver team
recommended discontinuing it due to possible effects on the
liver.
.
15. Chronic back pain.
The patient was given oxycodone as needed for chronic back pain
(and for foot pain). The oxycodone was held during periods of
acute mental status changes. It was discontinued on [**7-26**] due to
disorientation.
.
16. Prophylaxis
The patient remained on Protonix and was anti-coagulated as
above throughout his stay.
Medications on Admission:
Aspirin 325 mg QD
Metoprolol Tartrate 100 mg TID
Quinapril 20 mg PO QD
Atorvastatin 20 mg QD
Protonix 40 mg QD
Docusate Sodium 100 mg [**Hospital1 **]
Oxycodone-Acetaminophen 5-325 mg q4-6prn
Citalopram 10 mg QD
Isosorbide Mononitrate SR 90 mg QD
Clonidine 0.2 mg TID
Levofloxacin
Lasix 10 mg QD
Discharge Disposition:
Extended Care
Facility:
Emerald Court Health & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. Thrombocytopenia
2. Bacteremia
3. Pulmonary embolus
4. Elevated liver function tests
5. Confusion
.
Secondary:
1. Coronary artery disease
2. Ischemic L foot ulcer
3. Hypertension
4. Hypercholesterolemia
5. Anemia
6. Depression
7. Chronic back pain
Discharge Condition:
Afebrile, vital signs stable. Platelet count improved. Liver
function tests improved. On Lovenox for pulmonary embolus.
Mental status at baseline.
Discharge Instructions:
Please contact a physician if you experience fevers/chills,
chest pain, shortness of breath, or any other concerning
symptoms.
.
Please take your medications as prescribed. Please complete a
three-week course of Levofloxacin and a two-week course of
metronidazole
Followup Instructions:
Please follow-up with your primary care doctor.
|
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"511.9",
"276.52",
"V45.81"
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icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
21859, 21953
|
9613, 21513
|
359, 365
|
22257, 22406
|
2513, 9590
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21539, 21836
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22430, 22695
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1963, 2494
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277, 321
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393, 1373
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1395, 1617
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1633, 1914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
323
| 128,132
|
5128
|
Discharge summary
|
report
|
Admission Date: [**2119-9-21**] Discharge Date: [**2119-10-6**]
Date of Birth: [**2062-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
Intubation
Central line placement
Echocardiography
History of Present Illness:
58 year old with PMH of ischemic CM (EF 20%), CAD, severe 3VD
(not a CABG candidate), type 1 DM presents with nausea and
hypotension. Recently seen in advanced heart failure clinic on
[**9-14**], BP noted to be over 200, and his hyral was increased from
25 qid to 50 tid. Lasix increased from 60 qam to 60 am/40 qpm.
Also got MRI of his kidneys which showed severe renal artery
narrowing. Pt reports that since the next day after the MRI, he
has increasing nasuea; no
f
/
c
/
n
s
/
c
p/sob/pnd/orthopnea/vomiting/diarrhea/hematochezia/melena/recent
NSAID use/decreased UOP.
In ED, initial VS SBP in 60s, AF, pulse in 60s. Given
INsulin/D50, Kayexalate, Ca for K of 6.1. Blood and urine sent.
Started on dopa, central line placed. Given
vanc/levo/flagyl/hydrocort, 1 am Nabicarb.
Past Medical History:
1. Ischemic CM with EF 20%
2. CAD with severe 3VD, not cabg candidate
3. PVD s/p B AKA
4. Type 1 DM
5. Blindness
6. Complete occlusion of R ICA
7. CRI s/p renal xplant [**2103**]; b/l cr 1.2-1.4
Social History:
Lives alone, no smoking or alcohol use
Family History:
Non-contributory
Physical Exam:
PE 97.8 90 94/47 20 91%2L CVP 5
pertinents
mmm
supple, jvp 8 cm
rales [**12-19**] way up
rrr, grade ii/vi SEM, ?diastolic murmur
no tenderness around iliac fossa
Pertinent Results:
DATA CT [**9-22**]
1. No evidence of intraabdominal abscess.
2. Patchy consolidation at the right lung base. Could represent
pneumonia or atelectasis. Clinical correlation is recommended.
Bilateral pleural effusions, right greater than left.
3. Distended stomach likely representing gastroparesis.
4. Extensive vascular calcification.
5. Transplant kidney is seen in the right lower quadrant
Brief Hospital Course:
This is a 56 year old gentleman with DM Type I and a history of
3 vessel coronary disease (seen in [**2114**] cath.), ischemic
cardiomyopathy (EF of 25 % on echo this admission), aortic
stenosis ([**Location (un) 109**] 0.9 cm), PVD s/p b/l AKA, s/p renal transplant
(baseline Cr 1.2 to 1.4) who was admitted for hypotension and
nausea. PTA he had been in heart failure clinic on [**9-14**] where
SBP noted to be in 200's; his hydralazine dose was doubled and
his lasix dose increased. On presentation to ED SBP noted to be
60's pulse in 60s. Also Given INsulin/D50, Kayexalate, Ca for K
of 6.1. Started on dopa, central line placed. Given
vanc/levo/flagyl/hydrocort, 1 am Nabicarb. Pt admitted to MICU,
intubated. Started on 2 pressors for blood pressure support
with gentle IVF. Per cardiology service recommendations, a
Swan-Ganz catheter was placed to help determine etiology of
hypotension. Initial Swan numbers revealed elevated PCWP of 23,
PAP of 63/23, CVP 9, and SVR of 1300 consistent with cardiogenic
shock and L ventricular overload. Echo peformed on [**9-22**]
revealed no significant changes from prior with EF of 25%,
degree of AV stenosis was essentially unchanged. Pt weaned off
pressors and began lasix diuretic therapy for CHF exacerbation.
His estimated PCWP has trended down since then with creatinine
today 1.8 down from 2.2. Serial chest x-rays revealed resolving
pulmonary edema.
Pt also being followed by renal service for elevated creatinine
and for his status post renal transplant in [**2105**]. The patients
creatinine was elevated on admission but slowly trended back to
normal range by discharge. He was maintained on his
immunosuppressive therapy of azathioprine, prednisone, and
cyclosporine. Per his nephrologist Dr. [**First Name (STitle) **], his cyclosporine
levels were adequate. There was some concern for rejection on a
renal ultrasound but the patient's creatinine had returned to
his baseline
Pt was extubated [**9-30**]. Pt is now off pressors with stable
blood pressure, breathing normally on room air. Swan Ganz
catheter d/c'd [**2119-10-2**]. Last readings were PAP of 54/21 CVP
of 7. He was transferred to the floor. His stay was relatively
uneventful. His blood pressure was generally stable (SBPs in
100-110 range). His blood sugars were noted to trend downward
and was found to be 31 in morning of [**10-6**]. This resolved with
[**12-18**] Amp of D50 (to 131); his insulin sliding scale was converted
from regular to humalog; his NPH dosing was adjusted to 10 units
in the morning and 5 units at bedtime. Pt was also noted to
have a hematocrit that had trended down from 28 to 25 over the
prior week. Per renal service, this was felt to be secondary to
his renal disease and his Epogen was therefore doubled in
dosing; in addition, the patient received one unit of blood
before his discharge; blood was given with Lasix.
In summary, this is a 56 year-old type I diabetic male with 3
vessel CAD, ischemic cardiomyopathy with EF 25%, aortic
stenosis, s/p b/l AKA, admitted for hypotension after increases
in blood pressure medication and admitted to MICU for
hypotension, intubated for respiratory distress. Found to be in
cardiogenic shock necessitating pressor support and in CHF. Now
off pressors, blood pressure w.n.l. breathing on room air with
no sign of volume overload on physical exam. Infectious workup
has been unrevealing.
.
Issues and pal
1) Cardiovascular
.
Perfusion: Three vessel disease not amenable to PCI, not
candidate for CABG
-continue aspirin and plavix
-continue lipitor (40)
-started smaller dose of beta blocker (metoprolol 12.5)
.
Pump: EF 25%, aortic stenosis ([**Location (un) 109**] 0.9), CHF seems to be class
II. Status post cardiogenic shock--now resolved, appears
secondary to increase in his blood pressure medications.
-continue lasix at 40 mg PO BID
-continue digoxin at 0.0625 mg every other day, check digoxin
levels regularly
-avoid lisinopril given renal disease
-continue hydralazine at 25 mg PO TID
-please restart isordil and uptitrate as his pressure tolerates.
-will follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital1 **]
Outpatient Heart Failure service.
Rhythm: NSR occasional PVCs
-low EF, pt may benefit from ICD placement; per attending Dr.
[**Last Name (STitle) **], patient has declined this option understanding that he
remains at increased risk of SCD.
.
PVD: s/p b/l amputations
-continue aspirin and plavix
-will need physical therapy from extended hospital stay
.
2) Renal disease, s/p transplant, creatinine now at baseline
-continue azathioprine, cyclosporine, please have nephrologist
follow this patient. Dr.[**Name (NI) 4849**] is his primary nephrologist.
-CSA levels to be checked regularly
-if creatinine levels rise, please check renal ultrasound
-renally dose all medications
.
3) Anemia. Status post 1 pRBC transfusion prior to discharge
-have increased epogen from 4000 to 8000 qMWF
-monitor hct
-if pt needs further transfusion, please give Lasix (40 mg IV)
before and after transfusion to prevent volume overload.
.
4) Diabetes, (type I)
-In setting of renal insufficiency and renal transplant will
need to be on Humalog Sliding Scale. Also should continue NPH
10 units qAM, 5 units qPM.
.
5) FEN: Diabetic/cardiac healthy; please continue sodium and
fluid restriction.
.
6)Prophylaxis should include Hep SC, PPI
.
7) Code: Full
.
8) Disposition: Was seen by physical therapy who recommended
rehabilitation. Patient is being discharged to [**Hospital **]
[**Hospital **] Hospital.
Medications on Admission:
Prednisone 10 qod
Lipitor 40
Hydral 50 TID
Plavix
ASA
Enalapril 10 [**Hospital1 **]
Lasix 60/40
Toprol Xl 50
Imuran 50 qd
Isordil 20 tid
Cyclosporin 100/50
Ativan
Insulin
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. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cyclosporine Modified 100 mg/mL Solution Sig: 0.25 mL PO Q PM
().
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD ().
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO
Q AM ().
11. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
13. Lorazepam 1 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime) as needed for insomnia.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
16. Insulin NPH Human Recomb Subcutaneous
17. insulin
For insulin, please give 10 units in the morning and 5 units at
bedtime.
Please use humalog sliding scale per attached flow sheet.
18. Digoxin 50 mcg Capsule Sig: 1.5 Capsules PO EVERY OTHER DAY
(Every Other Day).
19. Metoclopramide 5 mg/mL Solution Sig: One (1) mL Injection
Q6H (every 6 hours).
20. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) injection
Intravenous Q8H (every 8 hours) as needed for nausea.
21. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cardiogenic shock.
Congestive heart failure exacerbation/ischemic cardiomyopathy.
Aortic stenosis.
Coronary artery disease (three vessel disease)
Diabetes Type I.
Peripheral
Status post kidney transplant.
Discharge Condition:
Good. Now breathing normally on room air. Blood pressure
stable. No symptoms of dizziness or nausea. No chest pain.
Able to work with physical therapy for rehabilitation exercises.
Discharge Instructions:
Please return to hospital if you experience chest pain,
shortness of breath or palpitations.
Please return to hospital if you start becoming light-headed,
dizzy, and/or you feel like passing out.
Please return to hospital if pt becomes hypotensive.
Followup Instructions:
Patient is going to rehabilitation facility.
Please follow up with the [**Hospital3 **] Nephrology service.
Please coordinate care with his PCP and Nephrologist Dr.[**Doctor Last Name 4849**]
[**Telephone/Fax (1) 12847**].
Pt also to be followed up by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital3 **]
outpatient Heart Failure service.
|
[
"285.21",
"584.5",
"518.81",
"593.9",
"414.01",
"401.9",
"276.7",
"V49.76",
"536.3",
"424.1",
"428.0",
"369.3",
"996.81",
"785.51",
"440.1",
"414.8",
"250.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"96.04",
"96.6",
"89.64",
"96.71",
"89.68",
"99.04",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9766, 9845
|
2119, 7706
|
322, 374
|
10094, 10281
|
1703, 2096
|
10580, 10954
|
1488, 1506
|
7928, 9743
|
9866, 10073
|
7732, 7905
|
10305, 10557
|
1521, 1684
|
276, 284
|
402, 1190
|
1212, 1416
|
1432, 1472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,418
| 140,232
|
45219
|
Discharge summary
|
report
|
Admission Date: [**2118-11-13**] Discharge Date: [**2118-11-23**]
Date of Birth: [**2040-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
CC:[**CC Contact Info 15943**]
Major Surgical or Invasive Procedure:
Colonoscopy
EGD
EGD with push enteroscopy
Tagged RBC scan
History of Present Illness:
78 yom with DM, HTN, HOCM s/p ablation), Small bowel AVM and
diverticulosis in USOH, woke up to go to bathroom to urinate and
felt lightheaded and fell to the floor. +LOC. This followed by
Bright red bowel movement with clots. Evaluated by EMS and
brought to ED. Patient denies preeceding or post fall symptoms
aside from lightheadedness. No cp/sob
.
In the ED, initially BP 90/60s, dusky fingertips placed Cordis
and given 2 units PRBC. pretransfusion hct returned as 32.5.
GI consulted and patient being admitted to ICU for further care.
Head CT C-spne negative.
.
On transfer to the unit, pt denies any complaints. Has not had
any recurrent episode of GIB. On ROs denies any fevers, chills
nausea, vomiting recently. Denies any falls recently. ROS
positve for 35 lbs wt loss over past 3-4 years.
Past Medical History:
HOCOM s/p two septal ablations ([**2114**] and [**2116**])
DM
*Nephropathy secondary to DM
Complete heart block, s/p pacer/ICD
HTN
*Hyperlipidemia
MVP
Stapedectomy
*Gastritis (AVMs in small bowel)
*Diverticulosis, internal hemorrhoids, small hiatal hernia
*H/O E. coli bacteremia
Sphincterotomy
Anemia
Hernia repair
s/p CCY
Carotid artery stenosis
Social History:
Quit smoking 40 yrs ago, Social EtOH, Married, lives with wife
Family History:
Father died from MI in 60s
Physical Exam:
Physical Exam:
Vitals: 98, BP 133/81 Hr 75 RR 12 O2sat 100%RA
.
Gen: pleasant elderly male lying in bed in nad
HEENT: MMM, PErrla, OP clear
Neck: supple, no jvd
CHest: CTAB, no crackles
CVR: RRR, nl s1, s2. +systolic murmor at LUSB II/VII.
Abdomen: soft, nt, nd
Ext: no edema, Right groin cordis site clean. First fingers
bilaterally cyanotic.
Rectal: in ED, clots in rectal vault, Guiac+.
.
Pertinent Results:
[**2118-11-13**] u/a
Color Yellow Appear Slhazy SpecGr 1.025 pH 5.5 Urobil 0.2
Bili
Neg Leuk Neg Bld Sm Nitr Neg Prot Tr Glu >1000 Ket Neg
.
[**2118-11-13**] 08:45a
137 | 99 | 35 AGap=15
-------------<359
4.3 | 27 | 1.8
.
MCV 91
7.3 >---< 219
......32.0
.N:67.2 L:23.0 M:5.6 E:3.6 Bas:0.6
.
PT: 13.1 PTT: 21.3 INR: 1.1
.
ECG: V paced at 70, +LVH. no st-T changes.
.
EGD [**2116-8-4**] - Few scattered superficial avms in jejunum-small
and not likely to have produced anemia in the duodenum
Otherwise normal EGD to second part of the duodenum
.
Colonoscopy [**2115-7-23**] -
Diverticulosis of the entire colon
Grade 2 internal hemorrhoids
Otherwise normal Colonoscopy to cecum
.
[**2118-11-16**]- Tagged RBC scan GI study: IMPRESSION: No active
bleeding during this study.
Brief Hospital Course:
Assessement and Plan: 78 yom with DM, HTN, h/o diverticulosis,
hemorrhoids and small bowel avm admitted after syncope and one
episode of BRBPR. On transfer to the unit, pt denies any
complaints. Has not had any recurrent episode of GIB. On ROs
denies any fevers, chills nausea, vomiting recently. Denies any
falls recently. ROS positve for 35 lbs wt loss over past [**2-5**]
years. EGD showed gastritis, tagged RBC scan was negative.
Colonoscopy showed diverticulosis and grade 2 internal
hemrrhoids but no active bleeding. Pt was called out to the
floor, and brief hospital course by problem below:
.
# GIB - Given h/o diverticulosis and hemorroids and one episode
of BRBPR LBIG most likely. Pt had three episodes of bleeding on
the floor- first in the toilet, bright red per nurse,
unspecified quantity, next was 200 cc of maroon stools. Finally,
pt had another ~100cc of maroon stools before being taken for
push enteroscopy which was negative for source of bleed. Small
bowel AVMs also likely culprit as seen in previous capsule
endoscopy. Ddx also includes ischemia (hypotension followed by
BRBPR). Patient given 2 units PRBC in the ED and Hct remained
stable thereafter.
Pt's hematocrit remained stable and vital signs also stable
during remainder of hospitalization. Of note, B12 level also
found to be low, so started on 100mg B12 PO daily.
.
# Syncope - Unclear etiology as pt lightheaded initially had a
fall which was followed by BRBPR. This most likely due to GIB
and given h/o HOCM pt may be volume sensitive. Pacer
interrogated by EP and was unremarkable. Monitored on tele with
no new events.
.
# Dusky fingers - On admission noted to have dusky fingers
likely secondary to hypotension. This resolved over the course
of the night, however had another episode of fingers turning
blue with good pulses and BP. Pt was not noted to have any
further episodes through remaining hospitalization. Although
patient denied previuos episodes similar to this, if this
persists should consider further work up for raynaud's.
.
# HOCM - s/p alchol ablation times 2. Echo repeated and
revealed an improved gradient. BB initially held off given GIB,
but restarted Atenolol at 100mg. Blood pressure remained well
controlled throughout hospital stay.
.
# CAD - RCA with 30% disease previously. Initially hld BB,
diuretic and ASA. Statin was continued. Per GI stopped ASA
given continued bleeding. Would consider restarting in future if
Hct remains stable.
.
# DM - Oral hypoglycemics held on admission and covered with
ISS. Restarted on oral agents prior to discharge. FSBG's were
variable depending on pt's daily intake, and should be followed
up after discharge.
.
# Acute on chronic Renal insuff - baseline around 1.2-1.5,
Admission creat of 1.8. Resolved after transfusion. Discharge
Creat=1.2
.
# Ophtho: continued timolol. no issues
.
# Depression - continued citalopram
.
Medications on Admission:
Metformin 500mg qid (recently discontinued)
Rosiglitizone 8 mg once day
glyburide 5mg [**Hospital1 **]
ASA 325 mg once day
Atenolol 175 mg once a day
atorvastatin 10 mg q mon and thurs
Hctz 37.5 mg once a day
Iron supplement 65 mg once daily
Vitamin c 500 mg once daily
coenzyme 10 100 mg once daily
Occuline
Timolol 0.25% once a day right eye
amantadine 100mg twice daily
citalopram 20 mg daily
losartan 50 mg daily
Buproprion 75 mg twice daily.
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-6**]
Drops Ophthalmic PRN (as needed).
10. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Hydrochlorothiazide 25 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
13. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
1. Small intestine GI bleed
2. Diverticulosis
3. Internal hemmorhoids
4. Vit B12 deficiency
Secondary Diagnoses:
1. DM
2. HTN
3. HOCM s/p ablation
4. Hyperlipidemia
5. Blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Please remember to make the follow-up appointments below.
.
You should call your PCP or return to the ED if you have:
*large bloody stools
*dizziness/lightheadedness
.
If you have any of the above, you should come immediately to the
hospital. Tell the ED that THE RADIOLOGIST ON CALL MUST BE PAGED
IMMEDIATELY AND YOU NEED TO GO DIRECTLY TO NUCLEAR MEDICINE FOR
A TAGGED RED BLOOD CELL SCAN. Take this paperwork with you.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] ([**Telephone/Fax (1) 96633**] within one month of discharge to check your blood
levels (hematocrit) and make sure your Diabetes is under
control. Call the number above to schedule an appointment at
your convenience.
.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2118-11-23**]
|
[
"414.01",
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"401.9",
"562.10",
"455.0",
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"V53.32",
"782.5",
"E888.9",
"537.83",
"287.5",
"583.81",
"584.9",
"535.50",
"585.9",
"780.2",
"285.1",
"424.0",
"V58.67",
"285.29",
"425.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"89.64",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7462, 7552
|
2989, 5881
|
346, 406
|
7801, 7810
|
2171, 2966
|
8280, 8763
|
1711, 1739
|
6378, 7439
|
7573, 7573
|
5907, 6355
|
7834, 8257
|
1769, 2152
|
7705, 7780
|
277, 308
|
434, 1244
|
7592, 7684
|
1266, 1615
|
1631, 1695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,716
| 178,228
|
15342
|
Discharge summary
|
report
|
Admission Date: [**2165-2-17**] Discharge Date: [**2165-2-26**]
Date of Birth: [**2105-7-23**] Sex: M
Service: Internal medicine.
CHIEF COMPLAINT: Coffee ground emesis.
HISTORY OF PRESENT ILLNESS: 59 year old man with primary
sclerosing cholangitis, cirrhosis, end stage liver disease,
known history of esophageal varices. He is currently
awaiting liver transplant. He was recently admitted to [**Hospital1 1444**] for diarrhea and failure to
thrive and was discharged to rehabilitation on [**2165-2-13**].
On [**2165-2-16**], he had nausea and abdominal pain while at
rehabilitation and subsequently had two episodes of coffee
ground emesis. He was transferred to the [**Hospital1 346**] Emergency Room where gastric lavage
showed coffee grounds with bright red blood that did not
clear after 500 cc of lavage. He received two units of fresh
frozen plasma, 10 mg of Vitamin K subcutaneously and was
started on Osteotribe drip. The hepatology service was
consulted for emergent esophagogastroduodenoscopy.
PAST MEDICAL HISTORY: 1.) End stage liver disease. The
patient also has hepatitis C cirrhosis but has undetectable
viral load. He has history of hepatic encephalopathy and has
known esophageal varices. 2.) Primary sclerosing
cholangitis, diagnosed in [**2161**]. 3.) Ulcerative colitis,
chronic, active per flexible sigmoidoscopy on [**2165-2-6**]. 4.)
History of duodenal ulcer. 5.) History of E. coli sepsis in
[**2164-11-2**]. 6.) Childhood asthma. 7.) Anemia. 8.)
Status post cholecystectomy for benign gallbladder polyp.
9.) Failure to thrive with multiple admissions for diarrhea.
10.) Restrictive lung disease of unclear etiology.
MEDICATION ON ADMISSION:
Natalol 20 mg q. day.
Lasix 40 mg q. day.
Protonic 40 mg q. day.
Mesalamine 1,000 mg three times a day.
Zoloft 50 mg q. day.
Spironolactone 300 mg q. day.
Ursodiol 900 mg q. day.
Vitamin D 400 units q. day.
Tums 1.25 grams three times a day.
Lactulose 30 cc twice a day to be titrated to four loose
bowel movements per day.
He also received tube feeds, to deliver 2.0 full strength 70
cc an hour times 12 hours q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives in [**State 792**]with his sister.
[**Name (NI) **] tobacco history. He quit alcohol six months ago. He is
disabled.
PHYSICAL EXAMINATION: On [**2165-2-16**], temperature was 97.3;
blood pressure 103/61; pulse 87; oxygen saturation 92% on
room air. In general: Cachectic, chronically ill appearing
man in no apparent distress. Chest: Clear to auscultation
bilaterally with decreased breath sounds at the bases.
Cardiovascular: Regular rate and rhythm, 2/6 systolic murmur
at the precordium. Abdomen: Soft, moderately distended,
nontender to palpation. Extremities: No edema or erythema.
Neurologic: Grossly intact. No asterixis. Skin noted to be
icteric.
LABORATORY DATA: On [**2165-2-25**], white blood count was 4.0;
hematocrit of 29.7; hematocrit stable at this level from
[**2165-2-18**] to [**2165-2-25**]. On admission, white blood count was 9.2;
hematocrit was 30.5; neutrophils 77%, bands 4%, lymphocytes
7%, monocytes 8%.
On [**2165-2-18**], neutrophils were 73%, bands 0%, lymphocytes
12.7%, monophils 8.6%, eosinophils 5.0%.
Platelets were 102 on [**2165-2-25**]. PT/PTT 14.9/36.3. INR of
1.5.
On admission, INR was 2.3. Platelets were 166.
Urinalysis on [**2165-2-16**] was without evidence of infection.
Ascites fluid on [**2165-2-19**] revealed White blood count of 35,
RBC of 590, polys 15, lymphs 19, monocytes 12; macrophages
54.
On [**2165-2-25**], sodium was 138; potassium of 3.7; chloride of
107; C02 of 25; BUN 9; creatinine 0.5. On [**2165-2-16**] on
admission sodium was 132; potassium was 5.9; chloride of 103;
C02 of 22; BUN 33; creatinine 0.7; glucose 108.
On [**2165-2-22**] total bilirubin was 2.9 (stable at this level
during this admission); alkaline phosphatase of 236; ALT 88;
AST 103. Lipase was 79 on [**2165-2-16**].
On [**2165-2-20**] albumin was 2.4; calcium 7.6; phosphate 3.0;
magnesium 1.8.
External jugular vein catheter tip was pulled on [**2165-2-21**] and
had greater than 15 colonies of coagulase negative
Staphylococcus which was sensitive to Vancomycin.
Peritoneal fluid of [**2165-2-19**] does not show any
polymorphonuclear leukocytes or organism. Fluid culture on
[**2165-2-22**] revealed no growth to date, that is [**2165-2-25**].
Imaging studies: Chest x-ray on [**2165-2-17**] revealed no evidence
for infection or pneumonia.
HOSPITAL COURSE: This is a 59 year old man with cirrhosis
and a history of esophageal varices. He presents to the
hospital with coffee ground emesis.
Issues: 1.) Coffee ground emesis. Two large bore
intravenous were placed and the patient received two units of
FFP as well as ten units of subcutaneous Vitamin K on his
arrival to the hospital. He was transfused with two units of
packed red blood cells on [**2165-2-16**] and also on [**2165-2-17**]. He
received esophagogastroduodenoscopy on [**2165-2-17**] which
demonstrated grade III varices in the lower and middle third
of the esophagus with stigmata of recent bleeding. There was
snake skin appearance of the mucosa, consistent with no
bleeding, and are compatible with portal hypertensive
gastropathy. He had five 2 cc sodium morrhuate injections
applied for hemostasis with success in the lower third of the
esophagus.
As earlier mentioned, he was started on five days of
Octreotide intravenous, starting on [**2165-2-17**]. He did not bump
his hematocrit status post transfusion of two units of
PRBC's. On [**2165-2-16**] and [**2165-2-17**], because his hematocrit did
not improve after two units of packed red blood cells
transfusion, he received a second esophagogastroduodenoscopy,
performed on [**2165-2-18**]. This showed grade III varices seen,
starting at 25 cms from the incisors and the whole esophagus.
There was stigmata of recent bleeding.
2.) Poor nutrition. The patient is receiving maximum
nutrition possible, with both spontaneously consumed oral
foods as well as nasogastric tube feedings at night, in order
to strengthen him up in anticipation of a renal transplant in
the future. The original plan was to place a nasogastric
tube with radiology guidance on [**2-21**] or [**2165-2-22**]. However,
given the recent esophagogastroduodenoscopy, the procedure
was deferred until [**2165-2-25**] when it was performed without
difficulty.
3.) For patient's history of malnutrition, he should continue
on tube feeds at night. Our current recommendation is deliver
tube feeds 55 cc a day times 12 weeks from 7 p.m. until 7
a.m.
4.) Ascites. The patient had diagnostic paracentesis
performed that did not show evidence or suggestion of
infection.
5.) For poor nutrition, the patient has nasogastric tube
placed on [**2165-2-25**]. Prior to that, he had been tolerating
some p.o. food without difficulty. He will continue on
Deliver at 55 cc an hour times 12 hours per day at the
rehabilitation center. The rehabilitation center may also
substitute an equivalent tube feed.
DISCHARGE DIAGNOSES:
Liver cirrhosis.
Esophageal varices, status post esophagogastroduodenoscopy
and banding times two.
Transfusion of four units total PRBC on [**2165-2-16**] and [**2165-2-17**].
Nasal jejunal tube placement on [**2165-2-25**].
DISCHARGE MEDICATIONS:
Spironolactone 400 mg q. day.
Vancomycin one gram intravenous q. 12 hours, last dosed on
[**2165-2-26**] afternoon.
The Vancomycin had been started because one of four blood
cultures was positive for Methicillin resistant staph aureus
around the time that we would start rounding.
Lasix 40 mg q. day.
Natalol 20 mg q. day.
Ursodiol 300 mg p.o. three times a day.
Mesalamine 1,000 mg p.o. three times a day.
Circuline 50 mg p.o. q. day.
Lactulose 30 cc p.o. three times a day, titrated to three to
four bowel movements per day.
Protonic 40 mg p.o. twice a day.
Calcium carbonate 500 mg p.o. q. day.
Vitamin D 400 units q. day.
The patient is discharged to rehabilitation center.
The patient will follow-up in the liver clinic.
DR.[**First Name (STitle) **],[**Doctor First Name 12161**] 12-ADH
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2165-2-26**] 03:33
T: [**2165-2-26**] 04:30
JOB#: [**Job Number 44572**]
|
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icd9cm
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icd9pcs
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[
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7346, 8295
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4526, 7076
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2332, 4408
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165, 188
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1706, 2164
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47,091
| 137,990
|
35922
|
Discharge summary
|
report
|
Admission Date: [**2191-11-19**] Discharge Date: [**2191-11-29**]
Date of Birth: [**2111-3-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
R foot cellulitis/osteomyelitis
Major Surgical or Invasive Procedure:
[**11-18**]: Radical debridement of right foot with open ray
amputation 2 and 3; Incision and drainage plantar abscess right
foot.
[**11-25**]: Right transmetatarsal amputation
History of Present Illness:
Patient is an 80 year old female with poorly controlled DM2. The
patient is transferred from [**Location (un) 8117**] NH for a right foot wound
that has been worsening over the past 4 months. On physical
exam, she was found to have evidence of wet gangrene with
osteomyelitis on x-ray. The patient was taken to the operating
room urgently for a 2nd toe amputation and wound debridement.
Dr. [**Last Name (STitle) 1391**] was consulted intraoperatively for wound
evaluation. At the time, it was felt that the patient would
ultimately require further amputation and debridement after an
initial period of stabilization.
Past Medical History:
DM2 (stopped medical treatment 1 year ago)
Social History:
Patient denies tobacco/ETOH/illicit drug use
Physical Exam:
at admission:
General: awake and alert
CV: RRR
Lungs: CTA bilaterally
Abdomen: soft, NT/ND, NABS
Ext: RLE w/ dressing in place c/d/i
At discharge:
VS: Tm 98.4 Tc 98.2 P 76 BP 131/62 RR 18 SaO2 97 RA
Gen: NAD
CV: RRR
Pulm: CTA B/L
Abd: soft, nt/nd
wound: R foot TMA site: plantar aspect wound with w-d dressing;
flap with cnetral necrosis (unknown depth), adaptic dressings
placed
Pertinent Results:
[**2191-11-19**] 08:35PM GLUCOSE-218* UREA N-29* CREAT-0.9 SODIUM-140
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-11
[**2191-11-19**] 08:35PM CALCIUM-8.2* PHOSPHATE-1.7* MAGNESIUM-1.6
[**2191-11-19**] 05:30PM %HbA1c-15.0*
[**2191-11-19**] 05:30PM URINE HOURS-RANDOM CREAT-34 SODIUM-17
[**2191-11-19**] 05:30PM URINE OSMOLAL-530
[**2191-11-19**] 05:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2191-11-19**] 05:27PM URINE BLOOD-LG NITRITE-POS PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2191-11-19**] 05:27PM URINE RBC-[**5-2**]* WBC-[**1-26**] BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2191-11-19**] 02:30PM GLUCOSE-491* LACTATE-1.6 NA+-138 K+-4.6
CL--98* TCO2-18*
[**2191-11-19**] 02:15PM GLUCOSE-544* UREA N-35* CREAT-1.2* SODIUM-135
POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-17* ANION GAP-27*
[**2191-11-19**] 02:15PM estGFR-Using this
[**2191-11-19**] 02:15PM ACETONE-LARGE OSMOLAL-325*
[**2191-11-19**] 02:15PM WBC-28.6* RBC-3.76* HGB-11.5* HCT-36.2 MCV-96
MCH-30.5 MCHC-31.7 RDW-12.5
[**2191-11-19**] 02:15PM NEUTS-97.6* LYMPHS-1.5* MONOS-0.8* EOS-0.1
BASOS-0
[**2191-11-19**] 02:15PM PLT COUNT-377
[**2191-11-19**] 02:15PM PT-12.9 PTT-24.1 INR(PT)-1.1
Culture data:
[**11-18**] blood: NG x2
[**11-18**] urine: E. coli 10,000-100,000 ORGANISMS/ML (pansensitive)
[**11-19**] wound: 2+PMN, 3+GPR, 2+GNR, 2+GPC; cx MSSA
[**11-21**] urine: NG
[**11-28**]: cdiff: neg
[**11-18**] R foot XR: IMPRESSION: Marked osseous destruction about
the second proximal phalanx and interphalangeal joint with
marked overlying soft tissue swelling. This is consistent with
osteomyelitis.
[**11-19**] R foot XR: interval resection of the distal second and
third rays when compared with [**2191-11-19**]. Assessment of the
regional osseous structures, particularly the base of the first
proximal phalanx, is markedly limited by overlying packing and
dressing material. Soft
tissue swelling about the forefoot persists. Assessment for the
presence
and/or absence of tracking subcutaneous emphysema is limited
also by the
overlying packing and dressing material.
[**11-20**] TTE: The left atrium is dilated. A mass is seen in the
right atrium. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
right ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: No valvular vegetations or significant regurgitation
seen. However, there is an echodense linear structure that
stretches across the right atrium from the inter-atrial septum
to the lateral atrial wall. This is probably a muscular band.
There does not appear to be a vegetation associated with it but
image quality is sub-optimal so a vegetation cannot be excluded.
Mildly dilated right ventricle. Normal biventricular function.
Moderate pulmonary artery systolic hypertension.
- medicine team discussed the R atrial band with the TEE fellow,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and her attending - this is a normal variant
that does not require further testing or follow up
[**11-20**] CTA chest:
IMPRESSION:
1. Recommend two-month followup for 2.6 cm right upper lobe
nodule which may represent infectious or neoplastic focus.
2. Recommend renal ultrasound for further evaluation of possible
right
hydronephrosis versus prominent extrarenal pelvis.
3. Diffuse edema involves the subcutaneous tissues, chest wall
and muscles, more pronounced on the left may represent anasarca,
however, recommend clinical correlation to exclude myositis.
4. Recommend thyroid ultrasound for further evaluation of a
right thyroid
lesion.
5. Recommend non-emergent evaluation of the supraglottic airway
to
distinguish secretions from polyps.
6. Moderate bilateral effusions.
[**11-22**] CXR: Small bilateral pleural effusions and right upper
lobe lung mass unchanged over two days. Heart size top normal.
[**11-22**] renal U/S: IMPRESSION: Severe right hydronephrosis with
several freely mobile calculi noted within the renal pelvis.
However, the right ureter is not evaluated. CTU can be performed
for further evaluation.
[**11-24**] CT abd/pelvis:
IMPRESSION
1. Atrophic right kidney with moderate right-sided
hydronephrosis secondary to chronic UPJ obstruction.
2. Bilateral renal calculi.
3. Cholelithiasis.
4. Dense atherosclerotic plaque involving the aorta and branch
vessels.
5. Colonic diverticulosis without evidence of diverticulitis.
6. Bilateral pleural effusion, generalized body wall anasarca
and edematous mesentery, which can be seen in hypoalbuminemia.
Recommend clinical correlation.
7. Tiny punctate calcifications in the head of the pancreas,
which may
represent parenchymal calcification or small stones in a side
branch duct. No pancreatic ductal dilatation.
8. Markedly fecal loaded rectum.
Brief Hospital Course:
[**11-18**]: admitted to MICU from ED, started on insulin gtt for
hyperglycemia to 555, vanco/zosyn, hypovolemic ARF (Cr peak at
1.2), DKA. She was afebrile with a white count to 32K. She was
hemodynamically stable. Right foot film showed marked osseous
destruction about the second priximal phalanx and
interphalangeal joint with marked overlying soft tissue
swelling. Podiatry was consulted for her right foot
osteomyelitis and too her to the OR for radical debridement of
right foot with open ray amputation 2 and 3; incision and
drainage plantar abscess right foot. Dr. [**Last Name (STitle) 1391**] was consulted
intra-operatively and felt that the patient would ultimately
require further amputation and debridement after an initial
period of stabilization. OSH blood cx grew out Strep agalactiae
[**11-19**]: continued abx, trending WBC (22K) and fever curve
(afebrile), glucose control; Cr trended down; urine cx showed
pan-sensitive e coli. blood cultures grew out MSSA - patient
left on broad spectrum coverage.
[**11-20**]: transferred to the floor; PICC line placed; TTE showed no
valvular vegeations or significant regurgitation; echodense
linear structure that stretches across the right atrium from the
inter-atrial septum to the lateral atrial wall, likely a
muscular band. The medicine team discussed the R atrial band
with the TEE fellow, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and her attending - this
is a normal variant that does not require further testing or
follow up. CTA showed a 2.6cm RUL nodule - recommend 2 month
f/u; right hydronephrosis - recommend f/u; thyroid nodule -
recomment f/u.; recommend non-emergent evaluation of the
supraglottic airway to distinguish secretions from polyps.
[**2114-11-21**] - WBC below 10, remained so for remainder of
hospitalization; urine cx came back negative. R renal U/S:
Severe right hydronephrosis with several freely mobile calculi
noted within the renal pelvis. However, the right ureter is not
evaluated. Recommend f/u
[**11-25**]: to OR for right TMA.
[**11-26**]: patient received 3U pRBC for acute blood loss anemia;
bandages were redressed; Hct stabilized.
[**11-27**]: cardiac enzymes negative
[**11-28**]: PT rec rehab; Medicine consult recs:
** Obtain Primary care physician **
1) nafcillin 10 days
2) pulm nodule - follow up in 2 months for repeat CT
3) R hydronephrosis - f/u with urology physician
4) DM2 - continue lantus, current regimen; f/u with PCP
5) HTN: metoprolol 12.5 [**Hospital1 **], lisinopril 2.5 Qdaily (titrate in
rehab)
6) osteoporosis: calcium (1500mg daily divided in 3 doses) and
vit D 800 U daily; consider fosamax
On [**11-29**], the patient was discharged to rehab stable, in good
condition, with the following recommendations:
- obtain a primary physician to follow up lung nodule, thyroid
nodule, right kidney hydronephrosis, diabetesm osteoporosis, and
high blood pressure
- follow up with Dr. [**Last Name (STitle) 1391**]
- follow up with podiatry
She will complete a 2 week course of nafcillin. Her pain is
well-controlled on oral agents, she is tolerating a regular
diet.
Medications on Admission:
none
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q6H (every 6 hours): complete a 2 week course: from
[**11-28**] to [**12-12**].
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. insulin sliding scale
10 glargine at lunch
regular insulin for SSI
sugar brk lunch din bedtime
0-70 4 oz. Juice and 15 gm crackers 4 oz. Juice
71-149 0 U 0 U 0 U 0 U
150-199 2 U 2 U 2 U 2 U
200-249 4 U 4 U 4 U 3 U
250-299 6 U 6 U 6 U 4 U
300-349 8 U 8 U 8 U 5 U
350-400 10 U 10 U 10 U 6 U
> 400 Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
DKA
ARF (hypovolemic)
osteomyelitis
Thyroid Nodule - will need follow up
Lung Nodule - will need follow up
Right Hydronephrosis - will need follow up
Discharge Condition:
good, stable condition
Discharge Instructions:
If you develop fevers, chills, foul-smelling or purulunt
drainage from your wound, new spreading redness or pain from
your wound, shortess of breath, chest pain, or any other
disturbing symtoms, please call the vascular surgery office of
Dr. [**Last Name (STitle) 1391**] at [**Telephone/Fax (1) 1393**] or go to the emergency room.
you may resume you regular diet.
NO WEIGHT BEARING ON RIGHT TMA SITE FOR AT LEAST 4 WEEKS.
Followup Instructions:
Follow up appointment with Dr. [**Last Name (STitle) 1391**] on [**2192-12-13**]:45 at
[**Doctor First Name **] (at [**Hospital1 18**]), the [**Hospital **] Medical Office Building
([**Telephone/Fax (1) 1393**])
Call Podiatry at [**Telephone/Fax (1) 543**] to schedule a follow up
appointment with Dr. [**Last Name (STitle) **].
Obtain a primary physician to follow up lung nodule, thyroid
nodule, right kidney hydronephrosis, diabetesm osteoporosis, and
high blood pressure
Completed by:[**2191-11-29**]
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46,442
| 169,189
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38438
|
Discharge summary
|
report
|
Admission Date: [**2107-6-15**] Discharge Date: [**2107-6-21**]
Date of Birth: [**2061-2-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Abdominal and chest pain
Major Surgical or Invasive Procedure:
[**2107-6-16**] Cardiac catheterization
[**2107-6-16**] LAPAROSCOPIC APPENDECTOMY
[**2107-6-17**] Diagnostic laparoscopy and abdominal washout
History of Present Illness:
46M with onset of pain at 1pm described as "under my
sternum, like heartburn". took prevacid without relief.
Associated with nausea but no emesis. Pain migrated towards his
epigastrium and umbilicus with time, but still with substernal
discomfort. Sought attn in ED at [**Hospital1 **] [**Location (un) 620**]. Pain then began
to be more diffuse abdominal with worst on right side. Pain
improved somewhat now after antibiotics and pain medication
(also
nitro and aspirin). Nausea somewhat improved as well. No
fevers
or chills at home but states febrile in ED at BIDN. No diarrhea
or constipation. Last BM this AM as routine, no change in color
or caliber, no blood. No jaw or arm pain. No h/o prior CP
episodes other than heartburn but significant family history of
early MIs. Has been fatigued today with pain onset. Has
baseline myalgias from underlying lower motor neuron disease
(being worked up with possibility of ALS). States he has
diminished appetite but thinks he would eat if food were in
front
of him.
Past Medical History:
Lower motor neuron dz (?ALS... being worked up)
PSH: intussuception as baby, rt knee [**Doctor First Name **]
Family History:
Father w/ MI at 49 (also late DM). Uncle died at 44 of MI.
Physical Exam:
Upon presentation to [**Hospital1 18**]:
99.5 97 122/75 16 96
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, diffusely TTP, worst rt abdomen/RLQ,
+rovsings, neg psoas but +obturator & abd discomfort when moving
his rt leg actively), mild localized RLQ rebound, no guarding,
normoactive bowel sounds, no palbable masses
DRE: normal tone, no gross or occult blood
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2107-6-16**]
Cardiac Cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically apparent flow limiting
stenoses. The
left main was normal with no angiographically apparent stensois.
The
left anterior descending had a 20% proximal lesion. The left
circumflex
had no angiographically apparent stenosis. The right coronary
artery
showed mild luminal irregularities.
2. Limited resting hemodynamics revealed moderately elevated
left sided
filling pressures with an LVEDP of 29 and normal systemic
arterial
pressures.
3. Left ventriculography revealed normal left ventricular
systolic
function with no mitral regurgitation.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal left ventricular sytolic function.
3. Elevated left sided filling pressures
CTA Chest [**2107-6-19**]
IMPRESSION:
1. No PE or acute aortic syndrome.
2. Bibasilar atelectasis/consolidation and small pleural
effusions.
3. Soft tissue in central airways likely represents mucus.
[**2107-6-20**] 05:19AM BLOOD WBC-8.5 RBC-3.92* Hgb-12.3* Hct-33.7*
MCV-86 MCH-31.3 MCHC-36.4* RDW-13.2 Plt Ct-203
[**2107-6-20**] 05:19AM BLOOD Plt Ct-203
[**2107-6-20**] 05:19AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-135
K-4.1 Cl-99 HCO3-30 AnGap-10
[**2107-6-18**] 10:25AM BLOOD CK(CPK)-635*
[**2107-6-20**] 05:19AM BLOOD CK(CPK)-443*
[**2107-6-18**] 10:25AM BLOOD CK-MB-10 MB Indx-1.6 cTropnT-0.28*
[**2107-6-19**] 04:19PM BLOOD CK-MB-15* cTropnT-0.09*
[**2107-6-20**] 05:19AM BLOOD CK-MB-11* MB Indx-2.5 cTropnT-0.06*
[**2107-6-20**] 05:19AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
Brief Hospital Course:
He was admitted to the surgery service and evaluated by
Cardiology for his chest pain and elevated troponins. Given his
family history of MI he was taken to the cath lab where he
underwent catheterization which did not reveal any significant
diseased vessels.
On [**6-16**] he was taken to the operating room for laparoscopic
appendectomy. On the 1st postoperative day he was noted to have
tachypnea with desaturation and an acute abdomen; he was
transferred to the ICu and subsequently was taken back to the
operating room for diagnostic laparoscopy and abdominal washout.
Postoperatively he was taken back to the ICU for a short time
and was then transferred back to the regular nursing unit where
he continued to progress.
He was noted with some pain control issues initially requiring
IV narcotics and was eventually changed to oral pain medications
with adequate relief. His diet was advanced slowly for which he
was able to tolerate. He was able to ambulate independently. On
[**6-21**] he was discharged to home with instructions for follow up.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-15**]
hours as needed for pain.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Levofloxacin 750 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:
Appendicitis
Peritonitis
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have been prescribed an antibiotic for your pneumonia;
please finish all of the medication as prescribed until it is
all gone. If you notice any fevers, chills, productive cough
and/or shortness of breath please return to the Emergency room.
You have been recommended to take a baby aspirin daily by the
Cardiologist; you should be sure to follow up with your PCP for
ongoing care.
Followup Instructions:
Follow up next week in Acute Surgery Clinic, call [**Telephone/Fax (1) 600**]
for an appointment.
Follow up with your PCP [**Name Initial (PRE) 176**] 1 week for a general physical.
Completed by:[**2107-8-17**]
|
[
"E878.8",
"997.39",
"788.20",
"518.81",
"518.0",
"540.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.01",
"57.94",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
5825, 5831
|
3925, 4981
|
339, 484
|
5909, 5909
|
2298, 2978
|
6470, 6683
|
1693, 1755
|
5038, 5802
|
5852, 5888
|
5007, 5015
|
2995, 3902
|
6059, 6447
|
1770, 2279
|
275, 301
|
512, 1543
|
5924, 6035
|
1565, 1677
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,327
| 180,839
|
34234
|
Discharge summary
|
report
|
Admission Date: [**2104-5-26**] Discharge Date: [**2104-6-17**]
Date of Birth: [**2037-1-27**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Left Lower Leg Ischemia
Major Surgical or Invasive Procedure:
[**2104-5-26**]
1. Exploration right groin thrombectomy of right limb
aortobifemoral graft.
2. Resection of right femoral artery pseudoaneurysm.
3. Interposition graft from aortobifemoral graft to common
femoral artery.
4. Thrombectomy left limb aortobifemoral graft.
5. Left above-knee amputation.
[**2104-5-27**]: Reexploration of right groin thrombectomy of right
aortobifemoral graft limb and interposition common femoral
artery graft. Angioplasty and stenting with a 13 mm Viabahn
self-expanding stent graft of the stenosis in the right
aortobifemoral graft limb. Balloon thrombectomy of right
femoral-popliteal graft and popliteal artery. Mechanical
thrombectomy of the posterior tibial artery.
Balloon thrombectomy of the tibial peroneal trunk and
peroneal artery. Exploration and balloon thrombectomy of the
distal posterior tibial artery. Four-compartment fasciotomy
and arteriography of the aortobifemoral graft and right lower
extremity.
[**2104-6-6**]
1. Portex 8.0 tracheostomy tube placement.
2. A 20-French Ponsky tube percutaneous endoscopic
gastrotomy placement.
History of Present Illness:
Pt is a 67M with a h/o PVD s/p s/p Aorto-Bifiem bypass,
bilateral fem-[**Doctor Last Name **] bypass who was transfered to the [**Hospital1 18**]
cardiology service. He presented to [**Hospital3 **] Hospital [**2104-5-23**]
wit complaints of L foot pain and numbness. Reportedly was seen
by a vascular surgeon there and was noted to be in SVT with BPs
in 90's. He was cardioverted, and post cardioversion he was
noted to have a new RBBB and ST elevations. He was taken
emergently to the cath lab which showed 3VD including a total
RCA occlusion and 90% LAD occlusion. No intervention was done;
and he was transfered here.
He has been on a heparin gtt, but no recent interventions have
been performed on the leg. CK's have been steadily rising.
Reportedly, outside vascular surgeon felt the leg was not
salvageable; their plan was to continue the cardiac work-up
prior to a AKA.
Past Medical History:
1. Tobacco Abuse - 1 to 1.5 PPD
2. Coronary Artery Disease, last MI [**2073**], no interventions
3. Peripheral Vascular Disease, s/p aorto [**Hospital1 **]-fem bypass, s/p
bilateral fem-[**Doctor Last Name **] bypass (all @ [**Hospital6 **]- [**Doctor First Name **]
[**Doctor Last Name 27785**]).
Social History:
Married, 6 children, lives in [**Location **], retired line chef.
Family History:
Non contrib
Pertinent Results:
[**2104-6-12**] 01:27AM BLOOD WBC-12.1* RBC-2.80* Hgb-8.1* Hct-25.2*
MCV-90 MCH-28.9 MCHC-32.1 RDW-13.7 Plt Ct-330
[**2104-5-26**] 06:11PM BLOOD WBC-10.8 RBC-3.99* Hgb-12.0* Hct-34.2*
MCV-86 MCH-30.2 MCHC-35.3* RDW-13.8 Plt Ct-167
[**2104-6-12**] 03:25AM BLOOD PT-13.3 PTT-66.5* INR(PT)-1.1
[**2104-6-12**] 03:25AM BLOOD Glucose-96 UreaN-44* Creat-1.4* Na-140
K-4.5 Cl-104 HCO3-27 AnGap-14
[**2104-6-10**] 03:57AM BLOOD ALT-89* AST-83* CK(CPK)-3012*
AlkPhos-222* TotBili-1.0
[**2104-5-26**] 06:11PM BLOOD CK(CPK)-[**Numeric Identifier 78848**]*
[**2104-6-6**] 03:42AM BLOOD Lipase-43
[**2104-6-4**] 11:14PM BLOOD CK-MB-10 MB Indx-0.2 cTropnT-1.83*
[**2104-5-26**] 06:11PM BLOOD CK-MB-269* MB Indx-1.4 cTropnT-0.66*
[**2104-6-12**] 03:25AM BLOOD Calcium-8.3* Phos-4.6* Mg-2.9*
[**2104-6-12**] 09:07AM BLOOD Type-MIX pO2-60* pCO2-43 pH-7.40
calTCO2-28 Base XS-0 Comment-GREEN TOP
[**2104-6-4**] 12:33PM BLOOD O2 Sat-89
[**2104-6-12**] 08:06AM BLOOD freeCa-1.09*
[**5-26**]: CXR - Opacification in the left lower lung accompanied by
marked leftward mediastinal shift reflects lower lobe collapse.
There may be a small left pleural effusion. Right lung shows
mild pulmonary edema. Heart is mildly to moderately enlarged. No
pneumothorax. Right jugular line ends in the SVC. ET tube tip at
the thoracic inlet between 4 and 5 cm from the carina is
acceptable with the chin elevated. Nasogastric tube is folded in
the stomach.
[**5-27**]: Cath - 1. Peripheral angiography performed via right
brachial 4
french retrograde access to the abdominal aorta. The abdominal
aorta
had previous aorto-bifem bypass with complete occlusion of the
left limb
of the graft. The right iliac limb of the aortobifem bypass was
patent
to the CFA. The previous CFA aneurysmal segment is nos s/p
surgical
repair and there was a noted "kink" in the mid-segment of the
repair.
There is flow to the fem-popliteal bypass on the right with
occlusion of
the native SFA and PFA noted. The fem-[**Doctor Last Name **] fills the native
popliteal but
with very slow flow and limited filling. There was evidence of
extensive, layered thrombus in the distal native popliteal and
in the
TPT extending into the PT. The PT is the only vessel runoff to
the foot
and had extremely sluggish flow noted.
Left leg: the graft is as noted above. There is no filling of
the native
CFA; only collaterals to the native PFA are noted.
[**5-28**]: Renal US - 1. No evidence of hydronephrosis or perinephric
fluid collection. 2. Mildly elevated resistive indices
bilaterally, of indeterminant etiology.
[**5-29**]: RUQ US - 1. The liver demonstrates heterogeneous
echotexture with focal areas of increased echogenicity. This
appearance is compatible with fatty liver; however, other liver
disease and more advanced liver disease including
cirrhosis/fibrosis cannot be excluded.
2. The liver demonstrates normal portal, arterial, and hepatic
vein flow.
3. Cholelithiasis with no evidence of cholecystitis.
[**6-11**]: CXR - 1. Right PICC terminating within the right atrium.
2. Interval improvement in interstitial edema with persistent
mild pulmonary edema.
3. Unchanged retrocardiac atelectasis and moderate cardiomegaly.
Brief Hospital Course:
The patient was admitted initially to the cardiology the to the
surgery service for evaluation and treatment; she was
transferred from Caritas. . She had a cardiac catheterization,
and subsequently went to the operating room with the vascular
service for and exploration of the right groin, thrombectomy of
right limb aortobifemoral graft, resection of right femoral
artery pseudoaneurysm, interposition graft from aortobifemoral
graft to common, femoral artery, Thrombectomy left limb
aortobifemoral graft, left above-knee amputation. On [**5-27**], the
patient returned to the OR for a reexploration; for details,
please see operative note. The patient remained intubated and
sedated and returned to the CVICU for further care.
Neuro: The patient received a fentanyl drip initally with good
effect and adequate pain control. Sedation was adjusted
accordingly. Post operatively, the patient was intermittently
confused and agitated; Haldol and other sedatives were given.
Sedation was weaned when appropriate.
CV: On [**5-26**], the patient underwent a cardiac catheterization
with successful revascularization and stent placement.
Cardiology continued to follow throughout her admission. Her
cardiac enzymes were cycled, revealing an acute MI on POD [**2-10**].
On POD [**9-17**], the patient had 2 episodes of asystole with
spontaneous recovery. Presedex was stopped at that time.
Lopressor, and other cardiac medications were adjusted when
appropriate to maintain stable vital signs.
On [**6-8**], the patient had episodic bradycardia to the 40's.
The patient's metoprolol was dosed accordingly, and on
admission, the patient was receiving metoprolol 125 mg TID.
Pulmonary: Post operatively, the patient remained intubated and
sedated.
By [**6-5**], thoracic surgery was consulted for trach/peg placement;
trach sutures were to remain in place until [**6-14**].
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF. Tube feeds
were started on POD [**3-11**] via DObhoff; nutrition was consulted for
tube feed recommendations.
Post operatively, the nephrology team was consulted for
recommendations for acute renal failure; the creatinine was 1.6.
A renal ultrasound was performed; see reports for results. It
was suspected that the renal insufficiency was secondary to
rhabdomyolysis. Her creatinine continued to rise subsequently,
though her urine output appeared to increase. By POD [**6-14**], a
gentle diuresis was initiated, which was continued as
appropriate based on daily I/Os, weights, etc.
By [**6-5**], thoracic surgery was consulted for trach/peg placement
(the heparin drip was held for that procedure).
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Post operatively, on POD
[**2-10**], the patient was pan cultured for a fever of 101. The
patient was started on ciprofloxacin on POD [**2-10**]; a urinary tract
infection was suspected from her urinalysis results. Vancomycin
was initiated on [**6-5**], and cipro was stopped. Ceftriaxone was
started on [**6-6**], and vanc was stopped.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient was maintained on aspirin, heparin drip
for anticoagulation. The patient's complete blood count was
examined routinely. On POD [**1-9**], the patient was transfused 2
units of packed red blood cells. When appropriate, the patient
was transitioned to coumadin, which was dosed daily per his
coagulation profile.
Prophylaxis: The patient received a heparin drip and aspirin
during this stay. The patient was transitioned to aspirin,
plavix and coumadin.
Other: Plastic surgery was consulted for evaluation of gluteal
wounds, who recommended enzymatic debridement with further
mechanical debridement possible when stable. Wound care was
also consulted for evaluation and treatment. The patient was to
continue with Accuzyme to the wound, and no futher mechanical
debridement was necessary.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a tube
feeds.
Medications on Admission:
Aspirin 81mg
Atenolol 100mg po qday
Multivitamin
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*60 ML(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin Lispro 100 unit/mL Solution Sig: variable
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO DAILY (Daily): per G tube. mg
10. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol Sig: One
(1) Appl Topical DAILY (Daily).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2
times a day).
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
13. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. Warfarin 1 mg Tablet Sig: variable Tablet PO DAILY (Daily):
goal INR [**2-10**].
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q6H (every 6 hours) as needed.
18. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
21. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
22. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. CeftriaXONE 1 gm IV Q24H
24. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1600 (1600) u/ml Intravenous ASDIR (AS DIRECTED): goal PTT
60-80, d/c hep gtt when INR >2.
25. 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:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. STEMI s/p cardiac catherization @ outside hospital
2. Thrombosed aortobifemoral graft
3. Acutely ischemic RLE
4. Respiratory failure
5. VAP
Discharge Condition:
Stable
Discharge Instructions:
1.. Continue coumadin & heparin drip until INR >2, then d/c
heparin drip
2.Staples may be removed on [**2104-6-18**]
Followup Instructions:
Please call Dr.[**Name (NI) 5695**] office at ([**Telephone/Fax (1) 18181**] to arrange
for a follow up appointment
|
[
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"410.71",
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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12696, 12768
|
5966, 10348
|
304, 1400
|
12955, 12963
|
2766, 5943
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13128, 13247
|
2734, 2747
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10447, 12673
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12789, 12934
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10374, 10424
|
12987, 13105
|
241, 266
|
1428, 2312
|
2334, 2634
|
2650, 2718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,202
| 178,758
|
38316
|
Discharge summary
|
report
|
Admission Date: [**2103-7-3**] Discharge Date: [**2103-7-26**]
Date of Birth: [**2072-10-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Occipital Bleed, Fever, Septecemia
Major Surgical or Invasive Procedure:
Extra ventricular drain placement and removal
History of Present Illness:
30 YO M s/p recent hospitalization at [**Hospital1 18**] [**Date range (1) 85383**] with
endocarditis. On [**2103-6-14**], he underwent aortic valve replacement
with repair of mitral valve and repair of several aortic root
abscesses. He was discharged on [**6-22**] to rehab. Of note, during
his post-op cardiac surgical course, he was noted within the
first 24h to have garbled speech, left facial droop, and left
sided weakness. Urgent head CT was negative. MRI of the head was
done on [**6-18**] findings were suggestive of infarction, but
inconclusive. He continued to gain strength of the left side and
repeat MRI was done on the day of discharge which demonstrated
an area of subacute infarct in the right precentral gyrus.
.
On [**2103-7-1**] while at the rehab facility, Mr. [**Known lastname 85379**] was noted to
have left-sided headaches, garbled speech, somnolence,
nausea/vomiting and was transferred to OSH. There, lab testing
was revealing for supratheraputic INR of 6.0 (since corrected to
1.3 prior to txfr) and head CT was performed where an occipital
hemorrhage measuring approx 5cm with and intraventricular
extension identified. He was loaded with Dilantin. Subsequent
hospital course was complicated by development of Torsades de
Pontes, for which he required defibrillation and had been
sustained on Isoprel. Once he was noted to be medically stable,
he was transferred to the MICU at [**Hospital1 18**] for definitive
evaluation and treatment.
.
On [**2103-7-3**], pt was evaluated by N-[**Doctor First Name 147**] who placed a bedside
ventricular shunt. Pt. also developed a few ([**3-8**]) short bursts
of tachycardia to 150-160, followed by a brief episode of
bradycardia, lowest HR was 34 usually would transiently go to
40s. Hydralazine was started for elevated BP (SBP goal
120-160).
.
On [**2103-7-4**], pt was exutubated, the ventricular drain was removed
and heparin sq was held for 5 days. Anticoagulation was
discussed thoroughly between N-[**Doctor First Name **] & CT-[**Doctor First Name **]. EP was
consulted, and believed that arrythmia was polymorphic VT. Some
decreases in mental status were noted - CT/CTA of head performed
urgently and showing some bleeding in the shunt tract. Fluid
bolus was given to maintain BP, there was questionable
increasing somnolence this morning, spoke with neurosurgery and
got repeat head CT.
.
On [**2103-7-5**], anisocoria was present in the morning, but reactive,
repeat head CT without change in bleed. Echo was performed
showing probable vegetation on aortic valve and new 2+ MR. Pt.
expressed desire for no further intervention, so TEE that was
ordered for Friday afternoon was canceled. Heparin gtt was
restarted without bolus in conjunction with NSG and CT surgery
attendings. Pt. was bolused for low Urinary output, vanco was
d/c'ed per N-[**Doctor First Name **] rec.
.
On [**2103-7-6**], CT head was stable, Hep gtt was continued. Pt had
supratherapeutic ptt, so values were decreased, and weight based
dosing began. Decided not to do BB test given stability and
lack of rhythm changes.
.
On [**2103-7-7**], Coumadin was restarted, PTT was therapeutic, CT head
maintained stable, per N-[**Doctor First Name **], BP goal was not as strict, and
N-[**Doctor First Name **] signed off.
.
On [**2103-7-8**], pt. was admitted to our floor/service, VS were:
T: 101, BP: 133/90, HR: 112, RR: 23, O2sat: 98%. Pt. was aware
of person, but lacks awareness of place and time. Neuro: A&Ox1,
unable to recall 3 words, CN II-XII intact, though L pupil
larger than R, Hyperreflexia to L 3+ UE & LE, L sided weakness
[**4-9**] UE & LE, L palmar drift.
.
On [**2103-7-9**], VS: 98.6 (101-98.6), 157/80 (157-80-132/80), 98
(112-98), 18 (23-18), 99% (100-98). CXR, in comparison with the
study of [**7-4**] shows no evidence of focal consolidation to
suggest pneumonia. Vancomycin, Cefepime and Gentamicin were
dosed per ID recs; Foley was d/c at midnight.
.
On [**2103-7-10**]
ID was consulted, and recommended continuation of Vanco,
Cefepime & gentamycin at current doses. PICC was pulled, and
peripheral access was was obtained.
.
On [**7-18**]
Broad spectrim ABx were d/c, and pt. was placed solely on
Ceftriaxone per ID recs.
.
[**2103-7-14**] - [**2103-7-16**], labs, VS & physical exam/neuro stable at
current baseline
CT head showed improvement from last CT head in the MICU. PICC
was put back in place b/c peripheral line was inadequate.
.
On [**2103-7-17**], tt. showed consistent neuro exams, more awake, but
increased WBC from 10-15.5. Pt. was then sent to get a CXR to
rule out pneumonia, blood cultures were taken and urine cultures
were taken. Neuro appointments were scheduled for a CT, folled
by an appointment with Dr. [**First Name (STitle) **] in [**Month (only) 216**].
.
On [**2103-7-18**]
We continued bridging to coumadin in an attempt to achieve
therapeutic INR. Neuro exams were mildly improved. There was a
mild elevation of WBC and temperature that returned to previous
baseline levels.
.
[**7-19**]-Present
Patient lost some hope about leaving, and we decided to start an
antidepressant. Throughout this time we started a 5 day
vancomycin antibiotic regimen per Infectious Disease's
recommendation (we also pulled your PICC line). We continued to
slowly increase your Coumadin levels to achieve a therapeutic
INR to protect your artificial heart valves.
.
[**7-24**]: d/c planning, scheduled PICC placement so pt. can maintain
heparin drip since subtherapeutic INR. OT/PT evaluated for
rehab. Granted stop at [**Hospital3 **] center, awaiting
insurance approval.
Past Medical History:
- Endocarditis
- Aortic Valve Replacement with a [**Street Address(2) 6158**]. [**Male First Name (un) 923**] Mechanical
Valve. Mitral Valve Repair with 28mm [**Company 1543**] Future Ring with
Repair of Anterior Leaflet of Mitral Valve. Repair of Two Aortic
Root Abscesses ([**2103-6-14**])
- PICC Lines
- History of ETOH Abuse
- s/p Tympanostomy Tubes
- s/p Dental surgery for "tooth growing into his sinuses"
- Possible drug abuse
- Prolonged QT/Torsades de Pointes
Social History:
Prior to recent admission and d/c to Newbridge on the [**Doctor Last Name **],
he was living at home with his parents, 2 cats, 1 dog, and fish.
He has no history of international travel, and no recent travel.
He works handling shipping products. Reports he drank 5+ shots
per night prior to admission, more on the weekends, smokes [**3-8**]
ppd x 15 years, denies illicit drug use, and specifically denies
IVDU. 1ppd.
Family History:
Mother with diabetes and hypertension. Father with hypertension.
Physical Exam:
Vitals (7/20@00:00) T:98.6, BP 98/65 (98-114/65-82, HR: 90
(90-104), RR: 18, O2: 93%
GEN: NAD, laying comfortably in bedside
HEENT: Healed surgical scar overlying the skin of R forehead, no
erythemia no drainage. MMM no lymphadenopathy
CV:RRR; III/VI systolic murmur at LUSB no rubs/gallops
PUL: CTA B/L, L basilar crackles that resolved after a couple of
deep inhalation with spirometer
ABD:soft, nontender, non descended, BS normoactive
EXT: L sided weakness 4/5, and L sided hyperreflexia 3+
NEURO: AOx2 fluctuating awareness of location, occasionally
believes he is not in [**Location (un) 86**] and is near his [**Location 27224**] & does not
know what day it is. Ansicoria L>Rm CNIII-XII intact, and
symmetric. Motor: LUE: [**4-9**] RUE: [**5-9**] RLE:[**5-9**] LLE:[**4-9**]. Sensation
to light touch perserved BL in Upper and Lower extermities.
Reflexes: R biceps: 2+ L biceps 3+, R Brachiorad 2+ R Brachiorad
3+, R patellar 2+ L patellar 3+. L palmar drift.
Pertinent Results:
Discharge labs:
[**2103-7-26**] 05:58AM BLOOD WBC-6.7 RBC-2.98* Hgb-8.7* Hct-27.2*
MCV-91 MCH-29.3 MCHC-32.1 RDW-17.8* Plt Ct-655*
[**2103-7-26**] 05:58AM BLOOD PT-17.8* PTT-96.2* INR(PT)-1.6*
[**2103-7-25**] 06:40AM BLOOD Glucose-89 UreaN-13 Creat-0.6 Na-140
K-4.6 Cl-102 HCO3-31 AnGap-12
[**2103-7-24**] 06:35AM BLOOD ALT-41* AST-33
[**2103-7-25**] 06:40AM BLOOD Calcium-9.7 Phos-5.5* Mg-2.1
[**2103-7-21**] 11:30PM BLOOD Vanco-15.1
.
Microbiology:
PICC tip: ([**7-19**]) (Final - no growth)
urine cx ([**7-18**])- (Final - no growth)
blood cx x1 ([**7-17**]) - STAPHYLOCOCCUS, COAGULASE NEGATIVE
Other blood cx X 9 from [**Date range (1) 85384**] - no growth to date
.
WBC:
[**7-17**] 15.5
[**7-18**] 11.3
[**7-19**] 11.4
[**7-20**] 7.7
[**7-21**] 8.3
[**7-22**] 7.1
[**7-23**] 6.0
[**7-24**] 5.6
[**7-25**] 6.2
[**7-26**] 6.7
.
TEE ([**2103-7-10**]): No vegetation of mitral valve or annuloplasty
ring. The mechanical aortic valve leaflets are not fully seen
but there is no overt vegetation. There is an echolucent area
posterior to the aortic root with flow that is new compared with
[**2103-7-5**]. This lucency has developed in the region of prior
phlegmon/abscess visualized in the [**2103-6-14**] transesophageal
echocardiogram (and probably also in the [**2103-7-5**]
transthoracic echocardiogram). There is also an echolucent area
anterior to the prosthetic aortic valve (similar to
transthoracic echocardiogram of [**2103-7-5**]) consistent with
aneurysmal right sinus of Valsalva in the region of prior
anterior aortic root abscess visualized in [**2103-6-14**] the
transesophageal echocardiogram. - Per Dr. [**Last Name (STitle) **], most likely
post-operative changes.
.
MRI/MRA Brain ([**2103-7-11**]): No significant change since the CT of
[**2103-7-7**]. Stable appearance to the left occipital hemorrhage
with intraventricular extension. Stable right frontal
ventriculostomy tract hematoma. No new sites of hemorrhage.
.
CT Head ([**2103-7-13**]): 1. No new intracranial hemorrhage. No acute
major vascular territorial infarct. No developing hydrocephalus.
2. Expected evolution of the known multifocal intraparenchymal
hemorrhages, with each focus decreased in size and attenuation.
.
CXR ([**2103-7-17**]):
In comparison with study of [**7-8**], there is the suggestion of some
vague asymmetry in opacification at the bases, with slightly
more prominent on the left. This is not definitely seen on
lateral projection, though it could represent a region of
developing pneumonia.
.
UE US ([**2103-7-17**]):
IMPRESSION: No DVT of the left upper extremity.
.
CXR [**7-24**]: IMPRESSION: New left subclavian PICC line with the
catheter tip in the azygous vein, retraction of the catheter by
3 cm is recommended.
Brief Hospital Course:
30 year old gentleman with a PMH significant for S. viridans
endocarditis, s/p 4 wk course of ceftriaxone (last day [**7-13**]) with
AV abscess s/p aortic valve replacement, mitral valve repair,
initially admitted for new occipital hemorrhage in the setting
of supratherapeutic INR (6) and 2 episodes of Torsades de Pontes
on [**2103-7-3**] requiring cardioversion, presented initially to the
MICU then was transferred to the medicine floor on [**2103-7-8**] once
stable.
.
(#)Occiptal Head bleed - presented with occipital hemorrhage in
setting of suprapeutic INR level of 6. The patient's INR was
reversed and was evaluated by Neurosurgery. A VP shunt was
placed briefly and removed once CT scans stabilized with no
evidence of midline shift. The patient was monitored closely
with q8H Neuro exams. He initally was unresponsive, L sided
aniscoria, hyperreflexia on the L UE and LE, left sided weakness
and L palmar drift. All of this has improved prior to
discharge, however her persists with confabulation, left sided
aniscoria, and mild weakness. He will require neuro rehab in
the future. Anticoagulation for prostetic valve was restarted
per N-[**Doctor First Name **] & CT [**Doctor First Name **] recommendations without changes in neuro
exam or CT findings.
.
(#)Prolonged QT / Torsades de Pointes - No subsequent episodes
following hospitalization. The cause was likely was related to
pt's concurrent intracranial process. Pt not on any notable
QT-prolonging drugs and normal QT interval seen on prior ECG
from [**6-14**]. The patient was monitored on Telemetry with no signs
of ectopy. Beta blocker was held since pt. did not exceed 120's
for extended time.
.
(#)Fever - Unclear etiology of initial fever on [**2103-7-8**], however
as below developed coag neg line infection on [**7-17**]. Given prior
endocarditis, TEE was repeated with no evidence of mass and two
aneurysms that were determined to be most likely post operative
changes by CT surgery. He was empirically treated with broad
spectrum antibiotics however given no obvious source of
infection his 4 week course of Ceftriaxone was completed on [**7-13**].
Following, Cefazolin was administered for 6 days for
superficial infection from staples & sutures to skull. At that
time, PICC tip cultures showed no growth, Blood & Urine cultures
show no growth
.
(#) Coag Neg Line Infection: On [**7-17**] the patient was found to
have positive blood cultures with coag neg staph from the PICC
line. Peripheral cultures were all negative. In consultation
with ID, the patient was treated with vancomycin for 5 days
(completed [**7-25**]) and the line was removed. WBC trended down to
5.6 and afebrile since [**7-8**] (elevated [**7-17**] to 100). Repeat blood
cultures are no growth to date.
.
(#) Endocarditis - s/p AVR & MV repair from prior admission.
Completed 4 week course of ceftriaxone on [**2103-7-13**] for S. viridans
on AV pathology. Recent TEE shows no mass as per CT sx &
healing processes.
.
(#) Prosthetic AV - As above restarted anticoagulation at the
recommendation of Neuro and CT surgery with stable appearance of
frontal hemorrhage. The patient is currently on heparin drip to
coumadin on discharge. Instructions on discharge plan.
Discharged with INR 1.6 on 7mg of coumadin, 1350units/hr of
heparin IV. His goal INR is 2.5 to 3.0, per CT surgery.
.
(#) Recent bouts of depression & confabulation- being in
hospital for extended stay. Celexa 10mg qDaily was ordered for
depression. Can think about increasing dose gradually if no
noticeable improvement. Thiamine 100 mg is also ordered for
confabulation, even though unlikely to have Wernickes. Folate,
B12, TSH and RPR all negative.
.
.
The patient was full code throughout this hospitalization.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
2. Aspirin 81 mg Tablet
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
4. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gms Intravenous Q24H (every 24 hours) for 3 weeks.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2.5-3.0 for mech AVR.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Medications at OSH (per discussion with [**Name8 (MD) **] RN at OSH):
Fentanyl drip
Propofol drip
Isuprel drip
Saline 75 cc/hr
Rocephin 2 gm daily
Protonix 40 mg IV daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for depression.
4. Warfarin 6 mg Tablet Sig: One (1) Tablet PO Once daily at 4pm
(16:00): Please take a total of 7mg Warfarin a day (one 6mg tab
& one 1mg tab) with daily INR level checks. .
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once daily at 4pm
(16:00): Please take a total of 7mg Warfarin a day (one 1mg tab
& one 6mg tab) with daily INR level checks.
6. Outpatient Lab Work
Please monitor PTT levels [**Hospital1 **] and adjust Heparin accordingly
according to scale. Discontinue heparin drip once INR above 2.5
consecutively for two days.
7. Outpatient Lab Work
Please take daily INR levels. Therapeutic goal is 2.5-3.5.
Once INR stable above 2.5 for two consecutive days, can
discontinue heparin drip
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. Heparin (Porcine) in NS 10 unit/mL Kit Sig: IV sliding scale
Intravenous continuous: Current infusion: 1300 units/hr
Target PTT: 60 - 100 seconds
If PTT <40: provide 1700 units bolus, then increase infusion
rate by 200 units/hr
If PTT 40 - 59: provide 900 units Bolus, then Increase infusion
rate by 100 units/hr
If PTT 60 - 100*: maintain infusion rate
If PTT 101 - 120: Reduce infusion rate by 150 units/hr
If PTT >120: Hold 60 mins, then Reduce infusion rate by 250
units/hr.
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: 2 mL IV
PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
13. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Principle Diagnosis:
Fever, Parieto-Occipital Hemorrhagic Stroke, Prosthetic AV heart
valve
Secondary Diagnosis:
Endocarditis, Prolonged QT/Torsades de Pointes, Memory deficit
Discharge Condition:
Mental Status: Confused at baseline
Activity Status: Ambulatory - requires assistance or aid
(personal assistant).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Thank you for letting us participate in your care. You were
admitted to the hospital for a change in mental status. You
were found to have a bleed in your brain. This has been treated
by the neurosurgeons and is stable. Your neurologic recovery
has been steady. You will continue to require neurologic rehab
on discharge. If there is any change in mental status,
immediately contact neurologist for further examination.
You were restarted on anticoagulation during this
hospitalization. You are currently taking both coumadin and
heparin, until your INR is therapeutic for two consecutive days
(goal 2.5-3.5 per CT-surgery & Neurosurgery recommendations).
If you develop sudden headaches, nausea, vomiting, change in
mental status, or other neurologic symptoms please go to the ED
immediately. You are NOT to drive & you cannot fully take care
of yourself.
.
START:
Take [**1-6**] of a 20mg Citalopram Hydrobromide tablet (10 mg) DAILY
Take one Thiamine 100 mg tablet DAILY
Take one Warfarin 6mg tablet & one Warfarin 1mg (total 7mg)
tablet DAILY @ 4pm (16:00)
Heparin IV Sliding Scale as provided
Take one Levetiracetam 500mg tablet two times a day (every
12hrs) for 2 weeks
One Nicotine patch once a day
One multivitamin every day
Followup Instructions:
Department: CARDIAC SURGERY
When: WEDNESDAY [**2103-8-1**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: THURSDAY [**2103-8-16**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2103-8-16**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2103-8-1**]
|
[
"285.9",
"379.41",
"427.1",
"305.1",
"999.31",
"421.0",
"790.92",
"303.91",
"V43.3",
"311",
"997.02",
"431",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"38.93",
"88.72",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
17248, 17318
|
10765, 14525
|
349, 397
|
17539, 17539
|
8009, 8009
|
18991, 19930
|
6939, 7006
|
15196, 17225
|
17339, 17432
|
14551, 15173
|
17727, 18968
|
8025, 10742
|
7021, 7990
|
275, 311
|
425, 5996
|
17453, 17518
|
17554, 17703
|
6018, 6488
|
6504, 6923
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,025
| 137,469
|
27154
|
Discharge summary
|
report
|
Admission Date: [**2110-12-2**] Discharge Date: [**2110-12-8**]
Date of Birth: [**2045-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy [**2110-12-5**]
History of Present Illness:
The patient is a 64 year old white male who underwent off-pump
coronary artery bypass with Dr. [**First Name (STitle) **] recently, and was
discharged to rehab on [**2110-12-1**]. He presented to the emergency
department on [**2110-12-2**] with decreased hematocrit and bright red
blood per rectum.
Past Medical History:
Coronary artery disease
s/p off pump cabg
[**2110-4-9**] - BMS (Driver) to OM1
[**2110-7-24**] - 95% in-stent thrombosis of OM1, tx with 2 DES (Xience)
in the proximal OM1 extending to the circumflex with no residual
stenosis; distal L Cx occluded
- per cath report, left main without significant disease
- LAD with 30-40% plaque after large septal branch
- known RCA occlusion with collateral flow
Dyslipidemia
ESRD on HD M/W/F
COPD
s/p CVA L MCA [**3-16**]
s/p CVA R MCA [**3-18**]
secondary hyperparathyroidism
Social History:
-Tobacco history: + [**12-11**] ppd
-ETOH: none recently, but + history
-Illicit drugs: pt denies
Family History:
No hx of CAD, MI, DM per daughter.
Physical Exam:
General HR 83, b/p 87/42, ht 5'[**12**]", wt 223 pounds, no acute
distress
Skin unremarkable
HEENT unremarkable
Neck supple full ROM
Chest Wheezing bilaterally
Heart regular no murmur
Abdomen soft, non distended, nontender
Extremeties warm well perfused +1 edema bilat, pulses with
doppler
Neuro alert and oriented x3, left side weakness that is baseline
Pertinent Results:
[**2110-12-8**] 08:00AM BLOOD WBC-8.4 RBC-2.78* Hgb-8.4* Hct-24.9*
MCV-90 MCH-30.1 MCHC-33.6 RDW-17.2* Plt Ct-301
[**2110-12-1**] 05:19AM BLOOD WBC-12.1* RBC-3.35* Hgb-9.9* Hct-30.2*
MCV-90 MCH-29.6 MCHC-32.8 RDW-17.2* Plt Ct-235
[**2110-12-8**] 08:00AM BLOOD Plt Ct-301
[**2110-12-7**] 09:10AM BLOOD PT-17.1* PTT-28.7 INR(PT)-1.5*
[**2110-12-1**] 05:19AM BLOOD Plt Ct-235
[**2110-12-2**] 10:30AM BLOOD PT-21.7* PTT-30.6 INR(PT)-2.1*
[**2110-12-2**] 10:30AM BLOOD PT-21.7* PTT-30.6 INR(PT)-2.1*
[**2110-12-8**] 08:00AM BLOOD Glucose-108* UreaN-39* Creat-6.4* Na-139
K-4.4 Cl-101 HCO3-28 AnGap-14
[**2110-12-2**] 02:12PM BLOOD ALT-21 AST-17 LD(LDH)-208 AlkPhos-115
Amylase-122* TotBili-0.4
[**2110-12-2**] 10:30AM BLOOD ALT-25 AST-33 LD(LDH)-338* CK(CPK)-57
AlkPhos-131* TotBili-0.3
[**2110-12-2**] 02:12PM BLOOD Lipase-118*
[**2110-12-8**] 08:00AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.0
[**2110-12-1**] 05:19AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.1
[**2110-12-2**] 11:11AM BLOOD Lactate-1.1
[**2110-12-2**] 10:33AM BLOOD Hgb-8.9* calcHCT-27
Brief Hospital Course:
The patient remained hemodynamically stable and was admitted for
further workup of bright red blood per rectum and decreased
hematocrit. The GI service was [**Month/Day/Year 4221**] and evaluated him in
the emergency department. He was admitted and received
transfusions for decreased hematocrit. He underwent colonoscopy
was performed on [**12-5**] and revealed a localized erythematous,
friable region with adherent exudate and surrounding edematous
folds with indiscrete cobblestone patterns noted in the distal
transverse colon, splenic flexure and proximal descending colon.
The source of the bright red blood per rectum may be explained
by the findings but there was no acute bleed found with the
colonscopy. He was maintained on hemodialysis throughout the
hospital course, with the assistance of the renal team, with
last hemodialysis [**12-8**]. His hematocrit was 24 at discharge with
plan for repeat hematocrit [**2110-12-12**] at rehab.
Medications on Admission:
plavix 75'
asa 81'
simvastatin 40'
mirtazapine 7.5'
pantoprazole 20''
sevelamer 800'''
metoprolol 25'
nephrocaps 1'
MVI
ipratropium bromide 1puffs q6hrs
colace 100''
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day.
8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): 12.5
mg daily .
10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Cinacalcet 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
gastrointestinal bleed
PMH:
coronary artery disease s/p CABG [**11/2110**]
end stage renal disease on hemodialysis
chronic obstructive pulmonary disease
s/p cerebral vascular accident [**2110-3-11**] and [**2108-3-10**]
secondary hyperparathyroidism
obstructive sleep apnea
hypertension
hyperlipidemia
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, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks from surgery
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Left knee with scab and mild erythema - please wash daily,
topical antibiotic and cover with guaze daily, please call if
erythema worsens or fevers
Followup Instructions:
Please call to schedule appointments
Dr. [**First Name (STitle) **] in 2 weeks
Dr. [**Last Name (STitle) 65155**] in 2 weeks
Dr. [**Last Name (STitle) **] (or Dr. [**Last Name (STitle) 15183**] after discharge from rehab
Dr. [**Last Name (STitle) 4539**] (GI) in [**1-12**] weeks
Labs: please check CBC [**2110-12-12**] at rehab prior to dialysis
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2110-12-8**]
|
[
"588.81",
"403.91",
"585.6",
"412",
"496",
"272.4",
"578.9",
"V45.81",
"285.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"38.93",
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5128, 5199
|
2863, 3818
|
349, 379
|
5545, 5552
|
1806, 2840
|
6253, 6722
|
1379, 1415
|
4034, 5105
|
5220, 5524
|
3844, 4011
|
5576, 6230
|
1430, 1787
|
282, 311
|
407, 708
|
730, 1245
|
1261, 1363
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,899
| 132,881
|
28151+57579
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-11-20**] Discharge Date: [**2113-12-28**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Syncope, dizziness, intermittent DOE
Major Surgical or Invasive Procedure:
AVR with 23 mm CE pericardial valve [**2113-11-20**]
subtotal colectomy/G-J tube placement/end ileostomy [**2113-12-12**]
History of Present Illness:
Hospitalized x2 this year for anemia, dizziness, and fainting.
Had multiple transfusions after diagnosis of duodenal adenoma
and angiodysplasia of colon. Workup revealed sev Aortic
stenosis and referred for surgery.
Past Medical History:
Duodenal Adenoma
Angiodysplasia of colon
GI bleed. H pylori
Anemia
HTN
Hernia repair
BPH
diverticulosis
remote MVA head trauma with ? metal plate
Social History:
Lives alone(wife in nursing home).
Retired
Tobacco- quit 3 years ago(124 pack year history)
ETOH- none x 3 years
no recreational drugs
Family History:
sister MI at 84 YO
Physical Exam:
Admission
VS HR 56 BP 172/80 RR 16
Gen NAD
Pulm CTA-B
Cor RRR 4/6 holosystolic murmur throughout precordium
Abdm soft/NT/ND/NABS. Well healed abdm scar
Ext warm well perfused. Edema 2+ bilat.
Pertinent Results:
CHEST (PA & LAT)
Reason: evaluate pleural effusion
HISTORY: Evaluate pleural effusion. Patient is status post AVR.
Two views. Comparison with previous study done on [**2113-11-23**].
There are small bilateral pleural effusions, unchanged. The
lungs appear otherwise clear except for minimal streaky density
at the right base most consistent with subsegmental atelectasis.
The patient is status post median sternotomy. The heart appears
large with cardiac size may be exaggerated by AP technique. The
patient is status post median sternotomy and AVR. Mediastinal
structures are otherwise unremarkable. The bony thorax is
grossly intact.
IMPRESSION: Persistent small bilateral pleural effusions not
significantly changed.
Reason: Reanal artery ultrasound, increasing creatinine from 1.2
to 2.9
REASON FOR THIS EXAMINATION:
Reanal artery ultrasound, increasing creatinine from 1.2 to 2.9
INDICATION: 83-year-old man with aortic valve replacement and
rising creatinine. Evaluate for renal artery stenosis.
COMPARISON: CT chest without contrast dated [**2113-11-7**].
RENAL ULTRASOUND WITH DOPPLER EXAMINATION: The right kidney
measures 8.5 cm. Renal Doppler examination at the upper, mid,
and lower pole demonstrate a slightly delayed upstroke with
resistive indices ranging from 0.63 to 0.66. The left kidney
measures 11.5 cm. Doppler examination of the upper, mid and
lower pole range from 0.71 to 0.74. There is no hydronephrosis,
stones, or masses bilaterally.
IMPRESSION: Findings suggesting right renal artery stenosis.
Cardiology Report ECHO Study Date of [**2113-11-24**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. S/p prosthetic aortic
valve function.
Height: (in) 68
Weight (lb): 198
BSA (m2): 2.04 m2
BP (mm Hg): 113/62
HR (bpm): 78
Status: Inpatient
Date/Time: [**2113-11-24**] at 14:50
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W045-0:45
Test Location: West Echo Lab
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: 0.39 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aorta - Arch: 2.7 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *2.8 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 32 mm Hg
Aortic Valve - Mean Gradient: 16 mm Hg
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 0.91
Mitral Valve - E Wave Deceleration Time: 147 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional
LV systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR
gradient.
MITRAL VALVE: Mildly thickened mitral valve leaflets. LV inflow
pattern c/w
impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets.
PERICARDIUM: Small pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. Regional left ventricular
wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%).
3. A bioprosthetic aortic valve prosthesis is present. The
transaortic
gradient is normal for this prosthesis.
4. The mitral valve leaflets are mildly thickened.
5. There is a small pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2113-11-24**] 15:42
Brief Hospital Course:
Mr [**Known lastname 48422**] was a direct admission to the operating room where he
had an Aortic valve replacement with a #23 CE pericardial valve.
Please see OR report for full details. Patient tolerated
operation well and was transferred from OR to Cardiac surgery
recovery unit following operation. Patient did well in the
immediate postoperative period, anesthesia was reversed and he
was successfully extubated. On POD#1 the patient complained of
abdominal pain an ultrasound r/o'd out cholestasis and LFT's
were normal. On POD 2 the patient experienced some post-op
confusion and stayed in the ICU to be monitored. Ultimately
transferred to the floor to begin advancing his activity level.
On POD 4 the patients creatinine was elevated to 2.9 a renal US
showed renal artery stenosis. A renal consult was
initiated.Foley was reinserted by the GU service. Creatinine
rose to 3.4 over the next several days. WBC rose and stool C.
dificile was positive. Flagyl was started.
Pre-renal acute renal failure continued with creatinine rising
to 6.2.
Transferred back to the CSRU on [**11-30**]. Hepatobiliary consult done
and [**Hospital1 **]-modal vancomycin therapy initiated for more complete
management of c. dif. This evolved into sepsis, but the pt.
refused colon surgery.ID also consulted as well as general
surgery for further evaluation for colectomy. A fib developed
briefly and then converted to SR with lopressor. Transfused on
POD #12 and CT scan revealed diffusely thickened bowel.
Unfortunately, patient's wife expired at her nursing home this
week, and patient unable to attend wake and funeral. This likely
contributed to his agitation and refusal to be treated. Afib
occurred again on [**12-3**] and was treated with amiodarone with
conversion again to SR. Agitation and outbursts continued and
haldol was given to calm the pt. TPN started on [**12-6**] as pt.was
made npo after not tolerating clear liquids. Stool incontinence
continued. His scrotum continued to become quite edematous and
he developed pressure ulcers on his coccyx/heels as he was not
cooperative with turning frequently. Wound nursing consult
completed and recs noted. He began to tolerate clear liqs. again
on [**12-8**]. Cipro given for UTI.
Creatinine began to trend down, but WBC remained elevated. Pt.
agreed to flex. sig./subtotal colectomy on [**12-10**] as ascites
continued to develop, but then refused to allow further
examination due to scrotal pain which then delayed surgery
again. Agreed to further care on [**12-12**] and was reintubated in
the CSRU prior to returning to OR for colectomy/end
ileostomy/G-J tube placement with Dr. [**First Name (STitle) **]. Extubated the
next afternoon and tube feeds instituted. Urology re-placed
foley cath due to scrotal/penile edema. Continued to make steady
progress and was transferred back to the floor on [**12-19**].His
abdominal wound developed a small opening and he continued to be
followed by general surgery team. Wet to dry dressings were
instituted as well as additional abx coverage. He was cleared
for discharge to rehabilitation on [**2113-12-22**].
Medications on Admission:
Protonix 40'
Atenolol
Metamucil
Iron 325'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4hrs/PRN as needed for shortness of breath
or wheezing.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
11. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
12. Furosemide 10 mg/mL Solution Sig: One (1) 40 Injection Q12H
(every 12 hours). 40
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ampicillin-Sulbactam [**1-25**] g Recon Soln Sig: Three (3) Recon
Soln Injection Q8H (every 8 hours) for 3 days: Please give 3 gms
Q8 hours for 3 days.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
unit/ml solution injection Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
s/p AVR(#23 CE pericardial)
s/p colectomy/ileostomy/G-J tube placement
PMH: duodenal adenoma, angiodysplasia of colon, GI bleed,
anemia, HTN, BPH, H. pylori [**7-30**] treated with abx.
diverticulosis, remote MVA with head trauma ? metal plate, C.
Diff. colitis with toxic megacolon
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed
Call for any fever greater than 100, redness or drainage from
wounds
no driving until cleared by surgeon at postop visit
no lifting greater than 10 pounds for 10 weeks from date of
surgery.
W-T-D dressing changes daily to abdominal wound.
Ostomy care per protocol.
Followup Instructions:
[**Hospital 2793**] clinic in 2 weeks call [**Telephone/Fax (1) 773**] to schedule appt
Dr. [**Name (NI) **] in 4 weeks call [**Telephone/Fax (1) 1504**] to schedule appt
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1693**] in [**12-26**] weeks
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (gen [**Doctor First Name **].)in [**7-3**] days
[**Telephone/Fax (1) 673**]
Completed by:[**2113-12-22**] Name: [**Known lastname 11748**],[**Known firstname 7484**] Unit No: [**Numeric Identifier 11749**]
Admission Date: [**2113-11-20**] Discharge Date: [**2113-12-28**]
Date of Birth: [**2030-9-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
Addendum:
Remained in hospital to evaluate rising creatinine.
Pertinent Results:
[**2113-12-28**] 05:56AM BLOOD WBC-11.3* RBC-2.94* Hgb-8.7* Hct-27.0*
MCV-92 MCH-29.4 MCHC-32.1 RDW-16.1* Plt Ct-547*
[**2113-12-28**] 05:56AM BLOOD Plt Ct-547*
[**2113-12-28**] 05:56AM BLOOD Glucose-107* UreaN-42* Creat-2.1* Na-140
K-4.4 Cl-108 HCO3-26 AnGap-10
[**2113-12-28**] 05:56AM BLOOD PT-18.3* INR(PT)-1.7*
Brief Hospital Course:
[**12-22**] was ready for discharge to rehab except creatinine
increased 2.5 related to diuresis. Diuresis was held and renal
was consulted. Echo cardiogram was done to evaluate ventricular
function which revealed new anterior wall and apex akinesis.
Troponin elevated to 0.19 with anterior wall myocardial
infarction, cardiology consulted and anticoagulation started.
His creatinine continued to increase and with metabolic acidosis
was transferred to CSRU for hemodynamic monitoring. Bipap was
started without improvement, he was electively intubated for
metabolic acidosis. He improved, was weaned and extubated the
next day. He has continued to slowly progress with ARF
resolving. He was then transferred back to the floor and was
ready for discharge to rehab on [**2113-12-28**].
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4hrs/PRN as needed for shortness of breath
or wheezing.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
11. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
12. Furosemide 10 mg/mL Solution Sig: One (1) 40 Injection Q12H
(every 12 hours). 40
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ampicillin-Sulbactam [**1-25**] g Recon Soln Sig: Three (3) Recon
Soln Injection Q8H (every 8 hours) for 3 days: Please give 3 gms
Q8 hours for 3 days.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
unit/ml solution injection Injection TID (3 times a day).
16. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
17. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
s/p AVR(#23 CE pericardial)
s/p colectomy/ileostomy/G-J tube placement
PMH: duodenal adenoma, angiodysplasia of colon, GI bleed,
anemia, HTN, BPH, H. pylori [**7-30**] treated with abx.
diverticulosis, remote MVA with head trauma ? metal plate, C.
Diff. colitis with toxic megacolon
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 greater than 100, redness or drainage from
wounds
no driving until cleared by surgeon at postop visit
no lifting greater than 10 pounds for 10 weeks from date of
surgery
Followup Instructions:
[**Hospital **] clinic in 2 weeks call [**Telephone/Fax (1) 618**] to schedule appt
Dr. [**Name (NI) **] in 4 weeks call [**Telephone/Fax (1) 2092**] to schedule appt
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-26**] weeks
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (gen [**Doctor First Name **].)in [**7-3**] days
[**Telephone/Fax (1) 242**]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2113-12-28**]
|
[
"424.1",
"608.86",
"995.92",
"414.01",
"410.11",
"276.2",
"401.9",
"038.3",
"427.31",
"569.84",
"578.1",
"599.0",
"789.5",
"707.03",
"707.07",
"584.5",
"008.45",
"293.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.61",
"99.15",
"45.24",
"38.93",
"35.21",
"45.73",
"88.72",
"38.95",
"46.21",
"46.32",
"99.04",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14766, 14814
|
12264, 13055
|
307, 433
|
15141, 15148
|
11924, 12241
|
15485, 16059
|
1017, 1037
|
13078, 14743
|
14835, 15120
|
8644, 8687
|
15172, 15462
|
2872, 5486
|
1052, 1247
|
231, 269
|
2089, 2846
|
461, 680
|
702, 849
|
865, 1001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,460
| 140,482
|
26098
|
Discharge summary
|
report
|
Admission Date: [**2121-1-7**] Discharge Date: [**2121-1-15**]
Date of Birth: [**2063-2-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:pt unable to give - reported by ED Chief resident to be non
responsive with corneals only. History obtained from outside
chart and [**Location (un) **] records. No family at bedside at present.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 57 y/o white male with history of DM and ETOH was on line
at
supermarket today / witnessed by bystanders to appear dizzy then
passed out. Pt brought to OSH [**Hospital1 **]/ [**Location (un) 16843**] where he had a
CT scan and was intubated. Pt had sz x 2 at OSH. Was loaded
with
cerebyx. CT scan by report from ED with SAH and SDH. Pt
currently in ED with C-collar in place on ventilator.
Past Medical History:
Hypertension
Hypercholesterolemia
DM
ETOH abuse (quit 4 yrs ago)
History of CDiff
CAD
PUD/UGIB (h/o Ex-lap for GIB)
S/P open cholecystectomy
Social History:
Previous ETOH abuse
Lives in a Veteran's house
Previous cocaine use
No history of tobacco
Family History:
Father died of prostate Ca
Physical Exam:
Exam upon admission:
VS: T: afebrile BP: 160's /70's HR: 60 R vented O2Sats 100%
Gen: WD WN white [**Last Name (un) **]/intubated/ chronic ulcers to bilateral LE
first digits.
HEENT: Pupils: 4.5mm briskly reactive to 3mm. EOM's unable to
assess / conjugate gaze / midposition. no hemotympanum or csf
rhinorrhea or otorrhea. + STS to right parietal region.
Neck: cervical collar in place
Lungs: CTA bilaterally./ decreased at bibasilar regions
Cardiac: distant heart sounds/ s1 s2 no obvious murmur to this
examiner.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. bilateral large toe ulcers/
wrapped
Neuro:
Mental status: opens eyes weakly to noxious
pupils as above. No obvious facial droop/ intubated
Localizes with bilateral UE to sternal rub/ + grimace to
noxious/
+ cough/ + gag/ moves bilateral LE spontaneously.
Toes without response to plantar reflex testing.
Pertinent Results:
[**2121-1-7**] 04:00PM PT-13.6* PTT-27.2 INR(PT)-1.2*
[**2121-1-7**] 04:00PM WBC-9.8 RBC-3.59* HGB-11.3* HCT-33.2* MCV-92
MCH-31.5 MCHC-34.1 RDW-13.9
[**2121-1-7**] 04:00PM NEUTS-86.5* BANDS-0 LYMPHS-10.3* MONOS-2.4
EOS-0.4 BASOS-0.3
[**2121-1-7**] 04:00PM PLT COUNT-221
[**2121-1-7**] 04:00PM CK(CPK)-119
[**2121-1-7**] 04:00PM CK-MB-3
[**2121-1-7**] 04:00PM GLUCOSE-135* UREA N-12 CREAT-1.3* SODIUM-142
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
[**2121-1-7**] CTA:IMPRESSION: Subarachnoid as well as subdural
hemorrhage with bifrontal hemorrhagic contusions. There is no
evidence of aneurysm. However, if there remains continued
clinical concern, consider obtaining conventional angiogram to
further evaluate for this potential pathology.
Brief Hospital Course:
57 y/o white male with history of DM and [**Hospital **] transferred from
OSH after falling
at the supermarket with (+)LOC. Pt had sz x 2 at OSH. He was
intubated and
sent to [**Hospital1 18**] for management of SDH and SAH found on head CT.
The patient was admitted to the ICU upon arrival to [**Hospital1 18**]. On
[**1-7**] he had a CTA which was negative for aneurysm.
He had some "coffee ground emesis" in his NGT on [**1-9**] and he had
a h/o previous GI bleeds, so was sent for an upper GI series.
That was negative for bleeding. The patient's respiratory status
improved and was intubated in the ICU. He remained difficult to
arouse but was neurologically stable.
On [**1-10**] was transferred to the neuro step-down unit but then had
oxygen desaturation to 78% the following day so went back to the
ICU. He was found to have pneumonia and was started on a 7-day
course of antibiotics.
On [**1-13**] his head CT showed increased edema and there appeared to
be evidence of strokes in the area of the previous hemorrhage.
There was 1.4 cm midline shift, subfalcine herniation and uncal
compression. On [**1-14**] the CT was slightly improved but the EEG
showed encephalopathy. His neuro exam remained the same until
about 4am on [**1-15**]. At that time he had an elevation in his blood
pressure, his pupils were ~4mm and only minimally reactive. He
had no gag, no motor exam, and slight corneal reflex on the
left/none on the right. The patient was sent for immediate head
CT, which was worse than the morning and showed impending
herniation. He was given 50 mg mannitol. Pt exam continued to
deteriorate. Family wished pt to be made comfort care only.
Patient was extubated and expired.
Medications on Admission:
Medications prior to admission: insulin/ atenolol/gabapentin/
metformin/simvastatin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
none
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2121-1-17**]
|
[
"348.30",
"578.0",
"507.0",
"852.05",
"401.9",
"707.14",
"518.5",
"780.39",
"996.62",
"434.91",
"482.2",
"790.7",
"E888.9",
"780.2",
"V58.67",
"272.0",
"250.80",
"348.4",
"253.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4796, 4805
|
2929, 4632
|
472, 478
|
4853, 4862
|
2137, 2906
|
4914, 5043
|
1194, 1222
|
4767, 4773
|
4826, 4832
|
4658, 4658
|
4886, 4891
|
1237, 1244
|
4690, 4744
|
235, 434
|
506, 906
|
1259, 1854
|
1869, 2118
|
928, 1070
|
1086, 1178
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,594
| 142,590
|
31710
|
Discharge summary
|
report
|
Admission Date: [**2144-12-9**] Discharge Date: [**2144-12-11**]
Date of Birth: [**2079-1-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
anemia, RLE swelling
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
Ms. [**Known lastname 47097**] is a 65 year old female with NASH cirrhosis, HTN,
diabetes, and history of Grade I esophageal varices admitted for
a slow hct drop with brown guiaic positive stool and 2-3 days of
RLE swelling. Paitent reports black stools though is on iron
supplementation. She denies BRBPR or hematemasis. She denies
chest pain, shortenss of breath, fevers, chills, abdominal pain,
headache, lightheadedness. She reports she would have not known
anything was wrong if she had not been called in by her
hepatologist for the Hct drop to 20.8 down from 24.4 one week
earlier.
In the ED, vitals were HR 96, BP 111/32, RR 16, 98% on RA. She
was given 2 units of PRBCs. She got LENIS to evaluate her RLE
swelling, which was negative for DVT. She was started on a
octreotide drip and given protonix 40 IV x 1. [**Name (NI) 5283**] sono showed
mild ascites and no cholecystitis.
Past Medical History:
ESLD [**2-22**] NASH with cirrhosis and portal hypertension, followed
by GI Dr. [**Last Name (STitle) 497**], on [**Last Name (STitle) **] list
Hypertension
diabetes mellitus type II
Psoriasis
depression
Social History:
She lives in [**Location 5344**] alone. She has 3 children who live in
[**Location (un) **], [**Location (un) **], and [**Location (un) 17927**]. Their ages are 37, 40, and 45.
She is a nonsmoker and has not had any alcohol in 2 years.
Apparently, she was not a heavy drinker. She has no illicit drug
use. She is not married and does not have a current partner. She
has not worked for 4-5 months and was released from her job as a
cashier due to confusion. She has applied for disability.
Family History:
mother with lung CA, 3 brothers with DM
Physical Exam:
afebrile, bp 130/70, hr 90, rr14 room air
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Crackles : bases bilateral)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Trace, Left: Trace
Skin: Warm
Neurologic: Responds to: Verbal stimuli, Movement: Purposeful,
Tone: Normal
Pertinent Results:
[**2144-12-9**] 03:20PM WBC-4.4 RBC-1.95* HGB-6.8* HCT-20.8* MCV-106*
MCH-34.8* MCHC-32.7 RDW-14.2
[**2144-12-9**] 03:20PM NEUTS-58.8 LYMPHS-26.7 MONOS-11.8* EOS-2.0
BASOS-0.7
[**2144-12-9**] 03:20PM PLT COUNT-212
[**2144-12-9**] 03:20PM OSMOLAL-279
[**2144-12-9**] 03:20PM ALBUMIN-2.8* CALCIUM-8.5 PHOSPHATE-3.0
MAGNESIUM-1.9
[**2144-12-9**] 03:20PM LIPASE-50
[**2144-12-9**] 03:20PM ALT(SGPT)-37 AST(SGOT)-76* ALK PHOS-118* TOT
BILI-2.5*
[**2144-12-9**] 03:20PM GLUCOSE-185* UREA N-20 CREAT-0.9 SODIUM-129*
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-18* ANION GAP-17
[**2144-12-9**] 03:34PM PT-19.4* PTT-39.0* INR(PT)-1.8*
[**2144-12-9**] 03:34PM AMMONIA-112*
[**2144-12-9**] 03:34PM calTIBC-360 VIT B12-1013* FOLATE-13.8
FERRITIN-22 TRF-277
[**2144-12-9**] 03:34PM IRON-15*
Imaging:
Rt lower extrem US ([**12-9**]): No evidence of DVT involving the
right lower extremity.
Abdominal US ([**12-9**]):
1. Cirrhotic liver without evidence of focal lesion.
2. Small amount of ascites in the right upper quadrant.
3. No [**Month/Year (2) 950**] evidence of acute cholecystitis. The main
portal vein is
patent with antegrade flow. Thickened / edematous gall bladder
wall noted.
Brief Hospital Course:
65 yo with NASH, HTN, DM II admitted for new asymptomatic anemia
and trace guiaic positive stool, admitted for [**Month/Year (2) 7941**] due to
varices.
# GIB: The patient had a slow decrease in Hct over the last
several months with no symptoms. She was found to have trace
guiaic positive stool with Hct drop of 4 points over one week.
She was known to have gastritis and grade I varices on previous
EGD, which was thought likely source of patients anemia. Iron
studies were consistent with iron deficiency anemia. She was
initially transfused two uPRBCs for hct of 20, with appropriate
rise to 26. Of note, her increased MCV is chronic and is
suggestive of marrow depression (B12 TSH and folate nml). Her
anti-hypertensives were initially held, and she was started on
protonix and octreotide gtts. The patient underwent an EGD
which showed gastric antral ectasia with varices but without an
active source of bleed. Her octreotide was stopped and she was
put back on her daily PPI. Her Hct remained stable after her
blood transfusion until discharge. She will follow up with Dr.
[**Last Name (STitle) 497**] as an outpatient for treatment of her gastric antral
ectasias.
# Cellulitis: The patient was noted to have erythema and pus
from a biopsy site on her right posterior calf (done by her
dermatologist as an outpatient). As this was concerning for
celluitis a swab was sent for culture and she was discharged
with a 7 day course of augmentin (as patient is a diabetic) and
bactrim (MRSA coverage) for likely cellulitis. She was
instructed to follow up with her primary doctor [**First Name (Titles) **] [**Last Name (Titles) 7941**]
of resolution of her cellulitis.
# Asymptomatic UTI: The patient had a negative UA, however her
UCx grew out E.coli sensitive for bactrim. She will be covered
for treatment by the 7 day course of bactrim given for
cellulitis as above.
# NASH cirrhosis: The patient is awaiting liver [**Last Name (Titles) **];
listed with a MELD score of 16 on admission. There was no
evidence of hepatic encephalopathy or SBP by labs or exam. She
was continued on her lactulose, rifaximin, lasix, and
spironolactone.
# Hyponatremia: The patient had worsening hyponatremia in
setting of recently increasing her diuretic dose, which improved
with transfusions, suggesting hypovolemic hyponatremia. Her
urine lytes were checked, suggesting a mixed picture, but likely
pre-renal. On discharge her Na was normal at 136.
# Lower ext swelling: The patient's right leg was initially
larger than her left. The patient had no DVT on LENI [**12-9**].
The morning of discharge there was no difference between her
legs.
Medications on Admission:
Albuterol PRN
Amitriptyline 10 mg qhs
Cipro 250 daily - chronic
Fluoxetine 20 daily
Advair 100-50 [**Hospital1 **]
Lasix 40 mg daily
Lactulose 45 qam, 30 qpm
Lisinopril 2.5 daily
Metformin 500 [**Hospital1 **]
Omeprazole 20 mg daily
Rifaximin 600 TID
Spironolactone 100 mg daily
Triamcinolone ointment 0.1 [**Hospital1 **] to face, axilla, groin
Calcium + Vitamin D
Iron 325 daily
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
12. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a
day.
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
14. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Lactulose 10 gram/15 mL Syrup Sig: 30-45 MLs PO TID (3 times
a day): Titrate for [**3-24**] bowel movements per day.
16. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
18. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
19. Outpatient Lab Work
please have a CBC drawn on [**2144-12-17**], and faxed to your
hepatologist Dr. [**Last Name (STitle) 497**] [**Name (STitle) **]. ([**Telephone/Fax (1) 1582**] Patient Fax: ([**Telephone/Fax (1) 48518**]
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Primary -
Anemia secondary to a chronic upper gastrointestinal bleed
likely from gastric antral ectasias
cellulitis s/p skin biopsy right leg wound.
Secondary -
Cirrhosis secondary to nonalcoholic steato hepatitis
Diabetes
Hypertension
Depression
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital due to a low blood count
(anemia) and concern for a gastrointestinal bleed. You were
trasnfused with 2 units of blood due to your anemia and your
blood count increased and remained stable after the transfusion.
.
You underwent an upper endoscopy which showed grade I varices
which had not recently bleed and gastric antral ectasia (small
vascular abnormalities). It is thought that your low blood
count is due to chronic blood loss from your gastric antral
extasia.
You were started on 2 antibiotics for concern of cellulitis at
the site of your skin biopsy. These are called augmentin and
bactrim. You should continue these for 7 days. You should
follow-up with your dermatologist within 7-10 days regarding
your skin wound.
.
Otherwise continue your outpatient medications as prescribed.
Call you primary doctor or go to the emergency room if you
experience fevers, chills, dizziness, shortness of breath,
abdominal pain, blood in your stool, vomiting of blood, or dark
black stool (different from your normal stool).
Followup Instructions:
Please keep your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2145-1-6**] 1:15
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-1-6**] 3:00
.
upon arriving home, please call your primary care doctor and
arrange to be seen within 10-14 days. you will specifically
need to be followed regarding the cellulitis on your right leg
wound.
.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2144-12-13**]
|
[
"276.1",
"571.5",
"599.0",
"998.59",
"537.83",
"250.00",
"456.21",
"571.8",
"572.3",
"401.9",
"041.4",
"V49.83",
"789.59",
"682.6",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8922, 8960
|
3867, 6521
|
337, 355
|
9252, 9262
|
2649, 3844
|
10372, 10997
|
2023, 2064
|
6953, 8899
|
8981, 9231
|
6547, 6930
|
9286, 10349
|
2079, 2630
|
277, 299
|
383, 1272
|
1294, 1500
|
1516, 2007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,731
| 195,511
|
37972
|
Discharge summary
|
report
|
Admission Date: [**2194-10-28**] Discharge Date: [**2194-10-31**]
Date of Birth: [**2133-4-6**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Aphasia and right-sided weakness
Major Surgical or Invasive Procedure:
Trans-esophageal echocardiogram
History of Present Illness:
PER ADMITTING RESIDENT:
HPI: 61 yo R handed man with PMH HTN, under control for
hyperglycemia (no diagnosis of DM) who was in his usual state of
health until 10:45 am. He was painting his house when he became
very sweaty and pale. He sat down as if he would faint. At that
time his son did not notice any weakness. His speech was fluent
and normal; he said "do not call an ambulance". Five minutes
later, his speech became slurred, impromprehensible and he
developed right arm and leg weakness. His comprehension was
intact. He was taken to [**Hospital1 **] at 11:25 am where he was
described to have expresive aphasia and 3/5 weakness on right
upper and lower extremities. He received IV tPA at 1:45pm. His
weakness improved significantly, however, patient remained with
expressive aphasia upon arrival here with NIHSS 2. He was
transferred here for evaluation of IA tPA. His CT hea showed
hypodensity in the area of superior division of MCA x
bifurcation
and CTA, preliminarily, did not reveal vessel occlusion.
Past Medical History:
HTN,
-under control for glycemia (no diagnosis of DM)
Social History:
- patient is retired
- used to work on maintenance
HABITS
denies smoking, alcohol and illicit drug use
Family History:
- Father died of heart attack at 68 yo.
- No hx stroke in the family
Physical Exam:
ON ADMISSION:
T-98.4 BP-124/72 HR-76 RR-17 100O2Sat
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. His comprehension was normal for simple and complex
commands such as touch your left ear with right thumb. He could
speak no words. Patient could not read. No right left confusion.
No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5- 5- 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes: B T Br Pa Pl
Right 2 1 2 1 1
Left 2 1 2 1 1
Toes were downgoing bilaterally.
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: not tested
Pertinent Results:
Admission Labs:
.
WBC-8.8 RBC-4.33* Hgb-13.3* Hct-38.5* MCV-89 Plt Ct-172
Glucose-110* UreaN-25* Creat-1.1 Na-138 K-6.5* Cl-105 HCO3-24
AnGap-16
Calcium-8.8 Phos-2.2* Mg-1.8
.
Modifiable Risk Factors for Stroke:
%HbA1c-6.2*
Cholest-202 Triglyc-153* HDL-39 CHOL/HD-5.2 LDLcalc-132*
.
IMAGING
.
CTA, Head and Neck with CT PERFUSION ([**2194-10-28**]):
IMPRESSION:
1. Acute infarcts in the left MCA distribution involving the
left frontal
lobe, with a perfusion abnormality that matches the area of
hypodensity on
non-contrast head CT and the subsequent diffusion abnormality.
2. Unremarkable CTA of the head and neck, with patent vessels,
including the
left MCA.
.
MR HEAD W/O CONTRAST ([**2194-10-28**]):
IMPRESSION:
Acute left MCA infarct, involving predominantly left frontal
lobe, but with a
portion extending into the left temporal lobe, stable since the
prior study,
with the distribution, corresponding to the area of perfusion
abnormality on
the CT perfusion study. No other focus of decreased diffusion is
identified.
.
CT Head without Contrast ([**2194-10-29**]):
IMPRESSION:
1. Hypodense, heterogeneous left frontal lobe lesion
encompassing the left
insula, consistent with evolving focal infarct. Internal
hyperdensities
consistent with reperfusion changes.
2. No evidence of frank hemorrhage.
3. No new territorial vascular infarct.
.
Transthoracic Echocardiogram ([**2194-10-29**]):
Conclusions
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thicknesses and cavity
size are normal. No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.
Trans-esophageal Echocardiogram ([**2194-10-31**]):
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Overall left ventricular systolic function is
normal (LVEF>55%). There is normal RV free wall contractility.
There are complex (>4mm) atheroma in the aortic arch. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
.
No intracardiac mass identified.
Brief Hospital Course:
Mr. [**Known lastname 84850**] is a 61 year-old man with a past medical history
including hypertension who presented for medical attention with
right-sided weakness and aphasia and was found to have an acute
left MCA infarct. Following the administration of IV tPa, he
was transferred to the [**Hospital1 18**] for possible intra-arterial tPa in
the setting of a persistent right hemiparesis. He was admitted
to the stroke service from [**2194-10-28**] to [**2194-10-31**].
.
Upon his arrival to the [**Hospital1 18**], imaging demonstrated patent
intracranial and extracranial arteries. As a result, he was not
a candidate for intra-arterial TPA. Mr. [**Known lastname 84850**] was monitored
closely in the intensive care unit. Within approximately
twenty-four hours of the administration of IV tPa, a
non-contrast CT of the head was repeated to evaluate for
hemorrhage. The CT brain was negative for bleeding.
.
As Mr. [**Known lastname 84850**] suffered the stroke while on aspirin, the [**Doctor Last Name 360**]
was initially discontinued in favor of plavix pending further
investigatory studies. Throughout the hospitalization, the
patient was monitored on cardiac telemetry which failed to show
contributory arrhythmias such as atrial fibrillation. Since the
stroke was thought to be the result of a cardioembolic event, a
transthoracic echocardiogram was performed. Although the study
failed to demonstrate a patent foramen ovale, atrial septal
defect, thrombi, or vegetations, suspician for a cardioembolic
etiology remained very high. Therefore, a trans-esophageal
echocardiogram was done. The study revealed complex atheroma in
the aortic arch. After discussions with the patient,
weight-based lovenox was started as a bridge to oral coumadin
with a target INR of [**2-18**]. The plavix was discontinued.
.
In the context of acute stroke, the lisinopril was held to
allow for blood pressure autoregulation with a target SBP of 140
to 180. Prior to discharge, the medication was restarted.
.
To evaluate modifiable risk factors for stroke, lipids and
glycosylated hemoglobin were measured. The LDL was found to be
132, so Simvastatin was started with a goal LDL <70. Although
the HBA1C was 6.2 %, blood glucose was monitored regularly and
an insulin sliding was instituted to maintain normoglycemia.
.
The patient was discharged home with a plan to participate in
outpatient speech therapy.
.
Code: Full
Medications on Admission:
-lisinopril 10mg
-aspirin 81mg
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*10 vials* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute left MCA infarct involving predominantly the left frontal
lobe, likely due to athermoa of the aortic arch
Discharge Condition:
Stable. The neurological examination is notable for slightly
non-fluent speech.
Discharge Instructions:
You presented to the hospital with right-sided weakness.
Imaging revealed a new stroke in the left side of the brain. Of
note, the vessels providing the brain's blood supply appear
patent. Continuous monitoring failed to show evidence of an
irregular heart rhythm. A transthoracic ultrasound of the heart
showed no clear predisposing factors (such as a blood clot,
vegetations, or structural abnormalities) for stroke. However,
a trans-esophageal echocardiogram did show complex atheroma in
the aortic arch. To help prevent future events, it will be
important to continue the "blood thinner" coumadin. To ensure
the drug level is in therapeutic range, it will be important to
have your INR checked regularly with a goal of [**2-18**]. A statin
has also been initiated to help lower your risk of future
events.
* Please note that aspirin has been discontinued. Coumadin has
been started in its place.
* It will be important to use the lovenox until the INR has been
therapeutic (value between 2 and 3) for at least 48 hours.
Thereafter, the lovenox can be discontinued. The coumadin
should be continued, probably for life.
* As noted above, a statin has also been started. Accordingly,
it will be beneficial to monitor your liver function tests.
* Please note the lisinopril was temporarily discontinued. It
should be resumed tomorrow, [**2194-11-1**].
* With your doctors, please monitor the results of pending blood
work (eg anti-cardiolipin IgG + IgM antibodies, homocysteine)
designed to evaluate for a presdisposition to clotting.
* Please take all medication as prescribed.
* Please attend all follow-up appointments.
* Participation in speech therapy could be beneficial.
* Please seek medical attention if you develop a change in
mental status (such as sleepiness, confusion, or lethargy),
increasing trouble speaking, difficulty walking, weakness -
especially on one side of your body, shaking of the limbs, chest
discomfort, shortness of breath, or any other symptom you find
concerning.
Followup Instructions:
Please attend the following appointments:
* Please visit your primary care doctor's office on Monday
[**2194-11-3**] to have your INR checked. Thereafter you should
connect with Dr. [**Last Name (STitle) **] to learn the appropriate dose of
coumadin. If you are not able to have your blood drawn at the
primary care doctor's office, please go to the nearest medical
center to have the labwork done.
* Primary care phsyician Dr. [**Last Name (STitle) **] ([**0-0-0**] at
11:00 am.
* Stroke Specialist Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2574**]) on [**2194-12-3**] at
3:00 pm.
|
[
"440.0",
"401.9",
"434.11",
"784.3",
"V45.88",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9298, 9304
|
6394, 8825
|
358, 392
|
9460, 9543
|
3400, 3400
|
11608, 12208
|
1651, 1722
|
8907, 9275
|
9325, 9439
|
8851, 8884
|
9567, 11585
|
1737, 1737
|
286, 320
|
420, 1436
|
2421, 3381
|
3416, 6371
|
1751, 2093
|
2132, 2405
|
2117, 2117
|
1458, 1514
|
1530, 1635
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,021
| 137,219
|
15320+15321+56633
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2178-10-2**] Discharge Date: [**2178-10-26**]
Date of Birth: [**2136-12-18**] Sex: M
Service: Trauma Surgery Service
HISTORY OF PRESENT ILLNESS: This is a 45 year old male
status post motorcycle crash with pelvic degloving injury of
the perineum, pelvic fractures, status post diverting
colostomy, debridements, orchiopexy, sepsis or asepsis. The
patient presented to the Emergency Room [**9-22**],
transferred from a rehabilitation facility. The patient
presents complaining of increased pain, drainage, infected
appearing wound started last night.
PHYSICAL EXAMINATION: The patient's initial physical
examination revealed vital signs 101.4, 100, 110/60, 18 and
96% on room air in triage and once within the Emergency
Department the patient's blood pressure was 75/28, 122, 22
and 93% on 2 liters. The patient's examination in general
revealed an ill-appearing gentleman, diaphoretic, pale.
Head, eyes, ears, nose and throat, anicteric, neck supple.
Chest examination, clear to auscultation bilaterally.
Cardiovascularly tachycardiac, regular rhythm. Abdomen,
bowel sounds soft, nontender. Pelvis with external fixators
in place, draining pus. Extremities, multiple open tracts in
perineum. Pus over scrotum. The patient has warm
extremities.
PAST MEDICAL HISTORY: The patient has no past medical
history except for open book pelvic fracture from his
previous [**Month (only) 216**] admission, small right pneumothorax,
right-sided rib fractures at #6 and 7, widening of the
sacroiliac joints bilaterally and a inferior pubic rami
fracture, status post external fixator repair, right
transverse acetabular fracture, status post exploratory
laparotomy with a diverting colostomy, status post incision
and drainage of right hemiscrotum with closure of scrotal
laceration, status post sphincter reconstruction as well as
external sphincteroplasty.
MEDICATIONS: The patient's discharge medications previously
in rehabilitation were Morphine Sulfate IR, 15 to 30 mg p.o.
q. 4-6 hours prn, MS Contin 60 mg p.o. q. 12 hours, Rofecoxib
25 mg p.o. b.i.d. times five days, Protonix 40 mg p.o. q.
day, Tizanidine HCL 2 mg p.o. t.i.d., Morphine Sulfate 4 mg
intravenously prn prior to dressing changes, Colace 100 mg
p.o. b.i.d., Benadryl 25 mg p.o. q. 6 prn for itching, Silver
Sulfadiazine 1 application t.i.d. to penile area, Lovenox 39
mg subcutaneously q. 12, Tylenol 325 to 650 mg p.o. q. 4-6
hours prn pain.
LABORATORY DATA: The patient's initial laboratory studies
revealed complete blood count 13.0, 30.6, 190, coagulation
screen 13.4, 29.4, 1.3. Urinalysis was negative except for
positive nitrites. Chem-7 135, 3.8, 98, 20, 12, 1.1, 98.
AST 45, ALT 49, alkaline phosphatase 16, total bilirubin 1.5,
amylase 38.
Initial radiology showed [**10-2**], chest x-ray with right
middle lobe pneumonia, computerized tomography scan of the
abdomen showed no abscess, computerized tomography scan of
the pelvis showed no abscess, it did show the right inferior
superior pubic rami fracture of previously and 1.8 times 1.1
cm right pulmonary nodule in the right lower lobe and a right
ninth rib fracture. The patient had a subsequent chest x-ray
on [**10-2**], which showed a right internal jugular line
placed correctly. Other studies during the hospital stay:
[**10-4**], ultrasound of lower extremity bilaterally, no
deep vein thrombosis; [**10-5**], increased infiltrate on
chest x-ray, suggests adult respiratory distress syndrome
bilaterally; [**10-7**], repeat ultrasound lower extremity
to visualize the left common femoral vein, not previously
seen, showed no deep vein thrombosis; [**10-9**], repeat
chest x-ray no change from previous; [**10-9**], the
patient had ultrasound of the gallbladder and right upper
quadrant for increased pain in the right upper quadrant and
fever, showed no stone, fluid or dilatation; [**10-11**] the
patient had a bilateral lower extremity doppler for
respiratory distress and showed no deep vein thrombosis;
[**10-14**], the patient had a pulmonary angiogram secondary
to shortness of breath and that was negative, inferior vena
cava was placed on the right side; [**10-15**], the patient
had a noted deformity which the patient had noted was there
previously, right shoulder showed a 2.7 cm superiorly
displaced clavicle relative to the acromioclavicular joint
and a PICC line was in place.
HOSPITAL COURSE: Subsequent hospital course to be added in
an addendum.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 43488**]
Dictated By:[**Last Name (NamePattern1) 21669**]
MEDQUIST36
D: [**2178-10-24**] 10:32
T: [**2178-10-24**] 13:06
JOB#: [**Job Number 4413**]
Admission Date: [**2178-10-2**] Discharge Date: [**2178-10-29**]
Date of Birth: [**2136-12-18**] Sex: M
Service:
NOTE: This is an addendum to part 1 of the discharge
summary.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit. The patient was started on vancomycin.
The patient's blood cultures showed, on [**10-2**],
Staphylococcus aureus oxacillin resistant susceptible to
vancomycin in 4 of 4 bottles. Right hip wound also showed
Staphylococcus aureus. Stool cultures for Clostridium
difficile were negative. Genital swab was positive for
Methicillin resistant Staphylococcus aureus. In the SICU,
the patient, on [**10-5**], developed respiratory
distress, was intubated. X-ray showed development of ARDS.
In the Surgical Intensive Care Unit, the patient had a left
A-line place, a right IJ central line placed. The patient
was evaluated by urology, wanted to insert a Penrose and
wanted to keep in place for two days and wet to dry dressings
to scrotal wounds.
On [**9-23**], the patient went to the Operating Room for
incision and drainage washout of scrotal/thigh debridement.
Penrose drain was placed. Tube feeds were started on
[**10-7**]. According to nutrition recommendations,
Zosyn was stopped. The patient returned to the Operating
Room [**10-8**] for debridement. The patient was
successfully extubated, stepped down to the floor. On
[**10-12**], a right basilic vein [**Last Name (un) **]-Hick was
placed. The patient was found also to have a left indurated
tender erythematous region of the left hip. Frank pus was
aspirated. The abscess area was incision and drained in the
Surgical Intensive Care Unit. On [**10-13**], 26th, 30th,
the patient had multiple VAC changes, debridements, incision
and drainage.
On [**10-14**], the patient was complaining of some
pleuritic chest pains, trouble breathing. Chest x-ray was
unchanged. The patient had a pulmonary angiogram to evaluate
for pulmonary embolus which was negative. A right IVC filter
was placed in the patient secondary to his heparin induced
thrombocytopenia and prolonged immobility. On [**10-22**], a
split thickness skin graft was placed by Plastics. The
patient's mobility status was changed to bed rest. On
[**10-24**], the patient was subsequently transferred to the
Plastic Surgery service as there were no more acute issues
besides the healing of the skin graft.
DISCHARGE DIAGNOSES:
1. Sepsis, patient on vancomycin intravenous for six weeks
total.
2. Pelvic fracture with external fixture.
3. Perineal degloving injury, status post skin graft.
DISCHARGE MEDICATIONS:
1. Methadone 20 mg tid
2. Fentanyl patch 100 mcg an hour changed every three days
3. Morphine 4 to 6 mg intravenous q4 prn, dressing change
breakthrough pain
4. Benadryl 25 mg po q hs prn insomnia
5. Colace 100 mg [**Hospital1 **]
6. Vitamin C 500 mg po bid
7. Zofran 2 mg intravenous q6 prn nausea, vomiting
8. Zinc sulfate 220 mg po qd
9. Ipratropium bromide 2 puffs qid
10. Vancomycin 1 gm intravenous q 12
12. Tylenol prn
13. Albuterol 1 to 2 puffs q6 prn
The patient should have physical therapy. Should have
pneumatic compression devices on legs at all times. Stoma
care. Activity status per plastic surgery addendum.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: The patient will be discharged to acute
rehabilitation.
DISCHARGE FOLLOW UP: The patient should follow up with
trauma surgery in two weeks after discharge. Can call
([**Telephone/Fax (1) 18746**]. Follow up with urology, orthopedics and
plastic surgery. Dates to be addended by plastic surgery.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 43488**]
Dictated By:[**Last Name (NamePattern1) 44531**]
MEDQUIST36
D: [**2178-10-24**] 10:49
T: [**2178-10-26**] 07:53
JOB#: [**Job Number **]
Name: [**Known lastname 8152**], [**Known firstname 8153**] Unit No: [**Numeric Identifier 8154**]
Admission Date: [**2178-10-2**] Discharge Date: [**2178-10-30**]
Date of Birth: [**2136-12-18**] Sex: M
Service:
NOTE: This represents an addendum to previous discharge
summary.
HOSPITAL COURSE: On [**2178-10-22**], patient underwent a
series of split thickness skin grafts to his perineal wounds
with the right thigh serving as the donor site for all
grafts. Patient tolerated the procedure well with minimal
blood loss and received 1800 cc of fluid intraoperatively.
Following stabilization in the recovery room, patient was
subsequently transferred to the plastic surgery service under
the direction of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5111**]. Patient remained stable
and on his baseline medical regimen through postoperative day
four, [**10-27**], at which point patient's bolster dressings
were removed and all skin grafts were noted to be taking
without evidence of failure, hematoma or infection. Of note,
a cavitating wound in patient's left groin area was noted to
be markedly improved with standard wet to dry dressing
changes twice per day.
The patient remained on bed rest until [**2178-10-30**], at
which point he was cleared for ambulation and was
subsequently evaluated by physical therapy who declared
patient fit for discharge to home with home services.
Patient was subsequently discharged to home with VNA services
and home P.T. on the evening of [**2178-10-30**], with
instructions for followup.
CONDITION ON DISCHARGE: The patient is discharged to home
with services and instructions for followup.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Vancomycin 1000 mg IV q.12 hours times six weeks.
2. Ipratropium bromide two puffs inhaled q.i.d.
3. Albuterol one to two puffs inhaled q.six hours p.r.n.
4. Zinc sulfate 220 mg p.o. q.d.
5. Fentanyl patch 100 mcg per hour t.p. q.72 hours.
6. Methadone 20 mg p.o. t.i.d.
7. Diphenhydramine, 25 mg p.o. h.s. p.r.n.
8. Docusate sodium 100 mg p.o. b.i.d.
9. Ascorbic acid 500 mg p.o. q.i.d.
10. Percocet one to two tabs p.o. q.four to six hour p.r.n.
FOLLOWUP: The patient's pin sites are to be dressed with
Xeroform and peroxide cleansing twice per day. Patient is to
receive wet to dry gauze dressing changes twice per day to
the open left groin wound. Skin graft recipient sites are to
be dressed with Xeroform and gauze dressings twice per day.
Donor sites may be left open to air. Patient's left lower
extremity is to be touch down weight bearing only for six
weeks. Physical therapy is to consist of strength, endurance
and gait training exercises. Patient is to receive
vancomycin for a six week IV course. Patient's PICC line
dressings are to be changed once per week. Vancomycin levels
are to be checked once per week. BUN and creatinine levels
are to be checked once per week. Patient is to follow up
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in orthopaedic clinic two to three weeks
following discharge. Patient is to call [**Telephone/Fax (1) 8155**] to
schedule this appointment. Patient is also to follow up in
plastic surgery clinic two weeks following discharge.
Patient is to call [**Telephone/Fax (1) 5721**] to schedule this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 8156**]
MEDQUIST36
D: [**2178-10-30**] 14:13
T: [**2178-10-30**] 14:12
JOB#: [**Job Number 8157**]
|
[
"998.59",
"038.11",
"486",
"682.6",
"518.5",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"78.19",
"86.22",
"38.7",
"62.69",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
8030, 8124
|
7181, 7347
|
10390, 12249
|
8974, 10234
|
8136, 8956
|
616, 1295
|
185, 593
|
1318, 4385
|
10259, 10367
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,891
| 178,347
|
10380+10381
|
Discharge summary
|
report+report
|
Admission Date: [**2119-4-14**] Discharge Date: [**2119-4-22**]
Date of Birth: [**2065-11-10**] Sex: M
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53 year old male
with a diagnosis of muscle invasive Grade II to III/III
bladder carcinoma. In addition, his prostatic urethral
biopsies had been positive for carcinoma in situ. He is
status post transurethral resection of bladder tumor and BCG
therapy. His pathology sides have been reviewed here at the
[**Hospital1 69**] and have shown a
micro-papillary variant which tends to be very aggressive.
He had undergone MVAC chemotherapy with Dr. [**Last Name (STitle) **]. At this
time, he presents for discussion for his continent urinary
diversion. His cystoprostatectomy will be performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**].
He had a CT scan and bone scan in [**2118-10-13**], prior to
his chemotherapy that showed no evidence of metastatic
disease. He had a recent prostate biopsy because of a
prostatic nodule which showed no malignancy.
PAST MEDICAL HISTORY:
1. Diet controlled type 2 diabetes mellitus.
MEDICATIONS: He is on no medications except a multivitamin.
PAST SURGICAL HISTORY:
1. Transurethral resection of bladder tumor.
SOCIAL HISTORY: He quit smoking eight years ago. He does
have a 30 pack year smoking history previous to that. He is
a district service manager for the Steris Company. He drinks
two to three caffeinated drinks per day and one to two
alcoholic beverages per day.
FAMILY HISTORY: Significant for his father with a history of
lung cancer and a sister with diabetes mellitus.
ALLERGIES: Allergies are a questionable possible allergy to
Ampicillin.
REVIEW OF SYSTEMS: Review of systems on pre-surgical
evaluation showed mild urinary urgency after BCG treatment
and had decreased erectile function.
PHYSICAL EXAMINATION: Vital signs were 130/88; pulse 78 and
regular; respiratory rate was 16 and unlabored. Abdomen
soft, nontender, no palpable masses. No costovertebral angle
tenderness. No inguinal lymphadenopathy. Genitourinary:
Normal phallus, meatus and testes. No inguinal hernia.
Rectal: Normal tone; 40 gram prostate. Nodularity in the
left prostatic lobe. Extremities and Neurological: Moves
all four extremities without difficulty. Normal gait.
Neurologically and mentally intact.
LABORATORY: White blood cell count 6.7, hematocrit 35,
platelet count 267, BUN and creatinine are 20 and 1.0.
Urinalysis dipstick was three plus glucose; otherwise
unremarkable.
Given this preoperatively assessment, he was given a NuLYTELY
bowel prep and erythromycin and Neomycin based antibiotics
preoperatively. He had a preoperative CT scan repeated that
did not show any evidence of metastatic disease at that time.
HOSPITAL COURSE: On [**2119-4-14**], he came to the [**Hospital1 346**] and underwent a radical
cystoprostatectomy with bilateral pelvic lymph node
dissection and a continent cutaneous diversion. This was
performed by Dr. [**Last Name (STitle) 986**] and also Dr. [**Last Name (STitle) 4229**], with assistant
of Dr. [**First Name (STitle) **]. This was done under general endotracheal
anesthesia. Approximately ten liters of fluids were utilized
interoperatively and the patient had a 1500 cc. blood loss.
Urine output was not complete measured but was thought to be
"very good" per the Anesthesia Record. He did receive two
units of autologous blood interoperatively and received
Clindamycin and Gentamicin for antibiotics during the case.
Specimens from the case included bladder, prostate, bilateral
pelvic lymph nodes, ureteral cuff margins bilaterally.
Drains were the suprapubic tube, the diversion tube,
bilateral stents, [**Location (un) 1661**]-[**Location (un) 1662**] times two, a subclavian line
and an arterial line.
Findings overall were that of a normal anatomy.
He was discharged, intubated, to the Post Anesthesia Care
Unit and ultimately to the [**Hospital Ward Name 1826**] Intensive Care Unit. He
was extubated overnight. His pain was being controlled with
an epidural and he was otherwise feeling okay. He was noted
to have some mild hypotension immediately postoperatively in
the 70s. He was resuscitated with aggressive normal saline
boluses.
His postoperative hematocrit was 32. Sodium was 138,
potassium was 4.8, BUN and creatinine were 17 and 1.0. His
epidural was titrated back to help enhance his blood
pressure. His Propofol was weaned off to extubation. The
neobladder had flushes serially with normal saline and he was
maintained on Clindamycin and Gentamycin for 48 hours
postoperatively. X-rays showed no pneumothorax and he had a
left subclavian line that was in appropriate position.
Over the next 48 hours, the patient had some low grade
temperatures to 100.5 and 100.8 F., respectively. He was
requiring significant fluid boluses to keep his mean arterial
pressure in the 50s to 70s. Central venous pressures were
measured to be around 12. Ultimately, his urine output
through his suprapubic tube picked up. He was transferred to
the Floor on postoperative day number two. His hematocrit at
this time was 23.9. He was given an additional two units of
packed red cells. Creatinine was 0.8. His INR was 1.5.
His arterial line had been discontinued by this point. He
had a right internal jugular at this time; it was a new site
and stick that was placed. He had two ureteral stents, a
Foley catheter and a suprapubic tube. His epidural was still
being utilized, but it had been titrated back and he was now
on a total regimen of epidural and PCA for pain control. He
was hemodynamically stable. He had had a low-grade
temperature to 100.3 F., the night before, but was ultimately
deemed stable and appropriate for discharge, and sent to the
Floor.
On postoperative day number three, he was off antibiotics,
feeling well with no pain. His post transfusion hematocrit
was 27.3. His tachycardia had subsided. His BUN and
creatinine were 12.0 and 0.7 respectively. His examination
was otherwise benign. He was now walking and out of bed
without assistance. He was learning to care for his drains.
Over the next three to four days postoperatively, the patient
did well. He ultimately passed gas by postoperative day six.
At this time, his diet was advanced. His epidural was
discontinued. He was being controlled for pain with a PCA.
He was tolerating a clear liquid diet.
At this point of his postoperative course, the stents had
essentially all but fallen out on their own, so they were
discontinued. The [**Location (un) 1661**]-[**Location (un) 1662**] outputs had dropped off on
the left side, but the right [**Location (un) 1661**]-[**Location (un) 1662**] was noted to
increase immediately after the stent removal. The fear for a
possible urine leak status post stent removal was
investigated and creatinine values on the [**Location (un) 1661**]-[**Location (un) 1662**]
drains were drawn. They were showing to be 0.6 on the right
side and 0.4 on the left. This all but practically refutes a
possible urine leak.
The patient did very well over the next couple of days and
ultimately, by postoperative day number eight, he was
afebrile with a temperature of 98.6 F., pulse 80, blood
pressure 140/90; respiratory rate was 20 with 98% room air
saturation. He was tolerating a regular diet. His fluids
had been Hep-locked. He was making over a liter and a half
of urine through the suprapubic tube. His right
[**Location (un) 1661**]-[**Location (un) 1662**] outputs were averaging 100 to 150 q. shift, and
his left [**Location (un) 1661**]-[**Location (un) 1662**] out between 30 and 50 cc. q. shift.
Blood sugars were adequately controlled just on diet, ranging
106 to 112.
His examination was otherwise unremarkable. His wound is
well approximated with no drainage. Steri-Strips were in
place at this point postoperatively. He did have bowel
sounds and he was soft and flat otherwise. [**Location (un) 1661**]-[**Location (un) 1662**]
sites were secure times two. Suprapubic tube was
additionally in place draining yellow urine. The remainder
of his examination was unremarkable. At this point, he was
deemed appropriate and stable for discharge.
DISCHARGE MEDICATIONS:
1. Percocet 5/325, one to two tablets p.o. q. four to six
p.r.n.
2. Colace 100 mg p.o. twice a day.
3. Protonix 40 mg p.o. q. day.
4. Multivitamin one tablet p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. He will receive 30 to 40 cc. of normal saline flushes
with pull-back gently through the suprapubic tube three times
a day and p.r.n.
2. [**Location (un) 1661**]-[**Location (un) 1662**] care and output recordings.
3. He will receive a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] him with these
tasks.
4. Follow-up instructions will be to see Dr. [**Last Name (STitle) 4229**] in
approximately one to two weeks.
5. He will have a cystogram to test the patency of the
neobladder in approximately two weeks from time of discharge.
6. He will not be accessing his Foley catheter at that time
in his continent cutaneous diversion. This will be only
accessed in the presence of Dr. [**Last Name (STitle) 4229**] in the office.
7. The patient is going to be required to have follow-up
with Dr. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) 4229**], [**First Name3 (LF) **] that his plan of
care can be coordinated.
DISCHARGE DIAGNOSES:
1. Bladder carcinoma.
PATHOLOGY: Final pathology was pending, and please refer to
the interim pathology specimen report that is in the
computer.
DISCHARGE STATUS: To home.
CONDITION AT DISCHARGE: Stable.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2119-4-21**] 17:49
T: [**2119-4-21**] 18:17
JOB#: [**Job Number 8149**]
Admission Date: [**2119-4-14**] Discharge Date: [**2119-4-22**]
Date of Birth: [**2065-11-10**] Sex: M
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53 year old male
with a diagnosis of muscle invasive Grade II to III/III
bladder carcinoma. In addition, his prostatic urethral
biopsies had been positive for carcinoma in situ. He is
status post transurethral resection of bladder tumor and BCG
therapy. His pathology sides have been reviewed here at the
[**Hospital1 69**] and have shown a
micro-papillary variant which tends to be very aggressive.
He had undergone MVAC chemotherapy with Dr. [**Last Name (STitle) **]. At this
time, he presents for discussion for his continent urinary
diversion. His cystoprostatectomy will be performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**].
He had a CT scan and bone scan in [**2118-10-13**], prior to
his chemotherapy that showed no evidence of metastatic
disease. He had a recent prostate biopsy because of a
prostatic nodule which showed no malignancy.
PAST MEDICAL HISTORY:
1. Diet controlled type 2 diabetes mellitus.
MEDICATIONS: He is on no medications except a multivitamin.
PAST SURGICAL HISTORY:
1. Transurethral resection of bladder tumor.
SOCIAL HISTORY: He quit smoking eight years ago. He does
have a 30 pack year smoking history previous to that. He is
a district service manager for the Steris Company. He drinks
two to three caffeinated drinks per day and one to two
alcoholic beverages per day.
FAMILY HISTORY: Significant for his father with a history of
lung cancer and a sister with diabetes mellitus.
ALLERGIES: Allergies are a questionable possible allergy to
Ampicillin.
REVIEW OF SYSTEMS: Review of systems on pre-surgical
evaluation showed mild urinary urgency after BCG treatment
and had decreased erectile function.
PHYSICAL EXAMINATION: Vital signs were 130/88; pulse 78 and
regular; respiratory rate was 16 and unlabored. Abdomen
soft, nontender, no palpable masses. No costovertebral angle
tenderness. No inguinal lymphadenopathy. Genitourinary:
Normal phallus, meatus and testes. No inguinal hernia.
Rectal: Normal tone; 40 gram prostate. Nodularity in the
left prostatic lobe. Extremities and Neurological: Moves
all four extremities without difficulty. Normal gait.
Neurologically and mentally intact.
LABORATORY: White blood cell count 6.7, hematocrit 35,
platelet count 267, BUN and creatinine are 20 and 1.0.
Urinalysis dipstick was three plus glucose; otherwise
unremarkable.
Given this preoperatively assessment, he was given a NuLYTELY
bowel prep and erythromycin and Neomycin based antibiotics
preoperatively. He had a preoperative CT scan repeated that
did not show any evidence of metastatic disease at that time.
HOSPITAL COURSE: On [**2119-4-14**], he came to the [**Hospital1 346**] and underwent a radical
cystoprostatectomy with bilateral pelvic lymph node
dissection and a continent cutaneous diversion. This was
performed by Dr. [**Last Name (STitle) 986**] and also Dr. [**Last Name (STitle) 4229**], with assistant
of Dr. [**First Name (STitle) **]. This was done under general endotracheal
anesthesia. Approximately ten liters of fluids were utilized
interoperatively and the patient had a 1500 cc. blood loss.
Urine output was not complete measured but was thought to be
"very good" per the Anesthesia Record. He did receive two
units of autologous blood interoperatively and received
Clindamycin and Gentamicin for antibiotics during the case.
Specimens from the case included bladder, prostate, bilateral
pelvic lymph nodes, ureteral cuff margins bilaterally.
Drains were the suprapubic tube, the diversion tube,
bilateral stents, [**Location (un) 1661**]-[**Location (un) 1662**] times two, a subclavian line
and an arterial line.
Findings overall were that of a normal anatomy.
He was discharged, intubated, to the Post Anesthesia Care
Unit and ultimately to the [**Hospital Ward Name 1826**] Intensive Care Unit. He
was extubated overnight. His pain was being controlled with
an epidural and he was otherwise feeling okay. He was noted
to have some mild hypotension immediately postoperatively in
the 70s. He was resuscitated with aggressive normal saline
boluses.
His postoperative hematocrit was 32. Sodium was 138,
potassium was 4.8, BUN and creatinine were 17 and 1.0. His
epidural was titrated back to help enhance his blood
pressure. His Propofol was weaned off to extubation. The
neobladder had flushes serially with normal saline and he was
maintained on Clindamycin and Gentamycin for 48 hours
postoperatively. X-rays showed no pneumothorax and he had a
left subclavian line that was in appropriate position.
Over the next 48 hours, the patient had some low grade
temperatures to 100.5 and 100.8 F., respectively. He was
requiring significant fluid boluses to keep his mean arterial
pressure in the 50s to 70s. Central venous pressures were
measured to be around 12. Ultimately, his urine output
through his suprapubic tube picked up. He was transferred to
the Floor on postoperative day number two. His hematocrit at
this time was 23.9. He was given an additional two units of
packed red cells. Creatinine was 0.8. His INR was 1.5.
His arterial line had been discontinued by this point. He
had a right internal jugular at this time; it was a new site
and stick that was placed. He had two ureteral stents, a
Foley catheter and a suprapubic tube. His epidural was still
being utilized, but it had been titrated back and he was now
on a total regimen of epidural and PCA for pain control. He
was hemodynamically stable. He had had a low-grade
temperature to 100.3 F., the night before, but was ultimately
deemed stable and appropriate for discharge, and sent to the
Floor.
On postoperative day number three, he was off antibiotics,
feeling well with no pain. His post transfusion hematocrit
was 27.3. His tachycardia had subsided. His BUN and
creatinine were 12.0 and 0.7 respectively. His examination
was otherwise benign. He was now walking and out of bed
without assistance. He was learning to care for his drains.
Over the next three to four days postoperatively, the patient
did well. He ultimately passed gas by postoperative day six.
At this time, his diet was advanced. His epidural was
discontinued. He was being controlled for pain with a PCA.
He was tolerating a clear liquid diet.
At this point of his postoperative course, the stents had
essentially all but fallen out on their own, so they were
discontinued. The [**Location (un) 1661**]-[**Location (un) 1662**] outputs had dropped off on
the left side, but the right [**Location (un) 1661**]-[**Location (un) 1662**] was noted to
increase immediately after the stent removal. The fear for a
possible urine leak status post stent removal was
investigated and creatinine values on the [**Location (un) 1661**]-[**Location (un) 1662**]
drains were drawn. They were showing to be 0.6 on the right
side and 0.4 on the left. This all but practically refutes a
possible urine leak.
The patient did very well over the next couple of days and
ultimately, by postoperative day number eight, he was
afebrile with a temperature of 98.6 F., pulse 80, blood
pressure 140/90; respiratory rate was 20 with 98% room air
saturation. He was tolerating a regular diet. His fluids
had been Hep-locked. He was making over a liter and a half
of urine through the suprapubic tube. His right
[**Location (un) 1661**]-[**Location (un) 1662**] outputs were averaging 100 to 150 q. shift, and
his left [**Location (un) 1661**]-[**Location (un) 1662**] out between 30 and 50 cc. q. shift.
Blood sugars were adequately controlled just on diet, ranging
106 to 112.
His examination was otherwise unremarkable. His wound is
well approximated with no drainage. Steri-Strips were in
place at this point postoperatively. He did have bowel
sounds and he was soft and flat otherwise. [**Location (un) 1661**]-[**Location (un) 1662**]
sites were secure times two. Suprapubic tube was
additionally in place draining yellow urine. The remainder
of his examination was unremarkable. At this point, he was
deemed appropriate and stable for discharge.
DISCHARGE MEDICATIONS:
1. Percocet 5/325, one to two tablets p.o. q. four to six
p.r.n.
2. Colace 100 mg p.o. twice a day.
3. Protonix 40 mg p.o. q. day.
4. Multivitamin one tablet p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. He will receive 30 to 40 cc. of normal saline flushes
with pull-back gently through the suprapubic tube three times
a day and p.r.n.
2. [**Location (un) 1661**]-[**Location (un) 1662**] care and output recordings.
3. He will receive a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] him with these
tasks.
4. Follow-up instructions will be to see Dr. [**Last Name (STitle) 4229**] in
approximately one to two weeks.
5. He will have a cystogram to test the patency of the
neobladder in approximately two weeks from time of discharge.
6. He will not be accessing his Foley catheter at that time
in his continent cutaneous diversion. This will be only
accessed in the presence of Dr. [**Last Name (STitle) 4229**] in the office.
7. The patient is going to be required to have follow-up
with Dr. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) 4229**], [**First Name3 (LF) **] that his plan of
care can be coordinated.
DISCHARGE DIAGNOSES:
1. Bladder carcinoma.
PATHOLOGY: Final pathology was pending, and please refer to
the interim pathology specimen report that is in the
computer.
DISCHARGE STATUS: To home.
CONDITION AT DISCHARGE: Stable.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2119-4-21**] 17:49
T: [**2119-4-21**] 18:17
JOB#: [**Job Number **]
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12,406
| 141,524
|
23134
|
Discharge summary
|
report
|
Admission Date: [**2138-1-1**] Discharge Date: [**2138-1-10**]
Service: [**Last Name (un) **]
SERVICE: Trauma surgery.
HISTORY OF PRESENT ILLNESS: This is an 81 year old female,
with a history of hypothyroidism. She was found by her
neighbors down on her back porch. It was unknown at the time
how long the patient was down for. The patient was unable to
give any history. She ws brought into the Emergency Room.
Core temperature was noted to be 86 degrees F. The patient
is known to have history of weakness, fatigue, malaise and 10
pound weight loss and dizziness over the last several months.
Her family believes that this may have contributed to her
fall.
PHYSICAL EXAMINATION: In the Emergency Department, the
patient's initial vital signs were temperature of 88 degrees;
pulse of 72 and blood pressure 80/palpable, respiratory rate
of 14. The patient was 100 percent on non rebreather.
General appearance: The patient appeared sedated. Body was
noted to be cold. HEAD, EYES, EARS, NOSE AND THROAT: Pupils
were 6 mm and minimally reactive to light. Cardiovascular:
Normal S1 and S2 with regular rate and rhythm. Lungs were
with coarse breath sounds bilaterally. Extremities revealed a
large bruise over the right lower extremity and what looked
to be chemical type burns. Distal pulses were 2 plus
bilaterally. As stated before, the patient was noted to be
cold and clammy in appearance.
HOSPITAL COURSE: The patient was started on warmed inhaled
oxygen immediately, warmed intravenous fluids and warming
blankets were placed. The patient was placed in a hard collar
and sent to the CAT scan. At that time, she underwent
pulseless electrical activity arrest. The patient was given
1 mg of epinephrine, 1 mg of Atropine, 2 amps of bicarbonate
and the patient returned with pulse and blood pressure
appropriately. The blood gas showed improvement at this
time. The patient was admitted to the trauma surgical
service and also evaluated by the plastic surgery team. They
recommended Silvadene cream topically twice a day to her burn
wounds. There was no concern for compartment syndrome at this
time. The patient was admitted to the Intensive Care Unit
for further evaluation and treatment. Chest x-ray revealed
no significant findings at this time. Pelvis x-ray revealed
no fractures. CAT scan of the head was negative. CAT scan
of the cervical spine was negative. CAT scan of the torso
revealed some lymph nodes with no acute process likely,
showing spleen enhancement heterogeneous in nature. Minimal
thickening of the first portion of the duodenum and a
pancreatic head 9 by 17 mm low density mass and mesenteric
fat stranding. The patient was able to have her collar
removed when the magnetic resonance scan of the head and
cervical spine returned. The patient, at this time, was also
receiving Levophed for blood pressure assistance. The
patient was also sedated on Propofol and was resuscitated
actively with Crystalloid solution. The patient was
receiving Fentanyl for pain control as well.
The patient was also evaluated by cardiology who noted that
there was no indication for catheterization at this point.
She was to receive an exercise tolerance test if she
clinically improves and was able to exercise, and to be
careful in terms of monitoring for possible signs of
pulmonary embolus. On hospital day three, Ipratropium was
added for increased wheeziness on examination and likely
failure on chest x-ray. Tube feeds were also started and the
patient's fluid was hep-locked. The patient's cervical
collar was removed as the magnetic resonance scan revealed no
signs of cord involvement or fracture, in addition to the CAT
scan of the cervical spine was obtained.
On hospital day number four, the patient was extubated and
was started on Ampicillin for pan sensitive Enterococcus. On
hospital day number five, the patient was able to be weaned
off of Levophed and insulin drips. The patient responded
well and was noted to be in rapid atrial fibrillation this
morning, [**2138-1-6**] and received Diltiazem twice. She
had no chest pain at this time and an electrocardiogram
revealed atrial fibrillation. The patient was cardioverted
and was rebolused with Amiodarone appropriately. The patient
responded by returning to sinus rhythm. The patient received
a swallowing evaluation on [**2138-1-6**]. The patient
was able to receive regular diet as tolerated. Her voice also
began to improve in quality. On hospital day number six, the
patient was taken to the operating room for tangential
excision of right lower extremity eschar down to viable
tissue. The patient was also assessed by physical therapy
who suggested need for a stint in rehabilitation facility.
On hospital day number seven, the patient was noted to be
having some difficulty with chest pain in the morning,
shortly after transfer from the Intensive Care Unit. An
electrocardiogram was done that revealed no significant
changes. The patient was ruled out via enzymes. Chest x-ray
was obtained and this revealed her to be somewhat in
congestive heart failure. The patient received Lasix at this
time and then improved her respiratory status. She proceeded
to not have any more complaints of chest pain or shortness of
breath during her stay.
On [**2138-1-10**], the patient was noted to be stable and
afebrile. Vital signs were within normal limits. Examination
revealed the patient's VAC drain placed the prior day to be
functioning well and on continuous therapy. Plan for the VAC
drain was to have it changed every three days. It was placed
on Thursday, [**1-9**]. The next change would occur on
Sunday or Monday.
DISCHARGE DIAGNOSES: Hypothermia.
Full thickness burn to the left leg.
Pulseless electrical activity.
Hypothyroidism.
Dyslipidemia.
MAJOR SURGICAL OR INVASIVE PROCEDURES: Right leg
escharotomy.
Endotracheal intubation.
Central line placement.
Wound VAC placement.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneous three times a day.
2. Albuterol one to two puffs every six hours as needed.
3. Aspirin 325 mg p.o. q day.
4. Ipratroprium bromide two puffs every four to six hours as
needed.
5. Colace 100 mg p.o. twice a day.
6. Levo-thyroxine 150 mg p.o. q day.
7. Regular insulin sliding scale. This will be printed out
and attached to the discharge paper work, as directed.
8. Ibuprofen 400 mg p.o. q 8 hours as needed.
9. Protonix 40 mg p.o. q day.
10. Lasix 40 mg p.o. twice a day.
11. Silvadene one application topically daily to her
left lower extremity wounds.
12. Metoprolol 25 mg p.o. twice a day.
DISPOSITION: The patient will be discharged to
rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2138-1-10**] 09:54:26
T: [**2138-1-10**] 11:36:04
Job#: [**Job Number 59538**]
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59,417
| 173,134
|
41224
|
Discharge summary
|
report
|
Admission Date: [**2146-10-31**] Discharge Date: [**2146-11-8**]
Date of Birth: [**2090-3-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone / Codeine / Sulfa (Sulfonamide
Antibiotics)
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
fevers, confusion
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Mrs. [**Known lastname **] is a 56yoF with chronic renal failure s/p DDRT in
[**2127**] due to congenitally malformed kidneys, HTN, neuropathy,
lung mass resection, GERD, depression who is transferred from
[**Hospital3 **] Hosptial for management of fevers and confusion,
nosebleed, and unsteady gait.
She was found by her neighbors found her stumbling, who then
activated EMS. At OSH, she was febrile to 103 and empirically
got vanco/ctx. CXR benign per report. CT head revealed a basal
ganglia bleed versus mass, so she was given 100mg IV methylpred.
Transferred to [**Hospital1 18**].
.
At [**Hospital1 18**] ED, initial vitals were T99.3, HR89, BP181/94, RR18,
Sat98%RA. Neurosurgery consulted but felt patient would be
better suited to medicine service due to elevated creatinine and
mild transaminitis. Recommended MRI/MRA for better evaluation
of the bleed/mass with BP control to systolics<140. Got IV
lopressor x2 with BP to 160. Creatinine appears at recent
baseline- she has chronic renal disease of her graft with biopsy
showing widespread sclerosis earlier this summer.
.
On arrival to the MICU, initial VS were T99.4 P83 BP147/84 RR18
97RA. The patient is a difficult historian, needing directed
questions to elicit a story. She relates intermittent fevers for
the past 3 weeks up to 102. Over past three days, noting vague
abdominal pain with nausea and vomiting in the morning.
Diarrhea 4 times daily. She feels generally weak and has been
walking unsteadily. She feels confused. No neck stiffness,
though with some photophobia. Mild SOB. No dysuria, hematuria.
No rashes
Past Medical History:
-HTN
-s/p CRT [**7-/2127**] in [**State 760**], secondary to a birth defect (born
with half kidney on left and abnormally formed right kidney) ?
mother taking anti-nausea medication during pregnancy.
-Herpes infection of kidney in [**2146**]
-Peripheral neuropathy
-Depression
-GERD
-Splenic Aneurysm, following radiographically
-Bronchitis/asthma
-Insomnia
-Osteoporosis
-Chronic elevated transaminases
-Fibromyalgia
-Right Lung mass resection [**7-1**]
-Lumpectomy, benign in [**2139**] on right
Social History:
Lives at [**Location (un) **]. Works as a secretary. Smokes [**1-23**] cigs/day x
10 years. Social drinker. Denies IVDU
Family History:
NC
Physical Exam:
Physical Exam on Arrival to MICU
T99.4 P83 BP147/84 RR18 97RA
General: appears confused, AAO to person and place, following
commands
HEENT: left pupil 4mm and reactive, right 2 mm and reactive, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Mild TTP over left
renal transplant site.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: anisicoria. strength 4/5 throughout, possibly decreased
on right. Right facial droop.
Discharge PE:
VS: Tc/m 97.8 146/88 (132-146/67-88) 98 (77-98) 20 98 RA
200 out/1080+50
GENERAL: Well-appearing woman in NAD, laying comfortably in bed
HEENT: sclerae anicteric, right sided facial droop
NECK: Supple
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat
ABDOMEN: Bowel sounds present, Obese, soft, non-tender,
non-distended, midline surgical scar, kidney graft palpable in
LLQ, no tenderness over graft site
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: AAOx3, alert and appropriate
Pertinent Results:
[**2146-11-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-11-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-11-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2146-11-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-11-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-11-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2146-10-31**] Blood Culture, Routine-PENDING
[**2146-10-31**] URINE CULTURE-FINAL INPATIENT
[**2146-10-31**] Blood Culture, Routine-PENDING
[**2146-10-31**] Blood Culture, Routine-PRELIMINARY LISTERIA
MONOCYTOGENES
.
STUDIES:
MR HEAD:
CONCLUSION: Interval development of extensive zone of T2
hyperintensity, with some mass effect in the left basal ganglia
and subinsular white matter. Right posterior temporal/occipital
lesion, which is smaller compared to the other lesion. In the
prior MR report, there was a provided history of renal
transplantation and immunosuppression. The findings could
represent multiple areas of infarction, with hemorrhagic
elements. However, given the history of immunosuppression, it is
conceivable, though not as likely, that a superimposed
infectious process could be considered. Obviously, a more
detailed work-up is necessary at this time.
.
[**2146-11-1**] Renal ultrasound transplant:
IMPRESSION: No evidence of hydronephrosis or perinephric
collection. Resistive indices of 0.75-0.82, slightly increased
as compared to [**2146-4-9**].
.
[**2146-11-1**] EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of focal slowing and attenuation of faster frequencies
over the left hemisphere indicative of focal cerebral
dysfunction in this region. Moderate diffuse background slowing
is indicative of a moderate to severe diffuse encephalopathy
which is etiologically non-specific. No epileptiform discharges
or electographic seizures are present.
.
[**2146-11-2**] ECHO:
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal regional and global biventricular systolic function. No
significant valvular regurgitation seen. If clinically
indicated, a transesophageal echocardiogram may better assess
for valvular vegetations.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 56yoF renal transplant recipient who presents
with fevers, confusion found to have listeria bacteremia and
brain abscess.
.
# Listeria bacteremia and brain abscess:
Patient was initially covered with broad spectrum antibiotics
for fevers, delerium, and concern for brain abscess, which
included vancomycin, meropenem, and acyclovir. She grew listeria
on day 2 of admission and antibiotics were narrowed to
ampicillin and gentamycin. Patient required desensitization to
ampicillin. Patient markedly improved after starting ampicillin.
Patient is currently on ampicillin (for planned 6 - 8 week
course) and gentamyin (planned for at least one week). The
patient was instructed to continue her ampicillin until [**2146-12-15**]
and she has follow up with ID at the beginning of [**Month (only) **]. She
also was instructed to get repeat brain imaging in 4 weeks to
evaluate the abscess.
.
# Delirium: The patient was delirius during her MICU stay;
likely secondary to her CNS infection. Neurology was consulted
while the patient was in the unit, and given the concern for
seizures, patient received one dose of keppra. However, the pt
had two EEGs, which were not suggestive of seizure activity and
the Keppra was stopped.
.
# Anemia: Patient had a drop in her HCT when she was first
admitted from 30 to 21.7 over one day. Patient found to have
guaiac positive brown stool. She was transfued 1 unit PRBC with
appropriate response. Etiology of anemia unclear, in ICU thought
possibly secondary to marrow supression given infection. The
patient had lower end of normal TIBC and transferrin, with
elevated ferritin possibly suggestive of anemia of chronic
disease. However, because the patient was acutely infected, her
ferritin levels are expected to be elevated because it is an
acute phase reactant.
.
# s/p kidney transplant: The patient was continued on her
immunosuppresive medications including her prednisone and MMF.
The patient's MMF was initially decreased in the unit to 250 mg
[**Hospital1 **] because of leukopenia, but was then increased back to her
home dose of 500 mg [**Hospital1 **] when she was on general floor.
.
#. Leukopenia: WBC dropped from 4.7 on admission to 1.9.
Patient's Mycophenolate dose was decreased in response.
However, after transfer to medicine floor, the patient's MMF was
increased to her home dose of 500 mg [**Hospital1 **].
.
# Hyponatremia: Thought possibly secondary to SIADH, especially
given the patient's brain abscess. Urine sodium was 30, also
supporting SIADH. While on the floor, the patient was fluid
restricted. On discharge, the patient's sodium was stable at
129.
.
# hypertension: The patient was started on Labetolol 200 mg [**Hospital1 **]
for blood pressure control and she was sent home on Lisinopril 5
mg once daily (dose reduction given her recent kidney injury).
.
# Acute on Chronic Renal Failure: On admission, creatinine was
1.9 (near baseline), but increased to 2.5. ICU team has
carefully been watching creatinine while patient on gent.
Trending down to baseline, at 2 today. While on the the
medicine floor, the patient was continued on the Gentamycin for
a total course of one week. Her creat at discharge was 2.1.
Medications were renally dosed and nephrotoxic agents were
avoided.
.
# Chronic diarrhea: Patient with chronic diarrhea. Work-up of
infectious etiology in ICU unrevealing. Stool studies, including
c. diff, campylobacter, O&P negative to date. Possible that
cellcept may be causing diarrhea. However, by the time she got
to the medicine floor, the patient reported that her diarrhea
was resolving, and by day of discharge, she reports that her
diarrhea had resolved.
..
Transitional Issues:
.
# hyponatremia: please follow up the patient's sodium levels as
an outpatient.
.
# repeat head imaging: The patient needs to get repeat head
imaging in 4 weeks.
Medications on Admission:
FUROSEMIDE 40 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg - [**1-23**] as needed for pain
LISINOPRIL 10 mg - 1 Tablet(s) by mouth twice a day
MYCOPHENOLATE MOFETIL - 500 mg Tablet - 1 Tablet(s) by mouth
twice a day
OMEPRAZOLE Dosage uncertain
PAROXETINE HCL - 40 mg Tablet - 1 Tablet(s) by mouth every other
day
PREDNISONE -5 mg Tablet - 1 Tablet(s) by mouth every other day
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice a
day
SODIUM BICARBONATE - 650 mg Tablet - 2 Tablet(s) by mouth three
times a day
Discharge Medications:
1. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 6 weeks: please take
ampicillin until [**2146-12-15**].
Disp:*296 grams* Refills:*0*
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO EVERY
OTHER DAY (Every Other Day).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Outpatient Lab Work
please get weekly CBC, chem 7, and LFTs every Tuesday, starting
Tuesday, [**11-15**] and fax results to Dr. [**Last Name (STitle) **] in the
transplant center at [**Telephone/Fax (1) 697**], thanks
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. hydrocodone-acetaminophen 5-500 mg Capsule Sig: One (1)
Capsule PO q6h:PRN as needed for pain.
8. omeprazole Oral
9. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
10. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO
three times a day.
11. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
12. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
primary diagnosis:
Listeria bacteremia
brain abscess
status post renal transplant
secondary diagnosis:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
very confused and had fevers. You were initially admitted to
the intensive care unit because you were very sick and you were
found to have bacteria in your blood. A scan of your head also
showed that you might have had some bacteria in your brain as
well (abscess). We started you on antibiotics through your
veins. You have an allergy to these antibiotics, so we had to
desensitize you by giving you very, very small doses until you
were able to tolerate the medication.
Since starting these antibiotics, your infection has been
improving and your mental status has returned back to your
baseline; you are no longer confused or disoriented.
Because of the infection in your brain, you must be on a
prolonged course of antibiotics through your veins. You are
being sent home with a PICC line, which allows us to keep giving
you antibiotics through your veins for a total of six weeks.
It is also very important that you re-image your head in 4
weeks. Please make sure you discuss this with you transplant
and ID doctors.
We made the following changes to your medications:
START ampicillin 2 grams every 6 hours through your PICC line;
please continue unti [**2146-12-15**]
START Labetolol 200 mg by mouth twice daily
DECREASE Lisinopril from 10 mg by mouth daily to 5 mg by mouth
daily
.
It is very important that you follow in transplant clinic and
see your primary care doctor as well. Appointments have been
made for you, see below.
If you have any confusion, high fevers, nausea or vomit,
headaches, any weakness or loss of sensation, please call your
doctor or return to the ED.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 26**] R.
Location: EMERALD PHYSICIANS
Address: [**Street Address(2) 89798**], [**Location (un) **],[**Numeric Identifier 58635**]
Phone: [**Telephone/Fax (1) 14888**]
Appt: Saturday, [**11-12**] at 2pm***Note appt is at the [**Street Address(2) 89799**] location***
.
Department: TRANSPLANT CENTER
When: MONDAY [**2146-11-14**] at 1:20 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: TRANSPLANT
When: TUESDAY [**2146-11-15**] at 11:30 AM
With: TRANSPLANT ID [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2146-11-10**]
|
[
"996.81",
"787.91",
"585.9",
"E878.0",
"323.9",
"348.9",
"790.7",
"493.90",
"403.90",
"276.1",
"287.5",
"288.50",
"V49.86",
"285.1",
"027.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11849, 11915
|
6179, 9873
|
348, 365
|
12076, 12076
|
3926, 6156
|
14019, 15052
|
2670, 2675
|
10670, 11826
|
11936, 11936
|
10085, 10647
|
12227, 13452
|
2690, 3351
|
9894, 10059
|
13481, 13996
|
3365, 3907
|
290, 310
|
393, 1993
|
12040, 12055
|
11955, 12019
|
12091, 12203
|
2015, 2516
|
2532, 2654
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,113
| 130,267
|
12739
|
Discharge summary
|
report
|
Admission Date: [**2196-6-27**] Discharge Date: [**2196-7-1**]
Date of Birth: [**2146-6-22**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old
patient of Dr. [**Last Name (STitle) **] [**Name (STitle) 39294**] who was diagnosed with persistent
lightheadedness and fatigue and had a positive tilt test and
a chest CT that was negative for sarcoid, but positive for
calcified coronaries. He had a Cardiolite ETT on [**2196-6-3**],
which showed no chest discomfort or electrocardiogram
changes, but imaging was remarkable for a moderate fixed
inferior defect consistent with either scar versus
diaphragmatic degeneration. There was also a moderately
sized moderately reversible anterior apical and septal
defect. EF was noted to be 43%. He has bee plagued with
chronic lightheadedness and flu since [**2186**] and no complaints
of chest discomfort or shortness of breath.
He was admitted overnight after some of these vague symptoms
and ruled him out for an myocardial infarction by
electrocardiogram and enzymes and was referred for cardiac
catheterization on late [**2196-5-28**]. The cardiac
catheterization report showed the patient to have coronary
artery disease requiring a coronary artery bypass graft.
Briefly it showed significant stenosis of the right coronary
artery, left anterior descending coronary artery and obtuse
marginal with a normal EF.
PAST MEDICAL HISTORY: Sarcoid in [**2180**], benign prostatic
hypertrophy, restless leg syndrome, high blood pressure,
hyperlipidemia. He had surgery for bilateral TMJ,
tonsillectomy and adenoidectomy and dissection of lipomas.
ALLERGIES: Penicillin.
MEDICATIONS AT HOME: Serax 30 mg q.h.s., Endocet 5 to 325 mg
q.h.s., Flomax 0.4 mg po q.h.s., Proscar 5 mg po q.d.,
Prednisone taper, which was stopped, Ranitidine and
multivitamin pills.
PREOPERATIVE LABORATORIES: Within normal limits.
He was taken to the Operating Room on [**2196-6-27**] for a
coronary artery bypass graft times three using a left radial
to obtuse marginal graft, saphenous vein graft to posterior
descending coronary artery and left internal mammary coronary
artery to left anterior descending coronary artery. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] was the attending of record. Postoperatively, the
patient was transferred to the Cardiac Intensive Care Unit
having received Vancomycin perioperatively for infectious
disease prophylaxis. Over the next day or so he was weaned
off pressors and vasodilatory drugs. We continued dilating
his radial artery graft using initially a nitroglycerin drip
and then switching him over to po ISDN 30 mg po q day.
HOSPITAL COURSE: 1. Neurological: The patient was
extubated on day number one. His pain complaints were then
controlled using a combination of around the clock Tylenol,
Dilaudid and Motrin. The patient had no neurological events
during the hospitalization.
2. Cardiovascular: The patient was on nitroglycerin and neo
immediately postoperatively and then was switched over to
ISDM for ventilatory effect. He was beta blockaded.
3. Pulmonary: The patient was extubated on the day of the
operation and was then encouraged on incentive spirometry and
chest physical therapy.
4. Gastrointestinal: The patient's diet was advanced as
tolerated. He was allowed a regular diet.
5. Genitourinary: The patient's Foley was discontinued upon
transfer out of the unit.
6. Abdomen: The patient's abdomen was soft and benign.
7. Infectious disease: The patient received Vancomycin
perioperatively, plus had a temperature spike to 101.5, which
was pan cultured and to date the cultures are negative. The
white count was not significantly elevated. Most likely the
spike was due to pulmonary nature and source.
8. Tubes, lines and drains: The patient's wires, chest
tubes, mediastinal tubes were all discontinued without
incident. His Foley was discontinued without incident. His
central line and Swan were discontinued without incident.
9. Chest wound: The patient's wound has no click, no
erythema and no redness. This was due to tissue in the
sternum as well approximated. No acute issues. His radial
artery graft wound site, is not infected looking as well.
10. Hematology: His hematocrit is steady. He was on deep
venous thrombosis prophylaxis while in house and was
ambulating well and will not require any such at home. The
patient was also diuresed during his hospital course, in
addition to his abandoned urine output in an attempt to get
rid of excess fluid from the day of the operation.
DISCHARGE MEDICATION ON [**2196-7-1**]: Protonix 40 mg po q day,
aspirin 325 mg po q day, ISDN 30 mg po q day, Flomax 0.4 mg
po q.h.s., Proscar 5 mg po q.d., potassium chloride 20
milliequivalents po b.i.d. times five days, Lasix 20
milliequivalents po b.i.d. times five days, Colace 100 mg po
b.i.d., Lopressor 25 mg po b.i.d., Dilaudid 2 to 4 mg po
q.4.h. prn for pain.
The patient is doing well upon discharge and is close to his
preoperative weight. The patient will follow up with Dr.
[**Last Name (STitle) 70**] in four weeks for surgical issues and Dr. [**Last Name (STitle) 39294**] of
cardiology for cardiology issues and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
all medical issues. The patient is doing well and is in no
acute distress.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2196-7-1**] 09:03
T: [**2196-7-1**] 09:15
JOB#: [**Job Number 39295**]
|
[
"135",
"272.4",
"414.01",
"411.1",
"401.9",
"780.6",
"998.89",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.72",
"36.15",
"42.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2695, 5677
|
1685, 2677
|
159, 1408
|
1431, 1664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,735
| 164,875
|
52289
|
Discharge summary
|
report
|
Admission Date: [**2180-10-30**] Discharge Date: [**2180-11-9**]
Date of Birth: [**2121-6-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Iodine / Codeine / Adhesive Tape
Attending:[**First Name3 (LF) 31685**]
Chief Complaint:
Transfer from IP for management of metastatic melanoma
Major Surgical or Invasive Procedure:
Thoracic Pigtail tube placement for pleural effusion
History of Present Illness:
Ms. [**Known lastname **] is a 59 year old woman with history of [**Initials (NamePattern4) 10834**] [**Last Name (NamePattern4) 1105**]
melanoma who is transferred from the IP service for treatment of
metastatic melanoma. She initially presented in [**2180-9-8**] with
relatively acute onset wheezing and dyspnea. She was initially
seen at NEBH and treated with antibiotics and steroids for
presumed lymphangitic spread of the melanoma. She was seen in
consultation in melanoma clinic, where it was determined that
she did not qualify for IL-2 or any ongoing studies given her
poor respiratory status. Her breathing continued to deteriorate,
and she developed orthopnea and small amount of hemoptysis. She
was seen by the interventional pulmonologist for evaluation for
possible stenting, but was unable to tolerate the procedure; she
was admitted to the IP service for further management of her
hypoxia and dyspnea.
.
In the SICU, her respiratory status improved after diuresis. She
was found to have a left pleural effusion; a pigtail catheter
was placed and drained 2000cc of exudative fluid, thought likely
to be malignant. She had a chest CT which showed a large
loculated pleural effusion (with pigtail catheter in place),
extensive right hilar and mediastinal lymphadenopathy, and
multiple pulmonary nodules. A V/Q scan demonstrated low
probability of pulmonary embolism. The pigtail catheter was
pulled on [**11-3**]. She was transferred to the [**Hospital Ward Name **] for
potential chemotherapy (Taxol).
.
On arrival to the floor, her respiratory status is much
improved, and she reports feeling much better. She also reports
headaches (which she attributes to oxygen therapy) and periodic
RUQ pain.
Past Medical History:
ONCOLOGY HISTORY:
- Diagnosed in [**2169**] with [**Initials (NamePattern4) 10834**] [**Last Name (NamePattern4) 1105**] melanoma in [**2165**] with wide
incision
- Developed right inguinal lymphadenopathy, s/p right radicular
inguinal dissection with positive lymph nodes, complicated by
post op skin infection requiring debridement
- No further therapy of melanoma at that time
- Bronchial washings from [**2180-9-29**] were positive for malignant
cells, consistent with metastatic melanoma; carinal lesion
biopsy form [**2180-10-3**] demonstrated malignant melanoma
.
PAST MEDICAL HISTORY:
- Hypertension
- Steroid-induced diabetes mellitus
- ITP s/p splenectomy
- Right knee replacement
Social History:
40 pack year history, quit [**2170**]. Lives in [**Location 19707**] with her
mother, who is independent. Denies alcohol or medications.
Family History:
Stomach cancer paternal grandmother, breast cancer in paternal
aunt, throat cancer in maternal uncle, and question stomach
cancer in maternal uncle.
Physical Exam:
VITALS: T97.6F, BP 100/72, HR 87, RR 22, O2sat 92%6L NC
GENERAL: Comfortable, no acute distress
NECK: No cervical lymphadenopathy
CARD: Regular rate & rhythm, 2/6 systolic murmur at LUSB
RESP: No accessory muscle use. Decreased breath sounds on left,
with crackles ~1/3 up; right essentially clear
ABD: Obese, + bowel sounds, non-tender, non-distended, no HSM
appreciated
BACK: No CVA tenderness, no spinal tender
EXT: No clubbing, cyanosis, or edema; 2+ DP pulses bilaterally
NEURO: CN II-XII intact, 5/5 strength in both upper and lower
extremities bilaterally. No sensory deficits appreciated.
PSYCH: Mood and affect appropriate.
Pertinent Results:
[**2180-10-30**] 07:35PM PT-13.4 PTT-24.8 INR(PT)-1.1
[**2180-10-30**] 07:35PM PLT COUNT-537*
[**2180-10-30**] 07:35PM NEUTS-69.4 LYMPHS-22.5 MONOS-5.0 EOS-2.8
BASOS-0.3
[**2180-10-30**] 07:35PM WBC-19.9* RBC-3.81* HGB-10.9* HCT-33.0*
MCV-87 MCH-28.6 MCHC-33.0 RDW-14.4
[**2180-10-30**] 07:35PM CALCIUM-9.5
[**2180-10-30**] 07:35PM estGFR-Using this
[**2180-10-30**] 07:35PM GLUCOSE-158* UREA N-16 CREAT-0.6 SODIUM-137
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-31 ANION GAP-12
.
ECG [**10-30**]: Sinus rhythm. Normal tracing. No previous tracing
available for comparison
.
Echo [**10-30**]: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild
pulmonary artery systolic hypertension.
.
CXR [**10-30**]: 1. Large left pleural effusion, bibasilar atelectasis,
and right basilar Kerley B lines. This suggests lymphangitis
carcinomatosa or direct, tumor-related pulmonary congestion. 2.
Hazy right upper lung opacity which may be bony confluence,
though not excluded would be a right upper lobe nodule. 3. If
clinically relevant to the patient's management, cross-sectional
imaging of the chest would further characterize these findings.
.
Cytology pleural fluid [**10-31**]: NEGATIVE FOR MALIGNANT CELLS.
.
[**10-31**] ECG: Sinus rhythm. Normal tracing. Compared to the previous
tracing of [**2180-10-30**] the findings are similar.
.
[**10-31**] ECG: Slight sinus tachycardia. Otherwise, within normal
limits. Compared to the previous tracing of [**2180-10-31**] the heart
rate is faster. The other findings are similar.
.
[**10-31**] CXR: In comparison with the study earlier in this date,
there has been placement of a pigtail catheter with removal of
substantial amount of fluid from the left chest. Several
lobulated opacifications suggest some loculated pleural fluid.
Specifically, no evidence of pneumothorax.
Relatively lower lung volumes with some opacification at the
bases consistent with atelectatic change. There is also some
increasing prominence of ill-defined pulmonary vessels that
could reflect some developing increased pulmonary venous
pressure.
.
[**11-1**] V/Q Scan: Low probability for PE. PE can not be excluded
with certainty due to bilateral pleural effusion and airway
disease affecting the interpretation of the lung scan.
.
[**11-1**] CXR: Moderate loculated left pleural effusion unchanged
since [**10-31**], 2:51 p.m., previously much larger following
placement of a left-sided pigtail drain unchanged in position
since prior study. Previous mild pulmonary edema has improved,
bibasilar atelectasis, more pronounced on the right, has not
cleared and small right pleural effusion has increased. Heart
size normal.
.
[**11-1**] CT Chest: Several bilateral pulmonary nodules. Extensive
right hilar adenopathy with subsequent hypoventilation of the
right lower lobe, combined with moderate mediastinal
lymphadenopathy. No obvious bone destruction. No pericardial
effusion.
.
[**11-2**] CXR: Several bilateral pulmonary nodules. Extensive right
hilar adenopathy with subsequent hypoventilation of the right
lower lobe, combined with moderate mediastinal lymphadenopathy.
No obvious bone destruction. No pericardial effusion.
.
[**11-3**] CXR: 59-year-old woman with history of metastatic melanoma
with
pleural effusion. Since yesterday, left pigtail was removed.
There is no overall change. Moderate loculated left pleural
effusion, vascular congestion, bibasilar atelectasis and small
right pleural effusion are unchanged. The study and the report
were reviewed by the staff radiologist.
.
[**11-5**] ECG: Sinus rhythm. Within normal limits.
.
[**11-5**] CXR (PA/Lat and Lat Decub): At the bases of the right lung,
no evidence of pleural effusion is seen. Newly occurred,
however, is a parenchymal opacity in the right upper lobe with
sparse air bronchograms that could be inflammatory in origin.
The large loculated pleural fluid on the left is grossly
unchanged as compared to the previous examination. Also
unchanged is a moderate related plate-like atelectasis. There is
no evidence of pneumothorax. The size of the cardiac silhouette
is unchanged.
Brief Hospital Course:
59yF with recent diagnosis of metastatic melanoma presenting
with shortness of breath, found to have metastatic spread to
lungs, pleura, and right hilar and mediastinal lymph nodes. She
was initially admitted to the interventional pulmonary/thoracic
service, where a workup for her shortness of breath (see below)
was performed; a thoracentesis was performed with improvement,
and she was transferred to the OMED service for further
management.
.
#) Metastatic melanoma. Known metastases to lungs/pleura, with
extensive chest lymphadenopathy. Patient also with headaches
more recently, and vague RUQ abdominal pain which raises concern
for additional metastases. Transferred to OMED for
administration of Taxol which was given on [**11-4**] without
complications. She was continued on steroids (5mg and 10mg
alternating days) and will receive her next dose of Taxol per
Dr. [**Last Name (STitle) **] (scheduled for follow up with him on [**11-13**]).
.
#) Dyspnea. Multiple reasons for her dyspnea, including known
metastatic disease, pleural effusions (malignant in nature),
lymphangitic spread of disease. IP did not believe talc
pleurodesis would be successful (and might be detrimental in
that she might not survive the procedure). Dyspnea improved s/p
thoracentesis. The last CXR on [**11-5**] demonstrated loculated
pleural effusions with nothing easily to take. She was continued
on nebulizers and steroids, to be tapered per Dr. [**Last Name (STitle) **] as an
outpatient.
.
#) Elevated WBC. On steroids, which could account for some of
the elevation. Infection is possible given immunocompromised
(splenectomy--which could also account for her elevated white
count). Blood and urine cultures were performed and were
negative throughout the hospitalization.
.
#) Hypertension. Held enalapril and carvedilol while in house;
she was discharged with instructions NOT to take these
medications.
.
#) Chronic pain. Patient on 300mg MS Contin [**Hospital1 **] at home per NEBH
notes, transferred from thoracics service on 260mg TID.
Continued pain medications.
.
#) Depression/Anxiety. Continue duloxetine.
Medications on Admission:
MS Contin 300 mg PO Q12H
MS IR 30mg Q8H
Lyrica 150 mg daily
Cymbalta 60 mg PO DAILY
Enalapril 10 mg PO BID
Coreg 12.5 mg PO BID
Lipitor 40 mg PO DAILY
Prednisone 15 mg daily
Provigil 100 mg daily
Discharge Medications:
1. Oxygen Therapy
Please provide continuous oxygen therapy, 6L.
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for
Depression.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for hypercholestrolemia.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*120 units* Refills:*2*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
Disp:*120 units* Refills:*0*
6. Prednisone 5 mg Tablet Sig: 1-2 Tablets PO once a day for 14
days: Please alternate between 10mg (two tablets) and 5mg (1
tablet)every other day for 14 days.
Disp:*21 Tablet(s)* Refills:*0*
7. Morphine 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID PRN as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
9. MS Contin 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day: Take with 200mg MS
contin for a total dose of 260mg TID.
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
10. MS Contin 200 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO three times a day: Please take with
1 (one) 60mg tablet for a total of 260mg every 8 hours.
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
11. Nebulizer & Compressor For Neb Device Sig: One (1)
Nebulizer unit Miscellaneous as directed: Please provide
nebulizer for medication use.
.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Metastatic Melanoma
Pleural Effusion
Anxiety
Discharge Condition:
The patient was hemodynamically stable, afebrile and without
pain at the time of discharge. She was stating 94% on 6L and
ambulatory stats ranged from 89-92%.
Discharge Instructions:
You were admitted for evaluation and treatment of shortness of
breath. You symptoms were due to the accumulation of fluid on
your lungs. This fluid was drained and your symptoms improved.
You continue to require 6L of oxygen.
.
During this hospitalization, you received Taxol, a chemotherapy
for the treatment of your melanoma. You have tolerated this
treatment well. You have been scheduled for a follow up
appointment with Dr. [**Last Name (STitle) **] on Monday, [**11-13**], at 11:00 am.
Please be sure to attend this appointment.
.
We have made several changes to your medications. First, you
have held your provigil due to concerns for a high high heart
rate. We have also dicontinued your blood pressure medications
as your blood pressures have been low. Please do not resume the
use of these medications until you discuss these changes with
Dr. [**Last Name (STitle) **].
.
We have increased your pain medication to a new dose for better
pain control. You will recieve a prescription for this at
discharge.
.
To help with your breathing, we are sending you home with a
prescription for albuterol and ipratroprium inhalers. You can
take these medications every 6 hours as needed for
wheezing/shortness of breath. You will need to complete a 2 week
taper of prednisone. Please take this and all medications as
directed.
.
Please call your doctor or seek medical attention if you develop
a fever higher than 100.3, increased shortness of breath, chest
pain, coughing up blood, nausea, vomiting, abdominal pain,
diarrhea or any other symptom of concern.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Phone: ([**Telephone/Fax (1) 33521**]
Date/Time: Monday, [**2183-11-13**]:00 am
Completed by:[**2180-12-18**]
|
[
"288.60",
"V15.82",
"V58.67",
"196.1",
"401.9",
"E932.0",
"786.3",
"197.0",
"511.81",
"249.00",
"338.3",
"518.81",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
12008, 12111
|
8045, 10155
|
380, 435
|
12200, 12362
|
3880, 8022
|
13978, 14199
|
3061, 3211
|
10402, 11985
|
12132, 12179
|
10181, 10379
|
12386, 13955
|
3226, 3861
|
286, 342
|
463, 2177
|
2792, 2891
|
2907, 3045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,118
| 117,655
|
33989
|
Discharge summary
|
report
|
Admission Date: [**2125-4-2**] Discharge Date: [**2125-4-10**]
Date of Birth: [**2047-1-17**] Sex: F
Service: CSU
PREOPERATIVE DIAGNOSES:
1. Iatrogenic injury to the thoracic aorta.
2. Pneumonia.
POSTOPERATIVE DIAGNOSES:
1. Iatrogenic injury to the thoracic aorta.
2. Pneumonia.
PROCEDURE:
1. Repair of descending thoracic aorta from iatrogenic
injury.
2. Left lower lobe bullectomy.
DATE OF OPERATION: [**2125-4-2**].
COMPLICATIONS: Respiratory failure, acute renal failure,
death.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 78 year-old lady
with past medical history significant for hypertension and
hypothyroidism as well as past surgical history significant
for appendectomy and bladder resuspension. She presented to
[**Hospital3 1443**] Hospital on [**3-23**] with shortness of breath
and weakness and was found to have bilateral pneumonia. At
the time, she was treated for the bilateral pneumonia and it
was discovered that she had significantly loculated
pneumothorax on imaging studies. Her respiratory status
worsened and she was intubated on [**2125-3-29**]. She eventually
required pressor support for presumed sepsis. On [**4-2**], at
[**Hospital3 1443**], there was an attempt to drain the large
loculated left pneumothorax by placement of a CT guided
pigtail catheter. Unfortunately, during the procedure , the
descending thoracic aorta was punctured. The patient was
transferred emergently to [**Hospital1 188**] for further evaluation and treatment. Upon arrival,
she was hypotensive to a systolic blood pressure of 70 and
was taken emergently to the operating room.
Intraoperatively, the pigtail catheter was found to be in
through the lung and in the descending thoracic aorta. The
aorta was primarily repaired and the pigtail catheter was
removed without any problems. At the same time, the thoracic
surgery team performed a left lower lobe bullectomy.
Postoperative, the course of the patient was fraught with
complications. She demonstrated extensive bilateral pulmonary
edema and required to be placed on N.O. for elevated
pulmonary pressures and in order to maintain sufficient mixed
venous saturations. Attempts to wean the N.O. initially
failed. The patient's renal function also gradually worsened
and she finally developed acute renal failure, requiring
CVVH. At the same time, she became coagulopathic and
presented with a picture of DIC. Indicative lab values are a
value of fibrinogen of 79, an INR of 4.6, PT which rose as
high as 42 and a PTT which rose as high as 60. Also
indicative was a value of D-Dimer that rose to 7183. Finally,
in the morning of [**2125-4-9**], she came off the N.O. but still
requiring high doses of Neo-Synephrine for pressor support to
maintain her blood pressure. Her condition did not improve
and in the afternoon of [**4-10**], the attending physician had [**Name Initial (PRE) **]
meeting with the family and the patient's critical condition
was discussed. The decision was made by the family for
pressor support to be withdrawn. Comfort measures were
started and the patient expired shortly thereafter. The date
of death was [**4-10**] and the time of death was 16:30 in the
evening. The medical examiner was contact[**Name (NI) **] and the case was
accepted by the medical examiner. The family also requested
an autopsy that will be performed by the pathology department
of [**Hospital1 69**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 78483**]
MEDQUIST36
D: [**2125-4-11**] 07:10:45
T: [**2125-4-11**] 07:29:48
Job#: [**Job Number 78484**]
|
[
"998.2",
"995.92",
"244.9",
"401.9",
"038.9",
"518.5",
"287.5",
"584.9",
"512.1",
"998.59",
"V09.0",
"427.31",
"482.41",
"286.6",
"E870.8",
"785.50",
"492.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.09",
"38.95",
"00.14",
"32.29",
"38.93",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
544, 3692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,511
| 164,348
|
24447
|
Discharge summary
|
report
|
Admission Date: [**2166-6-15**] Discharge Date: [**2166-7-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Fall down stairs
Major Surgical or Invasive Procedure:
s/p C3-7 posterior laminectomies and fusion
History of Present Illness:
82year old man with a past medical history significant for
cervical spondylosis, a.fib, and renal cell ca who presents [**6-15**]
with a fall at home and C3-4 cord contusion (with baseline exam
of plegic LUE, mild finger flexion in RUE, and could bend both
knees against gravity), who is now 1day postop C3-7
laminectomies/fusion and was found this am by the nurses to be
"unresponsive."
He arrived on [**6-15**] after a fall down stairs. Per the family, the
patient had just climbed to the top of the stairs carrying "lots
of tools" and "went to turn on the light switch" and fell
backwards down stairs. Family reports that pt complained of
"dizziness" just prior to fall. They also report that pt says he
knew he was falling, but was unable to catch himself. Family
believed there was no LOC, but there are other reports in the
notes that pt had syncope prior to fall. INR on arrival was 2.4,
there was small SAH in right parietal lobe on arrival. He was
given high dose steriods for acute cord injury. His coumadin was
stopped as well.
Medicine and cardiology consults were called for pre-op evals -
recommended bp control (hydral and lopressor for sbp > 160, and
aspirin post-op.
Patient underwent laminectomy yesterday, arriving in the PACU at
1pm, course unremarkable and transferred back to floor. Per
nursing was interactive, talking. Last seen at baseline 5:30am
per nursing. Per note written at 9am, pt noted at 7:15am to be
"unresponsive to verbal command, sternal rub and noxious stimuli
to UE bilaterally. eyes deviated to the left." BP 178/76, hr 90,
rr 22, afebrile. Had not been recieving narcotics. Emergent head
ct, labs, ecg were done. No acute process seen on head ct.
Neurology called for consult.
On initial exam, pt deeply comatose, not moving spontaneously
and no following commands. Eyes were deviated to the left with
intemittent rhyhtmic twitching of RUE. Given exam, there was
concern for nonconvulsive seizures. Therefore, he was given
total of 2mg of ativan empirically, and patient became more
drowsy with eyes now rhythmically moving right and left. He was
then loaded with 20mg/kg dilantin. EEG preliminary read with
severe encephalopathy with low voltage. He is now transferred to
the neurology service.
Past Medical History:
1.a.fib, dilated cardiomyopathy
2.htn
3.left renal tumor found [**1-1**], likely renal cell carcinoma. So
far no treatment as he was deemed not candidate for nephrectomy
given cardiac status. Planned for repeat MRI in [**8-1**].
4.bph s/p turp
5.right lung nodule - stable in size for over 2yrs
6.family reports history of "tortuous" carotid with episodes of
syncope in past when he turned head to right- was on
dilantin/phenobarbital per family. per family no history of
seizures.
7. family reports personality change ~2 years ago, with pt
becoming short-tempered, wanting to stay home all the time.
Social History:
per notes, has not smoked in >25yrs but used to smoke 3ppd for
35yrs. "very rare EtOH." is married.
Family History:
mother died in childbirth, father died at age 78 of MI.
Physical Exam:
Tm 99.8; BP 122-184/46-70s; HR 74-90; RR 16-22; O2 sat 95-100%
on 3L
gen - lying in bed, no acute distress.
heent - mmm. o/p clear. no scleral icterus or injection.
neck - supple. no lad or carotid bruits appreciated.
lungs - somewhat coarse bilaterally anteriorly with lots of
upper airway sounds
heart - irreg irreg, nl s1/s2
abd - soft, nt/nd, nabs
ext - warm, 2+ peripheral pulses throughout. no edema.
neurologic:
MS: deeply comatose, lying in bed. not following commands. not
moving spontaneously.
CN: PERRL 2-->1 mm. intact corneals. eyes midline. no VOR.
grimaces to painful stimuli though not vigorously and face
appears symmetric.
Motor: bends both knees to painful stimuli. minimal flexion of
upper extremities to pain.
Reflexes: toes upgoing bilaterally. DTRs normal and symmetric.
Sensation: minimal grimace/arousal to noxious in arms, triple
flexion in legs
Coordination & Gait: unable to assess given mental status
Pertinent Results:
wbc 12.6 hct 30.3 plt 158
pt 17.2 ptt 28.5 inr 2.0
Na 144 K 4.2 Cl 115 CO2 21 BUN 52 Cr 1.2 glucose 156
Ca 8.1 PO4 3.0 Mg 2.2
ALT 25
AST 29
Head CT ([**6-23**]): Remote infarcts in the mid right frontal lobe
and in the right basal ganglia. There is no evidence of acute
mass effect, hemorrhage, or displacement of normally midline
structures. There is no evidence of a focal extra-axial lesion
or fluid collection. Ventricles and sulci are mildly prominent,
consistent with mild brain atrophy, unchanged from prior study
CT C/T/L-spine: The vertebral body heights are preserved. There
are extensive degenerative changes, especially at the C4 through
C6 levels with disk space narrowing. The bones are severely
osteopenic, multiple lytic areas. Visualized spinal cord is
unremarkable. There is soft tissue swelling in the prevertebral
soft tissues. This could represent ligamentous injury.
Compression fracture T-7, probably remote. Healed or healing
fractures of multiple right sided ribs. Paget's disease L-1.
Extensive Paget's disease involving the pelvis and lumbar spine.
A left renal mass is visualized, measuring 2.5 x 3.3 cm. There
is a large right renal cyst. Extensive aortic calcification is
noted.
MRI C-spine: High signal in the cord at C3-4 is suspicious for a
contusion. There is also high signal along the anterior aspect
of C3 that may represent tearing of the anterior longitudinal
ligament. This is consistent with the swelling of the
prevertebral soft tissues and the apparent hematoma in this
location. Also degenerative changes at multiple levels.
MRI Head: No acute stroke. Old infarction right frontal lobe.
Periventricular white matter chronic ischemic changes. Focus of
increased susceptibility in the left temporal lobe, which, in
the absence of acute blood products on the CT of the same day,
represents a site of old hemorrhage. There is no mass effect or
shift of normally midline structures. There are normal flow
voids in the vasculature. The surrounding soft tissue and
osseous structures appear unremarkable
Brief Hospital Course:
A/P: The patient is an 82yo man with a h/o a.fib, htn, and
cervical spondylosis who p/w fall down stairs, and C3-4 cord
contusion. One day s/p cervical laminectomies and C3-C7 fusion
pt was found non-response. An MR head revealed new left MCA
stroke. Pt has had limited neurologic function since that time.
1. Injuries s/p fall: In the ED, the pt's head CT showed focal
linear hypodensity in R superior parietal region c/w small
subdural hematoma (MRI head negative for ischemic event). MRI
C-spine showed increased signal C3-4 c/w cord contusion/edema,
given dx of central cord syndrome, Coumadin d/ced, and pt was
started on steroids in ED. Pt was ruled out for MI on admission
and continued on steroids. He was transferred from SICU to floor
on [**6-18**] where pt was cleared by cardiology perspective for C3-C7
laminectomy except BP diff to control on hydralazine, clonidine,
and lopressor. On [**6-22**], had C3-C7 fusion and laminectomy.
2. CVA: On [**6-23**] am, pt was found unresponsive to voice, sternal
rub and only moderately responsive to noxious stimuli, eyes
deviated to left per notes, right leg twitching was noted by
neuro resident. His EKG was negative for changes, cardiac
enzymes negative. Head CT without contrast was negative for
bleed, though atrophy and old R frontal infarct, no acute
pathology. Differential dx at that time included ?embolic vs
hemorrhagic CVA vs nonconvulsive seizures. Due to concerns for
possible nonconvulsive status epilepticus, he was given 2 mg
ativan and dilantin load with improvement in eye deviation
though as yet no significant improvement in mental status.
Neurology felt that pt may have likely had status epilepticus
possibly from old R frontal infarct or alternatively, he may
have suffered a new infarct related to his a.fib given his known
afib and need to hold coumadin prior to surgery (although INR
was 2.0 [**6-23**] AM). EEG prelim read with severe encephalopathy,
low voltage; recommended MRI r/o acute infarct, transferred to
neuro service. On [**6-26**] pt's MR revealed new left MCA infarct. Pt
was maintained on ASA 325 mg qd for the remainder of admission.
Following the diagnosis of CVA, pt was initially allowed
permissive high SBPs(140s-200s) to maintian perfusion. On
discharge his blood pressure was allowed to return to baseline
of 120s-140s. Throughout his admission s/p infarct, pt made
little progree regarding neurologic status. Throughout, he was
unable to follow direct commands, was unable to communicate
through vocal or non-vocal means, though occasionally he
appeared to respond to his name and withdrew t painful stimuli
in all extremities.
3. Respiratory Distress: On [**6-24**] at 9 pm, following onset of
unresponsiveness, pt noted to have increased O2 requirement -ABG
at that time 7.42/30/276, CXR with new RML and partial RLL
collapse. At midnight, pt found to have increased work of
breathing and using accessory muscles with RR high 20s with O2
sats high 80s on NRB. ABG 7.42/32/105, EKG with afib rate 102,
new TWI V6, CXR with same changes as previous with ?RUL
infiltrate, transferred to unit and intubated. Placed on AC TV
600 x16 (actually breathing at 22), FIO2 100%, PEEP 5. ABG at 2
am 7.42/27/238, lactate 1.4. Mild amt of yellowish secretions
per nursing. Pt was transferred to MICU for further management.
Pt's distress felt most likely to be [**1-29**] aspiration PNA given
pt's neurologic status/unprotected airway. His Gram stain
demonstrated 4
+ GNR and 2+ GPC in chains and pair. Sputum cultures ultimately
grew out three different isolates of GNRs. He was covered from
[**6-24**] by clindamycin 600 mg tid and levofloxacin 250 mg qd. Pt
was extubated with stabilization of respiratory status and
tolerated spontaneous breathing well.
4. FEN: Pt was NPO on admission and placed on maintenance
fluids. Pt was placed on tube feeds per nutrition
recommendations in the MICU.
5. PPx: Pt was maintained on pneumoboots and protonix throughout
his admission.
6. Dispo/Future Plan of Care: Pt's plan of care was discussed at
length during several family meetings. Meetings included members
of the both the medical and nursing staff as well as social work
and palliative care. The pt's family, including the pt's wife
(also his health care proxy), decided that a continued trial of
tube feeds via Dobhoff tube was the most appropriate next step
for his care. Pt is to be transferred to Sunny [**Hospital **] Hospice
care with NG tube in place. The family will continue to discuss
the option of removing tube feeds.
7. CODE status: Pt's code status was change from DNR/DNI to DNR,
per family and health care proxy's request.
Medications on Admission:
(at home): coumadin, atenolol
(inpatient): decadron 8mg q8hrs, cefazolin, tylenol prn,
lopressor, prontix, morphine 2mg q4hrs prn (had 3mg in PACU
before 7:30pm none since)
Discharge Disposition:
Extended Care
Facility:
Sunny Acres
Discharge Diagnosis:
Aspiration PNA/L MCA infarct
Discharge Condition:
Pt has no functional status and is completely dependent on the
care of others.
Discharge Instructions:
Pt to be transfered to Hospice ECF where he will be continued on
tube feeds. His code status is DNR.
Followup Instructions:
Palliative care and social work at hospice.
|
[
"189.0",
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"401.9",
"852.01",
"E880.9",
"427.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.03",
"96.72",
"96.6",
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] |
icd9pcs
|
[
[
[]
]
] |
11329, 11367
|
6467, 11106
|
277, 322
|
11440, 11520
|
4381, 6444
|
11669, 11716
|
3352, 3410
|
11388, 11419
|
11132, 11306
|
11544, 11646
|
3425, 4362
|
221, 239
|
350, 2593
|
2615, 3218
|
3234, 3336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,051
| 184,534
|
3
|
Discharge summary
|
report
|
Admission Date: [**2172-3-26**] Discharge Date: [**2172-4-23**]
Date of Birth: [**2109-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Febrile, unresponsive--> GBS meningitis and bacteremia
Major Surgical or Invasive Procedure:
1. Rigid bronchoscopy, debridement, T-tube placement.
2. Baclofen Pump Removal.
3. RUQ Hematoma Evacuation.
4. Percutaneous Gastrostomy Tube.
5. Left Antecubital PICC Line.
History of Present Illness:
Ms. [**Known lastname 31**] is a 62 y.o. woman with primary progressive MS
[**Name13 (STitle) 32**] in [**2143**] with spasticity s/p intrathecal baclofen pump
placment in '[**64**], s/p tracheostomy in '[**65**] [**1-8**] to chronic
respiratory weakness, recurrent UTIs, aspiration PNAs, who
presents after being found to be febrile and unresponsive at her
nursing home. According to notes from [**Hospital6 33**], the
pt was found at her nursing home yesterday ([**3-26**]) AM, shaking
her head repeatedly, subsequently becoming obtunded (presumed
seizure). She was taken by EMS to [**Hospital1 34**] ED.
.
In the ED at [**Name (NI) 34**], pts vitals were: Tm 103.6, HR 110-150s RR
12-18 SaO2 98-99%NRB. Soon after, pt supposedly seized in the
ED, was given Ativan, Ambu'd and subsequently placed on SIMV
ventilation. Pt was empirically started on Vancomycin, Levoquin,
Ceftriaxone, Bactrim and Acyclovir. On exam, it was noted that
the skin overlying the baclofen pump (RUQ) appeared inflamed.
Labs were notable for a WBC of 25 with 68%polys and a bandemia
of 20%. U/A with 50-100 WBC, +leukocyte esterase, +nitrite. LP
was performed and CSF analysis showed 7,250 WBCs with 92% polys,
glucose 10, TP 1440, and gm stain with many polys, few gm+
cocci. Bcx revealed gm+ cocci in chains in [**3-9**] bottles. Micro
lab performed latex agglutination on CSF sample which was
positive for group B strep. Vanc and Ceftriaxone were dc'd and
ampicillin 2gm IV + benadryl given. Hydrocortisone 80mg was also
given. Left SC line and NGT were also placed at [**Hospital1 34**]. CXR showed
cardiomegaly but no infiltrate. Abdominal CT was negative for an
abscess or fluid collection surrounding the pump. Head CT showed
questionable changes from prior that might suggest the
possibility of a right MCA infarct. Pt was transferred directly
to the [**Hospital1 18**] MICU for further management.
Past Medical History:
PMH:
1. Chronic progressive multiple sclerosis - dx'd in [**2143**] when pt
was 34 years old; on intrathecal baclofen pump ('[**64**]) for
spasticity
2. Recurrent UTIs and hosp. for urosepsis - thought [**1-8**] to
chronic indwelling Foley catheter for neurogenic bladder. Last
admitted [**Date range (3) 35**] for urosepsis
3. Recurrent aspiration PNA - [**3-/2162**], [**10/2166**] - admitted both times
requiring MICU stay, during '[**65**] admission trach was placed
because was unable to clear secretions on her own [**1-8**] to
respiratory weakness
1/03 admitted for lingular PNA, unclear if [**1-8**] to aspiration
4. COPD
5. HTN
6. Osteoporosis
7. Scarlet fever as a child
8. Chronic constipation
9. Hx of sacral decubitus ulcer
Social History:
Social History: Pt is widowed. She has no children. She
currently lives in a nursing home. Has been there since '[**65**]? She
has no hx of smoking, EtOH, IVDU. Will call sister tomorrow for
more information.
Family History:
Noncontributory
Physical Exam:
PE: VS P 123 BP 129/73 O2Sat 97% on mechanical vent FiO2 0.50,
550, 15/5
General: older white female being mech ventilated through
tracheostomy
HEENT: pupils equal and reactive to light bilaterally 5-->3mm,
MMM, trach site clean, attempted to bend pt's neck but remained
stiff, unclear if that was volitional
Chest: coarse breath sounds throughout
Cardiac: sinus tach nl s1, s2, no s3, s4, no murmur appreciated
Abd: soft, obese, distended +bowel sounds throughout; in RUQ,
can appreciate outline of intrathecal baclofen pump, overlying
skin appears mildly erythematous, feels warm to touch, but then
again she feels warm to touch over the rest of her abdomen,
erythema appears localized to skin overlying pump, no streaking.
Ext: cool feet, faint DPs, legs appear thin and wizened.
Neuro: Brisk reflexes RLE, unable to elicit on left side. Pt
with Babinski bilaterally. Withdraws occasionally to noxious
stimuli. Does not respond to verbal stimuli.
Pertinent Results:
** admit labs **
[**2172-3-26**] 10:22PM LACTATE-2.4*
[**2172-3-26**] 10:15PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-264*
CK(CPK)-140 ALK PHOS-87 AMYLASE-214* TOT BILI-0.1
[**2172-3-26**] 10:15PM LIPASE-20
[**2172-3-26**] 10:15PM ALBUMIN-3.6 CALCIUM-8.6 PHOSPHATE-2.0*
MAGNESIUM-1.6 IRON-13*
[**2172-3-26**] 10:15PM calTIBC-265 VIT B12-428 FOLATE-17.0
FERRITIN-434* TRF-204
[**2172-3-26**] 10:15PM WBC-39.6*# RBC-3.35* HGB-10.0* HCT-30.1*
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.4
[**2172-3-26**] 10:15PM NEUTS-83* BANDS-9* LYMPHS-4* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2172-3-26**] 10:15PM PLT SMR-NORMAL PLT COUNT-517*#
[**2172-3-26**] 10:15PM PT-15.5* PTT-30.5 INR(PT)-1.5
[**2172-3-26**] 10:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2172-3-26**] 10:15PM URINE RBC-[**2-8**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-<1
.
** micro **
all blood cx no growth
.
GRAM STAIN (Final [**2172-4-6**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2172-4-9**]):
>100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
-STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci
-NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. pan [**Last Name (un) 36**] (except
bactrim)
.
TTE on admission:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. No obvious mass or vegetation seen.
.
CT abd post-op:
1) Large hematoma in the superficial tissues of the right upper
quadrant with associated edema and tracking into the abdominal
wall. No extension into the peritoneal space is seen. The
covering intern was notified by telephone at 10:30 a.m. on [**3-28**], [**2171**].
2) Gallbladder with dense material . this could represent
stones, sludge or vicarious excretion of iv contrast. If
clinically indicated, an ultrasound can be obtained for further
characterization.
3) Bilateral small kidneys with small nonobstructing stones.
4) Atelectasis and small pleural effusions at both lung bases.
.
EEG [**2172-3-28**]: This is a markedly abnormal portable EEG due to the
presence of generalized bursts of polymorphic disorganized
slowing
followed by periods of suppression. In addition, there were
independent
bifrontal sharp slow waves seen. This finding suggests deep,
midline
subcortical dysfunction and is consistent with a severe
encephalopathy.
A repeat EEG may be helpful to further evaluate the severity of
the encephalopathy.
.
EEG [**2172-3-31**]: This is an abnormal portable EEG obtained in stage
II sleep
with brief periods of drowsiness due to the presence of
intermittent and
independent shifting slowing in the parasagital region on both
sides.
This finding suggests deep, midline subcortical dysfunction and
is
consistent with the diagnosis of meningoencephalitis. In
addition,
exessive drowsiness was seen, perhaps also related to the
underlying
infection.
.
MRI [**4-4**]: Increased signal along the occipital horns could be
due to cellular debris from meningitis. No evidence of acute
infarct seen. Mild to moderate ventriculomegaly indicating mild
communicating hydrocephalus.
.
MRV [**4-4**]: The head MRV demonstrates normal flow signal in the
superior sagittal and transverse sinus without evidence of
thrombosis. Deep venous system also demonstrates normal flow
signal.
.
MRA [**4-4**]: Somewhat limited MRA of the head due to motion. No
evidence of vascular occlusion seen.
.
TEE:
1.The left atrium is normal in size.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve.
6.The mitral valve appears structurally normal with trivial
mitral
regurgitation. No mass or vegetation is seen on the mitral
valve.
7.There is a trivial/physiologic pericardial effusion.
.
Head CT [**4-7**]: Stable appearance of the ventricles and sulci.
Brief Hospital Course:
1. GBS meningitis/bactermia
In the unit, the pt was continued on Ampicillin and started on
Gentamicin (for synergy). Her intrathecal baclofen pump was
thought to be infected (on exam, erythema and warmth overlying
pump in RUQ). Pt went to surgery to have pump removed and the
operation appeared to be without complication. The following
day, pt had 11 point hematocrit drop and was noted to be
hypotensive with an SBP of 70. After spiking a temp, it was
thought that she might be septic. She was given fluids, PRBCs,
FFP, and placed on Levophed. Abd CT demonstrated a 7 x 13x 11 cm
hematoma in the RUQ at the former pump site. Pt was taken
emergently to surgery where the hematoma was evacuated, slow
ooze noted, and the bleeding vessel cauterized. She returned to
the floor and remained hemodynamically stable. Given 1
additional unit of PRBCs. Her hct bumped appropriately and
remained in the high 20s for the rest of her unit course. Pt
developed erythematous macular rash on face, arms, knees thought
to be [**1-8**] to PCN allergy. Amp was d/c'd and replaced briefly
with Vanc and then changed permanently to Cefrtriaxone. Repeat
LP was performed since the pt continued to be minimially
responsive (withdrawing to pain, occ. opening eyes to name). CSF
analysis showed a resolving bacterial meningitis. Prior to
leaving the unit, pt spiked a temp to 101.2. She was pancultured
and all cultures were negative. A TTE ruled out endocarditis in
the setting of group B strep bacteremia. On day #12 of
gentamycin, pt was changed to vanc/ceftaz for the completion of
her treatment course.
.
2. RUQ Hematoma: As above, after the removal of the baclofen
pump, pt had a hct drop and hypotensive episode and was found to
be bleeding into the RUQ pocket. She was taken to the OR for
emergent evacuation of the hematoma. On POD #16, pt was noted
to have oozing from the a site above the stitches in her RUQ.
Neurosurgery was reconsulted and they recommended an abdominal
ultrasound which showed vast improvement in the RUQ hematoma but
found a new fluid collection. Surgery was consulted and they
diagnosed a seroma and recommended conservative management given
that it had no signs of infection.
.
3. Pneumonia:
Towards the end of the pt's ICU stay, she was evaluated by
speech and swallow and she had a very difficult time with the
passy-muir valve. She underwent bronchoscopy and BAL was sent
for culture. The culture returned positive for MRSA and gram
negative rods (not pseudomonas). She was started on vancomycin
for MRSA and ceftaz/levaquin for double coverage of the GNR.
Once the GNR sensitivities showed that it was not pseudomonas,
ceftaz was stopped. Of note, pt had vancomycin troughs that
were persistently high. Vancomycin troughs should be checked
often and vanc should be adjusted for a level<15. After the
pt's swallowing study, she was noted to have increased
secretions and some food particles were suctioned up so it was
assumed that the pt aspirated. That day she also spiked a
temperature to 100 so Flagyl was added for anaerobic coverage.
Vancomycin and Levaquin will be finished on [**4-20**] (14-day course)
and Flagyl's course will be complete on [**4-24**] (after 10 days).
.
4. Supraglottic edema
As above, pt was evaluated by interventional pulmonary after she
failed a passy-muir valve. On bronchoscopy it was noted that
she had severe supraglottic edema with grabulation tissue and
the vocal cords could only be minimally visualized. She was
taken to the OR two days later for a rigid bronchoscopy where
her granulation tissue was debrided and a t-tube was placed.
ENT evaluated the patient and recommended a CT of the trachea to
evaluate her anatomy. The CT showed tracheal bronchomalacia and
narrowing of the glottic and subglottic airway. Ideally, she
will get surgery by ENT to improve her subglottic edema when the
patient has recovered from her acute illnesses.
.
5. Anemia: Iron studies indicate anemia of chronic disease.
Pt's baseline hct is between 26 and 29 and except for the hct
drop after the bleed in the RUQ pocket, pt's hct remained
stable.
.
6. Multiple sclerosis
Pt started on oral baclofen prior to pump removal. She was
without signs of baclofen withdrawal (i.e. incr HR, temp, BP,
seizures) once pump was removed. She continued on Baclofen 20mg
qid po with an Ativan taper. PO baclofen was then tapered to
20mg tid.
.
7. Mental status
At baseline, although pt is significantly debilitated by MS, she
is alert, oriented, and conversant. Her decreased responsiveness
was thought to be [**1-8**] to meningitis, but although pt seemed to
have resolving temp and WBC with Abx, her diminished
reponsiveness persisted. Repeat LP in the unit suggested a
resolving meningitis. Neurology was following the pt and
recommended an MRI to rule out stroke (esp given her ? of stroke
at OSH) an MRV to rule out sinus thrombosis and an EEG to rule
out subclinical seizures. An EEG on HD #3 was consistent with
severe encephalopathy and an EEG on HD #6 was consistent with
meningoencephalitis with no evidence of seizures. An MRI was
finally done on HD #10 and showed mild communicating
hydrocephalus, no evidence of cavernous thrombosis or stroke.
Towards the end of her unit stay pt opened eyes to name and
eventually returned to her baseline mental status. Pt's mental
status remained at baseline and pt will follow-up with neurology
as an outpatient.
.
8. Respiratory status
After a supposed seizure at OSH pt was mechanically ventilated
thru her trach site b/c no breath sounds were appreciated. (At
baseline, pt has respiratory weakeness 2/2 to multiple sclerosis
but does not require mechical ventilation. Trach in place to
help with clearance of secretions.) Pt placed on A/C in unit,
then transferred to CPAP and eventually placed on a trach mask
with good results. At time of discharge, she was satting well
on 40% trach mask.
.
9. HTN
In unit, pt initially normotensive, then mid-way through stay
became hypertensive with SBPs in the 150-170s. Pt has hx of
hypertension. Unclear whether BP was rebounding from baclofen
d/c. BP became well-controlled with systolic BP in the 90s-110s
on standing doses of Lisinopril 20mg po, Metoprolol 25mg [**Hospital1 **].
.
10. Sacral decub ulcer: Stage 1-2. Wound care nurse followed
while pt was in-house.
.
11. FEN: During pt's acute illness, she had an NGT placed.
Speech and swallow evaluated the pt and recommended thin liquids
and pureed food. The following day, she was noted to have soup
coming out of her trach so she was again made NPO. Pt then
passed the video swallow but again had some signs of aspiration
after trying some ground solids. She was made NPO and GI placed
a PEG for feeding. Pt should remain on tube feeds until her
tracheal swelling is much improved. At that point, another
swallowing study can be performed and another trial of po
feeding.
.
12. Code: DNR/DNI
Medications on Admission:
per note from [**Hospital6 33**]:
Bisacodyl 10mg
Folic acid
Vitamin B12
Gemfibrozil
Combivent 2 puff qid
Fe sulfate
Baclfen pump
Zantac 150mg qhs
Lisinopril 5mg qhs
Alprazolam 0.25 mg qhs
Oxybutynin
Discharge Medications:
1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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 DAILY (Daily) as needed.
9. Acetaminophen 160 mg/5 mL Elixir Sig: 325-650 mg PO Q4-6H
(every 4 to 6 hours) as needed.
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
11. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for SBP<100.
14. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily).
15. Lorazepam 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q8H (every
8 hours) as needed for anxiety.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every four (4) hours as needed.
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
units Subcutaneous ASDIR (AS DIRECTED) as needed for
hyperglycemia: per regular insulin sliding scale.
19. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: one
gram Intravenous Q24H (every 24 hours) for 4 days: please check
daily troughs and give dose if level<15.
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
1. Group B Streptococcal Meningoencephalitis - Stable
Hydrocephalus.
2. Group Streptococcal Bacteremia and Septicemia.
3. Infected Baclofen Pump, removal c/b hematoma and evacuation.
4. MRSA and GNR Ventilator Associated Pneumonia.
5. Subglottic stenosis s/p rigid bronchoscopy and debridement.
6. Dysphagia and Recurrent Aspiration.
7. Aspiration Pneumonia.
8. Blood Loss Anemia.
9. Stage II Sacral Decubitus Ulcer.
10. Thrush.
11. Drug rash to Ampicillin.
Secondary/Past Medical History.
1. Chronic Progressive Multiple Sclerosis.
2. Neurogenic Bladder - chronic foley catheter.
3. Chronic Obstructive Pulmonary Disease.
4. Hypertension.
5. Tracheobronchomalacia.
6. Constipation.
Discharge Condition:
good, breathing well on 40% trach mask
Discharge Instructions:
Take all medications as prescribed and go to all follow-up
appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Where: LM [**Hospital Unit Name 40**] (ENT) Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2172-5-27**] 10:00
.
Provider: [**Name10 (NameIs) 42**] [**Name11 (NameIs) 43**], MD Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2172-7-1**] 1:00
.
Please follow-up with your PCP in the next 1-2 weeks
|
[
"693.0",
"038.0",
"320.2",
"998.13",
"478.74",
"996.63",
"707.03",
"507.0",
"285.29",
"518.83",
"785.52",
"112.0",
"482.41",
"340",
"998.12",
"401.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"31.5",
"96.6",
"86.04",
"38.93",
"33.21",
"88.72",
"99.04",
"96.05",
"99.05",
"43.11",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
17935, 18042
|
8870, 15763
|
326, 501
|
18779, 18819
|
4423, 5940
|
18940, 19383
|
3420, 3437
|
16012, 17912
|
18063, 18758
|
15789, 15989
|
18843, 18917
|
3452, 4404
|
232, 288
|
529, 2416
|
5954, 8847
|
2438, 3178
|
3210, 3404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,805
| 188,991
|
46568
|
Discharge summary
|
report
|
Admission Date: [**2111-3-4**] Discharge Date: [**2111-3-12**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**Last Name (NamePattern1) 2499**]
Chief Complaint:
urinary retention
Major Surgical or Invasive Procedure:
foley placed
Central line placement
History of Present Illness:
Patient is a 88 y/o M with a invasive bladder cancer s/p
XRT/chemo, superficial bladder cancer s/p resection and BCG,
prostate cancer s/p prostatectomy but with rising PSA, and
recent urethral stricture disease s/p CKU [**8-13**], who presents
with urinary retention and rigors over the last few days. He has
been evaluated for urinary retention in the past and has had
chronic indwelling foleys.
In the ED VS were [**Age over 90 **]F, hr 121, bp 120/98 99%RA. Blood and urine
cultures were taken. Patient was given tylenol and ceftriaxone.
Patient was initially going to be admitted to the floor, but
then it was noted that repeat SBPs were in the 70s. Patient was
still mentating. RIGJ was placed. 3L NS were given.
Past Medical History:
bladder cancer
diabetes mellitus type 2
hypertension
Peptic ulcer disease
CAD: MIs in [**2091**] and again in [**2104**] with stents in place
perforated diverticulum with a colostomy x30 yers now s/p
reanastomosis.
Social History:
Retired, quit smoking 35 years ago, and drinks alcohol rarely.
Worked on real estate development. Prior to that he was a
musician.
Family History:
NC
Physical Exam:
PE: NAD, appears younger than stated age
VS: 97.5 102 84/52 on 0.15 levophed, 97% 3L
HEENT: s/p Cataracts bilaterally, PERRL, EOMI, OP dry
Neck: RIJ, no LAD
Chest: CTAB
Cardiac: tachy but regular
ABD: + BS, left abd scar
Ext: no edema, cool
Neuro: AAOx3, CN 2-12 intact. 5/5 strength throughout except
right deltoid [**4-11**]. light touch intact.
Pertinent Results:
Renal Ultrasound [**2111-3-5**]
IMPRESSION:
1. Bilateral hydronephrosis, grade 1 on the right and grade II
on the left. No proximal obstructing mass or stone is
identified.
2. Bilateral simple renal cysts.
3. Limited evaluation of the bladder due to decompression with a
Foley catheter. The bladder wall appears thickened.
.
ECHO [**2111-3-6**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. 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) 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. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
IMPRESSION: no obvious vegetations seen
.
Blood cultures x2
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ <=1 S <=1 S
.
Creatinine 2.6 -> 2.6 -> 2.6 -> 2.1 -> 1.6 -> 1.3 -> 1.2 -> 1.3
-> 1.1
Brief Hospital Course:
MICU course: Patient arrived with systolic pressures in the 90s
on low dose of pressors. An art line was placed. He was started
on vancomycin. Urology was consulted and initially recommended
outpt follow up. Patient was weaned off of pressors on [**3-5**] in
the am. Renal u/s showed bilateral hydronephrosis. His blood
cultures grew Coagulase negative staph. He was hemodynamically
stable for >48 hours off of pressors and transfered to the
oncology service.
.
Oncology Course:
Coag negative Staph: Pt remained afebrile and stable white count
on the floor. He had a PICC placed for IV vanco infusion for
total of 14 days.
.
Acute Renal Failure: Pt had acute renal failure likely both post
renal and prerenal. He has prostate CA, and hydronephrosis on
ultrasound. Prerenal causes more likely considering his
hypotension while in the MICU. This was monitored and resolved.
.
Urinary complaints: patient has had problems with urinary
dribbling and retention in the past. Here had a foley placed and
will be discharged with it per urology and follow up with
urology as an outpatient.
.
Bright Red Blood Per Rectum: on [**2111-3-10**] AM, patient had bright
red blood per rectum. He got out of bed and on his way to the
bathroom had red blood puddled on the floor. No pain. This has
happened one time in the past, but with red blood in the toilet.
This is likely a result of know radiation proctitis (on
colonoscopy [**7-13**]). Also has internal hemorrhoids that may
contribute. GI was called and recommened sigmoidoscopy with
argon gamma ablation only if it recurrs, which it did not. He
remained hemodynamically stable and maintained his hct.
Medications on Admission:
glipizide, vicodin, hyrdrocort 30 qam 10 q pm, ketoconaazole 400
[**Hospital1 **], crestor, zoloft , lupron given recently.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Hydrocortisone 20 mg Tablet Sig: 1.5 Tablets PO QAM (once a
day (in the morning)).
4. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QAFTERNOON
().
5. Ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 6 days: Please complete
on [**2111-3-18**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center Elmhurst
Discharge Diagnosis:
Primary:
Urosepsis
hypertension
radiation proctitis
bladder cancer
urethral stricture
.
SECONDARY DIAGNOSIS:
diabetes mellitus type 2
Peptic ulcer disease
CAD: MIs in [**2091**] and again in [**2104**] with stents in place
perforated diverticulum with a colostomy x30 yers now s/p
reanastomosis.
Discharge Condition:
stable, with foley catheter, ambulating with assistance, and has
returned to his baseline condition.
Discharge Instructions:
You came to the hospital with fevers and chills. You were found
to have a urinary tract infection that had [**Last Name (un) 84876**] to your blood.
You were treated with antibiotics through an IV. On discharge,
you have a more permanent IV line called a PICC line through
which you can complete your course of antibiotics at rehab.
.
You also had one episode of rectal bleeding. This was thought to
be secondary to radiation proctitis. You should make a follow up
appointment with your Gastroenterologist in the next few months
if this happens again.
.
You are also being discharged with a foley catheter. You should
keep this until your appointment with Dr. [**Last Name (STitle) **], the urologist,
scheduled for Monday [**2111-3-16**].
.
Please call your doctor or return to the hospital if you have
more fevers or chills, bleeding from your rectum or any other
concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2111-3-26**] 11:00
Please follow up with the urologist, Dr. [**Last Name (STitle) **], on Monday [**2111-3-16**]
at 9am. His clinic is in the [**Hospital Ward Name 23**] building [**Location (un) **]. If you
need to reschedule, please call his office at [**Telephone/Fax (1) 921**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2111-5-7**] 1:10
|
[
"599.0",
"569.49",
"188.8",
"185",
"401.9",
"038.19",
"455.0",
"707.03",
"584.9",
"414.01",
"788.20",
"591",
"533.90",
"250.00",
"995.91",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6374, 6435
|
3702, 5348
|
246, 284
|
6775, 6878
|
1830, 3679
|
7814, 8389
|
1442, 1446
|
5523, 6351
|
6456, 6544
|
5374, 5500
|
6902, 7791
|
1461, 1811
|
189, 208
|
312, 1038
|
6565, 6754
|
1061, 1278
|
1294, 1426
|
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