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Discharge summary
|
report
|
Admission Date: [**2149-9-12**] Discharge Date: [**2149-9-23**]
Date of Birth: [**2067-1-13**] Sex: M
Service: MEDICINE
Allergies:
Neurontin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Left 2nd toe amputation by Vascular Surgery
History of Present Illness:
(history obtained from the patient, his wife, and [**Name (NI) **])
82yo M with h/o ESRD on HD, PVD s/p multiple amputations, right
ankle septic arthritis Rxd with Vanc/CTZ until [**2149-8-15**] admitted
from dialysis with fevers and chills. Patient had episode of
right ankle septic arthritits in the spring of this year. He was
treated with washout and Vanc/CTZ for several months. The abx
were discontinued on [**2149-8-15**]. He had surveillance cultures drawn
at HD that have reportedly been negative. On Wednesday at HD (2
day PTA) the patient had low grade fevers to 100. His temp came
down to 97 after HD. Afterward the patient was extremely
fatigued and slept all day. He was scheduled to have his G-tube
placed that day but [**2-10**] his fatigue he put it off until the next
day. On the day PTA he underwent G-tube placement for a history
of chronic dysphagia and aspiration diagnosed on swallow exam.
this went smoothly and he went home. Per his wife he was much
stronger that day than the day prior.
The next am he went to his scheduled HD session. While at
dialysis he felt feverish and had a dry cough. He has not had
SOB, chest pain, abdominal pain, nausea, vomiting, diarrhea. At
HD he spiked a fever and received Vanc/Gent - cultures were
reportedly drawn prior to ABx. He was transferred to the [**Hospital1 18**]
ED.
In ED initial VS were: T: 102 BP: 101/46 -> bounced down into
80s multiple times. O2 sats 99% on [**1-10**] L NC. Initially, patient
had lactate of 7.2. He underwent an abdominal CT scan given the
recent G-tube placement however, it revealed no acute issues and
surgery consult did not feel he needed any urgent intervention.
He had a sepsis line placed in ED in RIJ and was given CFTZ,
morphine IV and 3.4L NS. His lactate improved to 1.3 with IVF.
.
Prior to transfer to the floor his VS were: HR 62 BP 95/40 RR 13
100% on 1-2L NC
.
On arrival to the floor patient c/o severe pain in his feet. He
denied abdominal pain, chest pain, nausea, vomiting, ankle pain.
He denied pleuritic pain. He did c/o dry cough for the last day
and funny looking urine although he denied dysuria and
frequency. Rest of ROS negative including no confusion, hip
pain, rash.
Past Medical History:
* ESRD on HD MWF via L AVF since [**2-/2149**] , now had L fem tunn
cath since [**2149-8-11**]
* CAD s/p PCI x3 [**2130**], 4v CABG in [**2138**]
* HTN
* dyslipidemia
* PAD s/p aortobifem bypass, s/p multiple b/l toe amputations
* R ankle septic arthritis
* h/o of colon ca s/p partial colectomy and end to end
[**Last Name (un) **]-colonic anastomosis of the proximal sigmoid colon.
* h/o TIA
* fall with rib fractures c/b PTX with chest tube placement [**7-17**]
Social History:
no ETOH, former smoker 1 ppd X "[**Age over 90 **]years", retired police
officer. Married. Lives with wife at home.
Family History:
no h/o renal disease
Physical Exam:
VITALS: T 99.8 rectal HR75 reg BP 104/48 RR 16 O2 100% on RA
GEN: Cachectic elderly male in NAD
HEENT: NC/AT anicteric sclera Dry MM
NECK: JVP at mid-neck lying flat
LUNGS: breathing comfortably with no accessory muscle use. CTAB
posteriorly and anteriorly
HEART: midline sternotomy scar RRR no M/R/G
ABD: Scaphoid. Soft. GTube site clean, dry, no
discharge/exudate, no tenderness to palpation. No HSM. Negative
hepatojugular reflex
EXTREM: right ankle with eschar with no drainable exudate.
Several necrotic toes and most of right toes amputated with
clean scar. Left femoral line with slight surrounding erythema
and ttp along catheter site.
NEURO: A+OX3.
Pertinent Results:
[**2149-9-12**] 12:10PM BLOOD WBC-7.4 RBC-5.37# Hgb-14.6# Hct-50.2#
MCV-93 MCH-27.3 MCHC-29.2* RDW-18.3* Plt Ct-121*
[**2149-9-13**] 04:37AM BLOOD WBC-24.6*# RBC-3.95*# Hgb-10.8*#
Hct-37.3*# MCV-94 MCH-27.3 MCHC-28.9* RDW-18.8* Plt Ct-129*
[**2149-9-14**] 04:18AM BLOOD WBC-22.5* RBC-4.36* Hgb-11.9* Hct-41.6
MCV-95 MCH-27.2 MCHC-28.5* RDW-18.5* Plt Ct-141*
[**2149-9-15**] 06:01AM BLOOD WBC-14.3* RBC-4.34* Hgb-11.7* Hct-40.9
MCV-94 MCH-27.0 MCHC-28.7* RDW-19.9* Plt Ct-154
[**2149-9-16**] 05:49AM BLOOD WBC-23.6*# RBC-4.16* Hgb-11.4* Hct-38.4*
MCV-93 MCH-27.4 MCHC-29.6* RDW-19.0* Plt Ct-106*
[**2149-9-16**] 12:40PM BLOOD WBC-22.8* RBC-4.10* Hgb-11.3* Hct-38.1*
MCV-93 MCH-27.7 MCHC-29.8* RDW-18.8* Plt Ct-98*
[**2149-9-19**] 07:02AM BLOOD WBC-8.4 RBC-3.89* Hgb-10.2* Hct-35.6*
MCV-92 MCH-26.1* MCHC-28.5* RDW-20.1* Plt Ct-93*
[**2149-9-21**] 06:05AM BLOOD WBC-11.2* RBC-3.86* Hgb-11.2* Hct-36.2*
MCV-94 MCH-29.1 MCHC-31.1 RDW-19.0* Plt Ct-108*
[**2149-9-22**] 07:10AM BLOOD WBC-13.7* RBC-3.74* Hgb-10.1* Hct-34.7*
MCV-93 MCH-27.0 MCHC-29.1* RDW-21.1* Plt Ct-158
[**2149-9-23**] 05:25AM BLOOD WBC-9.1 RBC-3.27* Hgb-9.5* Hct-30.6*
MCV-93 MCH-28.9 MCHC-30.9* RDW-19.9* Plt Ct-161
[**2149-9-12**] 12:10PM BLOOD Neuts-94.0* Lymphs-2.5* Monos-2.4 Eos-0.8
Baso-0.3
[**2149-9-13**] 04:37AM BLOOD Neuts-92.6* Lymphs-4.0* Monos-3.2 Eos-0.1
Baso-0.1
[**2149-9-16**] 12:40PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Pencil-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**]
[**2149-9-18**] 05:28AM BLOOD PT-12.7 INR(PT)-1.1
[**2149-9-17**] 06:10AM BLOOD PT-13.9* INR(PT)-1.2*
[**2149-9-15**] 06:01AM BLOOD PT-13.3 PTT-35.7* INR(PT)-1.1
[**2149-9-13**] 04:37AM BLOOD PT-16.6* PTT-39.2* INR(PT)-1.5*
[**2149-9-12**] 12:10PM BLOOD PT-15.3* PTT-129.5* INR(PT)-1.3*
[**2149-9-16**] 12:40PM BLOOD Fibrino-431*#
[**2149-9-12**] 12:10PM BLOOD Glucose-82 UreaN-13 Creat-2.2* Na-146*
K-3.9 Cl-98 HCO3-30 AnGap-22*
[**2149-9-13**] 04:37AM BLOOD Glucose-36* UreaN-16 Creat-2.0* Na-144
K-4.0 Cl-113* HCO3-24 AnGap-11
[**2149-9-14**] 04:18AM BLOOD Glucose-41* UreaN-21* Creat-2.2* Na-142
K-3.8 Cl-113* HCO3-22 AnGap-11
[**2149-9-15**] 06:01AM BLOOD Glucose-99 UreaN-27* Creat-2.6* Na-140
K-3.6 Cl-111* HCO3-23 AnGap-10
[**2149-9-23**] 05:25AM BLOOD Glucose-140* UreaN-17 Creat-1.3* Na-141
K-3.7 Cl-107 HCO3-30 AnGap-8
[**2149-9-22**] 07:10AM BLOOD Glucose-140* UreaN-25* Creat-1.5* Na-142
K-3.2* Cl-106 HCO3-29 AnGap-10
[**2149-9-21**] 06:05AM BLOOD Glucose-187* UreaN-21* Creat-1.3* Na-141
K-3.1* Cl-108 HCO3-29 AnGap-7*
[**2149-9-20**] 05:11AM BLOOD Glucose-169* UreaN-29* Creat-1.7* Na-145
K-3.4 Cl-111* HCO3-27 AnGap-10
[**2149-9-15**] 06:01AM BLOOD ALT-9 AST-16 LD(LDH)-172 AlkPhos-113
TotBili-0.3
[**2149-9-12**] 12:10PM BLOOD ALT-16 AST-45* AlkPhos-161* TotBili-0.9
[**2149-9-12**] 12:10PM BLOOD Lipase-19
[**2149-9-12**] 12:10PM BLOOD Lipase-19
[**2149-9-23**] 05:25AM BLOOD Calcium-7.5* Phos-1.7* Mg-1.4*
[**2149-9-22**] 07:10AM BLOOD Calcium-8.1* Phos-1.5* Mg-1.8
[**2149-9-22**] 07:10AM BLOOD Calcium-8.1* Phos-1.5* Mg-1.8
[**2149-9-21**] 06:05AM BLOOD Calcium-7.7* Phos-1.3* Mg-2.1
[**2149-9-12**] 12:10PM BLOOD Calcium-8.6 Phos-2.0*# Mg-1.4*
[**2149-9-12**] 10:45PM BLOOD Calcium-7.0* Phos-3.5 Mg-1.2*
[**2149-9-13**] 04:37AM BLOOD Calcium-6.6* Phos-3.4 Mg-2.4
[**2149-9-14**] 04:18AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.1
[**2149-9-15**] 06:01AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.1
[**2149-9-16**] 12:40PM BLOOD D-Dimer-4622*
[**2149-9-15**] 06:01AM BLOOD TSH-0.99
[**2149-9-14**] 04:18AM BLOOD PTH-64
[**2149-9-13**] 04:55AM BLOOD Temp-36.1 O2 Flow-1 pO2-46* pCO2-55*
pH-7.30* calTCO2-28 Base XS-0
[**2149-9-12**] 03:53PM BLOOD Type-MIX pO2-87 pCO2-46* pH-7.39
calTCO2-29 Base XS-1 Intubat-NOT INTUBA
[**2149-9-12**] 12:26PM BLOOD Lactate-7.2* K-4.3
[**2149-9-12**] 03:53PM BLOOD Lactate-1.9
[**2149-9-12**] 05:45PM BLOOD Lactate-1.3
[**2149-9-13**] 04:55AM BLOOD Lactate-1.2
[**2149-9-22**] 08:24PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2149-9-19**] 04:09PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2149-9-12**] 02:35PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2149-9-15**] 06:01AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.026
[**2149-9-12**] 02:35PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-MOD
[**2149-9-15**] 06:01AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2149-9-19**] 04:09PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2149-9-22**] 08:24PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2149-9-12**] 02:35PM URINE RBC-[**6-18**]* WBC->50 Bacteri-MOD Yeast-MOD
Epi-[**3-13**]
[**2149-9-15**] 06:01AM URINE RBC-21-50* WBC-21-50* Bacteri-MOD
Yeast-MANY Epi-0-2
[**2149-9-19**] 04:09PM URINE RBC-14* WBC-92* Bacteri-FEW Yeast-NONE
Epi-<1
[**2149-9-22**] 08:24PM URINE RBC-17* WBC-18* Bacteri-NONE Yeast-NONE
Epi-0
[**2149-9-22**] 08:24PM URINE CastHy-11*
[**2149-9-12**] 12:30 pm BLOOD CULTURE
**FINAL REPORT [**2149-9-18**]**
Blood Culture, Routine (Final [**2149-9-18**]):
ENTEROBACTERIACEAE. UNABLE TO IDENTIFY FURTHER.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTERIACEAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2149-9-13**]): GRAM
NEGATIVE ROD(S).
[**2149-9-15**] 10:20 am BLOOD CULTURE
**FINAL REPORT [**2149-9-21**]**
Blood Culture, Routine (Final [**2149-9-21**]):
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2149-9-18**]): GRAM NEGATIVE
ROD(S).
[**2149-9-15**] 9:12 pm CATHETER TIP-IV Source: HD tunnelled line
tip.
**FINAL REPORT [**2149-9-17**]**
WOUND CULTURE (Final [**2149-9-17**]): No significant growth.
[**2149-9-18**] 5:28 am BLOOD CULTURE Source: Line-central.
**FINAL REPORT [**2149-9-24**]**
Blood Culture, Routine (Final [**2149-9-24**]): NO GROWTH.
[**2149-9-22**] 8:24 pm URINE Source: CVS.
**FINAL REPORT [**2149-9-23**]**
URINE CULTURE (Final [**2149-9-23**]): NO GROWTH.
[**2149-9-23**] 5:25 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS SP..
Aerobic Bottle Gram Stain (Final [**2149-9-24**]):
REPORTED BY PHONE TO DR. [**First Name (STitle) **] [**Doctor Last Name **] PAGER# [**Serial Number 56165**] @
0139 ON
[**2149-9-24**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**Known lastname **],[**Known firstname **] A [**Medical Record Number 97972**] M 82 [**2067-1-13**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2149-9-12**]
12:08 PM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2149-9-12**] 12:08 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 97973**]
Reason: Eval pneumonia
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with ? fevers
REASON FOR THIS EXAMINATION:
Eval pneumonia
Final Report
REASON FOR EXAM: Fever.
COMPARISON: Chest radiograph from [**2149-8-7**].
SINGLE FRONTAL VIEW OF THE CHEST: Thin linear lucencies adjacent
to the liver
likely represent pneumoperitoneum as seen on subsequent CT.
Femoral
hemodialysis catheter is partially seen. Sternotomy wires and
CABG post-
operative changes are seen. The lungs are hyperinflated with
flattening of
bilateral diaphragms consistent with COPD. No focal
consolidation, congestive
heart failure, pneumothorax or pleural effusion is seen. A few
left-sided rib
fractures appear stable as compared to prior exam. The heart is
not enlarged.
The aorta is calcified and tortuous. The bones are osteopenic.
IMPRESSION:
No focal consolidation.
Thin linear lucencies adjacent to the liver likely represent
free air seen on
subsequent CT. Please refer to report on subsequent CT.
Findings consistent with COPD.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 3247**] [**Name (STitle) 3248**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2483**]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: WED [**2149-9-17**] 2:41 PM
Imaging Lab
[**Known lastname **],[**Known firstname **] A [**Medical Record Number 97972**] M 82 [**2067-1-13**]
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2149-9-12**]
12:59 PM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2149-9-12**] 12:59 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # [**Clip Number (Radiology) 97974**]
Reason: Eval abscess, AAA, acute process
Contrast: OPTIRAY Amt: 130
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with back pain and possible fevers, recent G
tube placed
yesterday
REASON FOR THIS EXAMINATION:
Eval abscess, AAA, acute process
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SHfd FRI [**2149-9-12**] 1:58 PM
Small pneumoperitoneum
G tube baloon likely in the stomach.
Left perinephric stranding and small amount of fluid. Multiple
non-emergent
findings in final report.
Bowel wall enhancement maybe secondary to hypoperfusion.
Wet Read Audit # 1 SHfd FRI [**2149-9-12**] 1:36 PM
Small pneumoperitoneum
G tube baloon likely in the stomach.
Multiple non-emergent findings in final report.
Final Report
REASON FOR EXAM: Abdominal pain. Status post gastric tube
placement
approximately 24 hours ago.
COMPARISON: CT abdomen and pelvis from [**2140-12-28**], [**6-23**], [**2140**]. CTA
aorta [**2149-7-31**].
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were obtained
after administration of IV contrast. Coronal and sagittal
reformatted images
were also submitted for interpretation.
FINDINGS:
CT ABDOMEN WITH IV CONTRAST: The lung bases demonstrate
emphysematous and
chronic fibrotic changes. The heart is not enlarged. There is no
pericardial
effusion. Small amount of pneumoperitoneum mostly in the upper
abdomen is
seen. Too small to characterize hypodensities in the dome of the
liver are
new since [**2139-8-25**]. The gallbladder is unremarkable. A
focal wedge-
shaped hypodensity in the posterior aspect of the spleen with
punctate
calcification may represent prior trauma. The pancreas is fatty
infiltrated.
Multiple bilateral renal cysts are grossly stable since prior
exam. There has
been interval increase in perinephric stranding and fluid on the
left side.
Extensive atherosclerotic disease of the aorta and iliac vessels
is seen. The
patient is status post aortobifem bypass. Atherosclerotic
calcifications at
the origin of patent celiac and superior mesenteric arteries are
seen. A
hemodialysis catheter extending from the left femoral vein to
the junction of
the inferior vena cava and right atrium is seen. There is no
lymphadenopathy.
PELVIC CT WITH IV CONTRAST: The urinary bladder contains a Foley
catheter.
The prostate gland measures 4.8 cm in transverse diameter,
mildly enlarged.
GI TRACT: Contrast within the colon likely represents barium
from prior
esophagogram from [**2149-9-4**]. There is no bowel
obstruction. Mucosal
enhancement of the wall of the stomach and small bowel may
represent
hypoperfusion. No wall thickening is seen. There is a gastric
tube with the
tip within the stomach.
OSSEOUS STRUCTURES: Severe osteopenia and degenerative changes
with no acute
fracture are seen.
IMPRESSION:
Small amount of pneumoperitoneum, especially within the superior
aspect of the
abdomen, likely secondary to recent gastric tube placement.
Gastric tube tip
is within the stomach.
New left perirenal fluid and stranding is of unclear etiology,
could perhaps
be due to a recently passed stone.
Gastric and small bowel wall enhancement may be related to
hypoperfusion.
Clinical correlation is recommended.
Too small to characterize hypodensities in the dome of the liver
are new since
[**2139-8-25**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 3247**] [**Name (STitle) 3248**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2483**]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: WED [**2149-9-17**] 2:41 PM
Imaging Lab
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 97975**],[**Known firstname **] A [**2067-1-13**] 82 Male
[**-9/3570**] [**Numeric Identifier 97976**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mtd
SPECIMEN SUBMITTED: second toe.
Procedure date Tissue received Report Date Diagnosed
by
[**2149-9-18**] [**2149-9-18**] [**2149-9-24**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **],DR. [**Last Name (STitle) **].
[**Doctor Last Name 15706**]/ttl
Previous biopsies: [**-9/3297**] GI BIOPSIES (3 JARS)
[**Numeric Identifier 97977**] Right second toe.
[**-5/3480**] EGD
[**-3/4353**] GI BX.
(and more)
DIAGNOSIS:
Amputation, second left toe:
1. Gangrenous necrosis and acute inflammation involving skin,
subcutaneous soft tissue, and underlying bone.
2. Bony and soft tissue resection margin free of necrosis and
acute inflammation.
Clinical: Second toe.
Gross:
The specimen is received fresh labeled "[**Known lastname 3647**], [**Known firstname 122**] A" with
the medical record number and additionally labeled "left second
toe". The specimen is an ulcerated gangrenous toe that measures
3.9 x 1.7 x 2.2 cm. The toe has a dark gangrenous area at the
most distal end of the toe, which measures approximately 1.4 x
1.6 cm . The nail is fragmented. Immediately proximal to the
gangrenous area is an area of ulceration with circumferential
necrosis. This area measures 1.7 x 1.5 cm and the underlying
bone is seen. The resection margin has pink healthy soft tissue.
The specimen is represented as follows: A = samples of
gangrenous area with abutting non gangrenous tissues, B =
necrotic ulcerated area, C = soft tissue margin, D = bone
underlying necrotic area with attached tendon, E = bony margin.
D and E are submitted for decalcification.
By his/her signature above, the senior physician certifies that
he/she personally conducted a gross and/or microscopic
examination of the described specimens(s) and rendered or
confirmed the diagnosis(es) related thereto.
Immunohistochemistry test(s), if applicable, were developed and
their performance characteristics were determined by The
Department of Pathology at [**Hospital1 69**],
[**Location (un) 86**], MA. They have not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined that such
clearance or approval is not necessary. These tests are used for
clinical purposes. They should not be regarded as
investigational or for research. This laboratory is certified
under the Clinical Laboratory Improvement Amendments of [**2128**]
(CLIA - 88) as qualified to perform high complexity clinical
laboratory testing.
Brief Hospital Course:
#. Sepsis: Patient presented after spiking fevers at dialysis.
On presentation the patient was found to be in sepsis with
multiple possible sources of infection. He was given IV fluids
and admitted to the CCU. He was started empirically on Cefepime
and vancomycin. His blood cultures subsequently grew
Enterobacteriaceae that was sensitive to cefepime and vacomycin
was stopped. The most likely source was thought to be his left
groin HD line as he was only having fevers during HD. His line
was kept in until [**2149-9-15**] when he had a temp of 100 during HD.
Blood cultures from [**2149-9-15**] subseaquently grew Stenotrophomonas
that was sensitive to bactrim. He was then started on bactrim.
Patient remained stable and afebrile through admission. He was
discharged with a prescription to finish a 14 day course of
cefepime and another 14 days of bactrim. On the day after he
discharged blood cultures grew Enterococcus sp. this was
informed to Dr. [**Last Name (STitle) **] who is going to inform Dr. [**Last Name (STitle) 2204**] about
this finding so it can be addressed as an outpatient.
.
#. PVD: Patient has severe PVD with multiple toe amputations in
the past and gangrenous toes currently. He had persistent pain
on his left foot needing IV morphine. He underwent vascular
surgery for L 2nd toe amputation on [**2149-9-18**] with resolution of
his pain. He did well post-op and was able to ambulate on
post-op day 2.
.
#. Nutrition: Patient with long history of dysphagia accompanied
by severe reflux. PEG placed on [**9-11**] on he was started on tube
feeds for nutrition. He was continued on these throughout
admission and discharged with a prescription to continue these
at home.
.
#. Hypophosphatemia: Patient was found to be hypophosphatemic on
the last few days of his admission. This was aggressively
repleted. He was discharge with a prescription for neutraphos
that he was to take everyday until his phosphate was rechecked
as an outpatient.
.
#. Thrombocytopenia: Patient's platelet count decreased
throughout admission. It was lowest at 93 in [**2149-9-19**]. It was 161
on the day of discharge.
.
#. Erythrocytosis/Anemia: Patient was found to have
erythrocytosis, Hct 50.2, on admission. This resolved after IVF
and it was thought to be due to dehydration and
hemoconcentration. Subsequently his Hct decreased and it
stabilized around mid 30s. This was thought to be anemia of
chronic disease and also due to ESRD. No obvious source of bleed
was found, his Hct was 30 on discharge.
.
#. ESRD on HD: Patient was MWF schedule on admission. He
continued to receive HD as scheduled but missed a day while he
was on a 48hr line free period after his groin line was taken
out.
.
#. HTN: Patient had low blood pressure on admission and his
hypotensive medications were held on admission. His hypotension
resolved with IVF and antibiotics. Once his blood pressure was
back to normal his antihypertensives were re-started at his home
dose. Lasix was not re-started.
.
#. Systolic CHF: As above.
.
#. Hypercholesterolemia: Patient had hisstory of
hypercholesterolemia. Meds held on admission but these were
subsequently re-started.
Medications on Admission:
Renal Caps daily
ASA EC 81mg daily
lasix 40 mg po bid
glipizide 5mg daily
Nitro 0.3mg tab PRN
Omeprazole 20mg daily
Oxycodone 10mg Q4H PRN
Lyrica 25mg daily
Simvastatin 40mg daily
diovan 80 mg daily
Viteyes 2 tablets daily
Ambien 10mg QHS
Colace
Senna
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet
Sig: One (1) Powder in Packet PO ONCE (Once) for 1 doses.
Disp:*30 Powder in Packet(s)* Refills:*0*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. Cefepime 1 gram Recon Soln Sig: 0.5 Recon Soln Injection
Q24H (every 24 hours) for 4 days.
Disp:*2 Recon Soln(s)* Refills:*0*
11. Tube feeding
Nutren Pulmonary Full strength
Goal rate:48 ml/hr
Flush w/ 30 ml water q6h
Other instructions: Please do not exceed 1L/day of free H2O
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
Please obtain 2 sets blood cultures drawn from different
sites(one from PICC, one peripheral)upon cessation of antibiotic
treatment on [**2149-10-2**]
14. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
15. Outpatient Lab Work
Please check calcium, magnesium, and phosphate on [**2149-10-4**].
16. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
HD line infection induced sepsis
Secondary diagnosis:
ESRD on HD
Hypertension
Discharge Condition:
good, abumbulating, afebrile
Discharge Instructions:
You were admitted because you were found to have an infection in
your blood that caused your blood pressure to be low. You were
first admitted to the intensive care unit were they gave you
fluid and antibiotics and your condition improved. You were then
transfered to the medical floor. You were continued on
antibiotics. You had another fever during a dialysis session and
we decided to remove your catheter as this might have been the
cause of your infection. The interventional radiologists
introduced a new line 2 days later. That same day you underwent
amputation of you the second toe of your left foot. You
tolerated surgery well and were able to walk after the surgery.
You continued to receive dialysis and did not have any more
fevers after that one episode.
While you were here, we made the following changes to your
medications:
1. You are to receive an antibiotic called Cefepime for a total
of 14 days. At home a visiting nurse will help you with this.
2. We stopped your lasix during this admission because your
blood pressure was low. Please follow up with your PCP regarding
the need for this medication.
3. We added neutraphos to your medication regiment because of
low phosphate in your blood. You should take this until your PCP
instructs you otherwise.
No other changes were made to your medications.
If you at any point feel chest pain, shortness of breath,
dizziness, lightheadedness, fevers, chills, diarrhea, burning on
urination, fainting or any other symptom that concerns you
please return to the hospital for further evaluation.
It was a pleasure to take care of you.
Followup Instructions:
Please keep the following appointments:
Dr.[**Name (NI) 2935**] office will call to schedule your appointment.
If you do not hear from them by Thursday, call [**Telephone/Fax (1) 2205**].
Please follow up with Dr. [**Last Name (STitle) 1391**] of vascular surgery on
[**10-15**] at 11am, office number [**Telephone/Fax (1) 1393**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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349, 2542
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25534, 25560
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,189
| 145,457
|
7896
|
Discharge summary
|
report
|
Admission Date: [**2178-5-11**] Discharge Date: [**2178-5-16**]
Date of Birth: [**2118-10-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Asymptomatic - abnormal stress test
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2178-5-11**]
Coronary artery bypass graft (left internal mammary artery>left
anterior descending, saphenous vein graft>diagonal, saphenous
vein graft>obtuse marginal, saphenous vein graft>right coronary
artery and endartectomy to right coronary artery) [**2178-5-12**]
History of Present Illness:
59 year old male s/p syncopal episode in [**2175**] thought to be
related to dehydration verse vasovagal. Stress test showed ST
depression at that time. Surveillance stress test was positive
and referred for cardiac catherization.
Past Medical History:
GERD on protonix
Sarcoid dxed in 87?????? s/p left salivary glad removal
Prostate cancer s/p prostatectomy [**3-30**]
HTN dxed in 01?????? controlled on avipro, last stress test [**2174-4-29**]
Stress test: The rhythm was sinus with rare VPBs, v.couplets,
brief bursts of v.bigeminy, and one ventricular triplet.
Hypercholesterolemia- controlled on lipitor
IBS, occasional decreased appetite.
Social History:
Married lives at home with wife. Two kids out of the house.
1 bottle wine per week
Denies tobacco
Family History:
Father deceased at 60 from vascular disease
Physical Exam:
General NAD
Skin unremarkable
HEENT unremarkable
Neck supple no bruits s/p left salivary surgery
Chest CTA bilt
Heart RRR no m/r/g
Abd soft, NT, ND +BS
Ext warm well perfused no edema
Neuro non focal grossly intact
Pertinent Results:
[**2178-5-11**] 07:05AM BLOOD WBC-6.9 RBC-5.06 Hgb-16.1 Hct-44.8 MCV-89
MCH-31.8 MCHC-36.0* RDW-12.7 Plt Ct-191
[**2178-5-11**] 07:05AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.2*
[**2178-5-11**] 07:05AM BLOOD Glucose-99 UreaN-17 Creat-1.4* Na-144
K-3.8 Cl-107 HCO3-24 AnGap-17
[**2178-5-11**] 08:50AM BLOOD ALT-27 AST-30 CK(CPK)-393* AlkPhos-61
Amylase-31 TotBili-0.9
[**2178-5-11**] 09:15AM BLOOD %HbA1c-5.2
[**2178-5-11**] 08:50AM BLOOD Albumin-4.2
[**2178-5-11**] Cardiac Cath:
1. Coronary angiography in this right dominant system
demonstrated an LMCA with 70% ostial and 70-80% distal lesions.
The LAD
had an 80-90% stenosis after D1. The LCX was totally occluded
proximally
and filled distally via left-left collaterals. The RCA had a 90%
proximal lesion.
2. Limited resting hemodynamics revealed systemic arterial
systolic
hypertension of 170 mmHg. LVEDP was elevated at 24 mmHg. There
was no
gradient across the aortic valve.
[**2178-5-12**] Intraop TEE:
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. There are focal calcifications in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was notified in person of
the results on [**Known firstname **] [**Known lastname 28412**] in the operating room before the
surgical start
POST-BYPASS:
There was a mild to moderate RV systolic dysfunction especially
in the diaphgragmatic surface of the RV. Patient was placed on
an epinephrine drip 0.02 mcg/kg/min. Thoracic aortic contour is
intact. Minimal MR, TR.
Brief Hospital Course:
Presented for cardiac catherization on [**2178-5-11**], which revealed
left main and three vessel coronary artery disease. He was
admitted and underwent surgical evaluation. On [**2178-5-12**] he went
to the operating room and underwent coronary artery bypass
grafting surgery. Please see operative report for further
surgical details. He received Vancomycin for perioperative
antibiotics, since he was in the hospital preoperatively for
greater than 24 hours. Following the operation, he was brought
to the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
experienced short runs of ventricular tachyacardia and was
temporarily started on Lidocaine with transition to beta
blockade. He otherwise maintained stable hemodynamics and
transferred to the SDU on postoperative day one. His epicardial
wires and chest tubes were removed. He was seen in consultation
by physical therapy on POD 3. Later that same day was ready for
discharge to home.
Medications on Admission:
Avapro 150 qd, lipitor 10 qd, pantoprazole 40 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months: for 1 month .
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
.vna of southeastern ma.
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Elevated lipids
Syncope
Sarcoidosis
Osteoarthritis
Prostate cancer
Irritable bowel syndrome
Gastritis
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) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 693**])
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28413**] in [**3-1**] weeks.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2178-5-15**]
|
[
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"V10.46",
"997.1",
"585.3",
"564.1",
"530.81",
"403.90",
"427.1",
"414.01",
"135",
"272.0",
"428.0",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"37.22",
"88.55",
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
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6338, 6393
|
3944, 4964
|
358, 654
|
6585, 6592
|
1760, 3921
|
7103, 7517
|
1465, 1510
|
5113, 6315
|
6414, 6564
|
4990, 5090
|
6616, 7080
|
1525, 1741
|
283, 320
|
682, 915
|
937, 1332
|
1348, 1449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,020
| 104,168
|
51634
|
Discharge summary
|
report
|
Admission Date: [**2184-5-27**] Discharge Date: [**2184-6-9**]
Date of Birth: [**2139-8-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Nausea and Vomiting
Major Surgical or Invasive Procedure:
[**5-30**]: Stereotactic brain biopsy
History of Present Illness:
44yo F with recent dx of lung lesion (3wks ago...currently
undergoing outpt w/u) admitted for nausea & vomiting. Per
patient she has not been feeling quite herself recently
(mentally) and it got to a point on [**5-27**] where she soughtmedical
treatment. Does not report any difficulty with motor skills,
gait, sensation, or vision at the time of presentation. She
reports her current state in very vague terms as "not feeling
right".
Past Medical History:
-Asthma
-Recent tooth infection/extractions ( [**2184-2-15**].)
-metaphalangeal subluxation following an injury on [**2178-6-17**]
-Obesity
Social History:
Lives with three children and Fiancee in [**Location (un) 1411**].
Originally from Sicily, [**Country 2559**]. Moved to US in 60s.
Travels include [**Country 2559**], Caribbean and US.
US travels ( [**State 108**], NC, [**State 350**].)
TB risk factors: prior incarceration for one day during teens.
Hx
of homelesness during teens.
Hx + BCG, has had negative PPDs in past (used to work in health
care facility.)
Recurrently on disability after injury at work. Used to work in
health care field.
Tob:One pack daily x 30 years.
EtOH: N
IVDU: past cocaine (snorting) and IVDU in teens. None recent.
Sexual history: 3 lifetime sexual partners. Genital warts.
HIV neg in [**2177**].
Exposures: + sick contact. Fiance with cold symptoms.
Pets: + dog
Family History:
-No hx htn, cad/mi, cancer
-Diabetes--mother, grandfather, grandmother
-Father passed away at 76 due to "natural causes'
-Mother is 76
Physical Exam:
On Admission:
Vitals: T 99.5 BP 187/79 (180-217/70-85) HR 68 RR 18 SaO2 96%ra
General: no acute distress, sitting in bed talking on phone,
comfortable and appropriate
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Mental Status:
Awake and alert, following all commands, slightly odd affect
Oriented to person, place, time
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors, or asterixis. Strength full power [**6-15**] throughout. No
pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 1 1 1 3 1
Left 2 2 2 3 2
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam on Discharge:
XXXXXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2184-5-27**] 11:00PM BLOOD WBC-10.3 RBC-3.95* Hgb-11.5* Hct-34.2*
MCV-87 MCH-29.0 MCHC-33.6 RDW-14.0 Plt Ct-425
[**2184-5-27**] 11:00PM BLOOD Neuts-71.6* Lymphs-19.4 Monos-3.2
Eos-5.1* Baso-0.8
[**2184-5-28**] 05:20AM BLOOD PT-14.9* PTT-33.1 INR(PT)-1.3*
[**2184-5-27**] 11:00PM BLOOD Glucose-89 UreaN-7 Creat-0.7 Na-143 K-3.4
Cl-103 HCO3-28 AnGap-15
[**2184-5-27**] 11:00PM BLOOD ALT-17 AST-14 LD(LDH)-281* AlkPhos-80
Amylase-29 TotBili-0.5
.
Imaging:
EKG [**5-27**]:
Sinus bradycardia. Poor R wave progression. Cannot rule out
prior
anteroseptal myocardial infarction. Compared to the previous
tracing of [**2184-5-14**] there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 142 82 468/461 56 75 59
.
CXR 4.17:
FINDINGS: Heart size unchanged. Right upper lobe opacification
and right
mediatinal fullness corresponds to thick walled upper lobe
cavity and
mediastinal lymphadenopathy with differential including
Wegener's, SCC/cancer, and fungal infection. No new focus of
consolidation is seen. There is no effusion or pneumothorax.
IMPRESSION: Unchanged highly abnormal chest radiograph.
.
MRI Head [**5-29**]:
IMPRESSION: Multiple enhancing lesions are identified in the
brain as
described above. Although metastatic disease is a consideration,
given the
restricted diffusion on the diffusion-weighted images, infection
needs to be considered in the differential diagnosis. The
appearances could also be
secondary to multiple tuberculomas given a cavitary lesion in
the lung.
.
CT Torso [**5-30**]:
IMPRESSION:
1. Findings consistent with extensive metastatic disease,
including pulmonary nodules, bilateral adrenal masses, and
bilateral renal masses. Lymphadenopathy in mediastinal, right
greater than left hilar, retroperitoneal, and mesenteric
locations, consistent with nodal spread of neoplastic disease.
Bronchoscopic biopsy is recommended.
2. Cavitary pulmonary nodule in the posterior segment of the
right upper
lobe, suspicious for primary lung carcinoma. Please see the
differential
discussion in the prior chest CTA report for less likely
considerations.
3. Right upper lobe pulmonary interstitial thickening,
suspicious for
lymphangetic spread.
4. Subtle sclerosis in the T4 vertebral body. While
indeterminate, osseous
metastasis is not excluded. If there will be a change in
clinical management, then a bone scan may be helpful.
5. Wedge-shaped peripheral opacity in the right middle lobe,
evolving since
the prior chest CTA. Second evolving process in the right upper.
While these may be secondary to infection, the morphology of the
right middle lobe opacity raises the possibility of a pulmonary
infarct.
6. Aberrant right subclavian artery.
.
Head CT [**5-30**](post-bx):
IMPRESSION: Post-surgical changes from recent resection of the
left frontal
lesion with minimal high attenuation in the resection bed and
moderate
perilesional vasogenic edema causing effacement of the left
frontal [**Doctor Last Name 534**] of
the left lateral ventricle without shift of midline structures.
.
ECHO [**2184-6-1**]
Conclusions
The left atrium and right atrium are normal in cavity 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 valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No valveular pathology or pathologic flow
identified. Normal biventricular cavity sizes and regiona/global
systolic function.
.
[**2184-6-4**] CT head
IMPRESSION: Extensive bilateral areas of vasogenic edema, from
known brain
metastasis. Compared to [**2184-5-30**], the overall appearance
is not
significantly changed.
.
Labs on discharge:
***************
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] after complaints of nausea,
vomiting, and not "feeling herself". Of significance, she is
status post diagnosis of lung mass for which she was being
worked up on an outpatient basis.
.
1. NSCLC, metastatic to brain/nausea/vomiting/headache -- Upon
admission a head CT was performed which identified multiple
infra and supra tentorial brain lesions, including the brain
stem. High dose steroid therapy was initiated to treat
associated vasogenic edema. A left stereotactic brain biopsy
was performed on [**5-30**]. Post-operatively a head CT was done, and
determined to be stable. She was then returned to the ICU
pending diagnosis and further management. She was initiated on
whole brain radiation on [**2184-6-2**] and was monitored in the ICU
for signs and symptoms of increased ICP. She was subsequently
transferred to the hospitalist service for the remainder of her
course.
During initiation of her brain radiation treatments, patient had
intractable nausea, vomiting, headache, and hypertension, but
repeat CT head did not show increased edema. She continued on
IV dexamethasone 6 mg q6 hours, IV keppra 1000mg q12 hours, and
IV hydralazine for blood pressure control (see below).
For nausea control, she was kept on compazine, zofran, ativan,
phenergen PRN.
Oncology, neuro-oncology, and neurosurgery was involved
throughout her hospital course. Her symptoms gradually subsided
and she was transitioned to po meds. She will complete the
remainder of her radiation treatments as an outpatient. She has
follow up scheduled with thorcaic oncology and neuro-oncology.
.
2. Hypertension -- While unable to tolerate po, she was treated
with IV hydralazine for goal SBP of less than 130 mmHg. When
able to tolerate po, she was transitioned to Lisinopril. The
patient was instructed to followup with her PCP regarding her
blood pressure.
.
3. Asthma -- remained stable throughout her course, continued
prn albuterol.
.
4. Hyperglycemia -- associated with high dose steroids and
managed with a sliding scale without difficulty.
.
5. Dispo: The patient ambulated without difficulty and was
discharged home in stable conition.
Medications on Admission:
albuterol, percocet
Discharge Medications:
1. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
2. Dexamethasone 6 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 20 days.
Disp:*80 Tablet(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
5. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for fever or pain.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath.
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO q6h prn pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Non-small cell lung cancer with multiple brain metastases
2. Hypertension
Discharge Condition:
Neurologically Stable
Discharge Instructions:
You were admitted with altered mental status secondary to your
newly [**First Name9 (NamePattern2) 106995**] [**Last Name (un) **] metastasis. You underwent brain biopsy and
whole brain radiation. You should attend follow up appointments
with the thoracic oncologist and neuro-oncolgist.
.
- Take lisinopril for high blood pressure. Your PCP should
follow up on your blood pressure.
- Take lorazepam at night as needed for anxiety.
.
General Instructions/Information
?????? Have a friend/family member check your incision daily
for signs of infection.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Use a shower cap to cover your head if you are going to
shower.
?????? You have been prescribed Keppra for anti-seizure medicine,
take it as prescribed
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? [**Male First Name (un) **] NOT DRIVE. 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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions:
- Follow up with your PCP on [**Name9 (PRE) 766**] [**6-14**] at 6pm regarding
this hospitalization. Please call and reschedule if you cannot
make this appointment.
- Please call the neurosurgery clinic to arrange an appointment
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 that office, please make arrangements for the
same, with your PCP.
[**Name10 (NameIs) 106996**] your radiation treatments as scheduled at 12pm on [**3-17**], [**6-14**] and [**6-15**].
- Thoracic oncology clinic: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD
Phone:[**0-0-**] Date/Time:[**2184-6-22**] -10:30
- [**Hospital **] clinic. Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD
Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2184-6-28**] 3:00. The Brain [**Hospital 341**]
Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**]
Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you
need to change your appointment, or require additional
directions.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2184-6-9**]
|
[
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"493.90",
"348.5",
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"E932.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"87.03",
"92.29",
"01.13",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
10630, 10636
|
7613, 9793
|
333, 373
|
10757, 10781
|
3532, 3537
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12544, 13987
|
1786, 1922
|
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10657, 10736
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1937, 1937
|
274, 295
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7572, 7590
|
401, 841
|
2670, 3475
|
3494, 3513
|
3551, 7553
|
2445, 2654
|
2430, 2430
|
863, 1005
|
1021, 1770
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,377
| 148,190
|
14600+56558
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-7-2**] Discharge Date:
Date of Birth: [**2069-11-10**] Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Pancreatic pseudocyst.
HISTORY OF PRESENT ILLNESS: Patient is a 65-year-old male
with a history of hypertension, alcohol abuse, gastroesophageal
reflux disease, who presented as a transfer from an outside
hospital with a pancreatic pseudocyst after prolonged
hospitalization. The patient was admitted in early [**2135-4-18**]
with acute pancreatitis and had an endoscopic retrograde
cholangiopancreatography that revealed presence of gallstones.
The [**Hospital 228**] hospital course was complicated by the discovery of
a 10 cm pseudocyst. His course was also complicated by [**Female First Name (un) **]
albicans fungemia, worsening pancreatitis, bilateral pleural
effusions, status post multiple thoracenteses, left upper
extremity subclavian vein thrombosis, as well as several trips to
the Intensive Care Unit for episodes of hypotension. The patient
had been treated with multiple antibiotic courses. The patient
was finally transferred on [**2135-7-2**] to [**Hospital6 649**] for evaluation for a pseudocyst drainage
procedure. It is also noted that at the outside hospital, the
patient had a slight decrease in his platelets and hematocrit. On
arrival to [**Hospital6 256**], the patient was
found to be tachycardic to the 130s, tachypneic to the 40s with
an arterial blood gas revealing a pH of 7.46, a PC02 of 32 and
PAO2 of 92. Patient underwent a CT angiogram to evaluate for a
pulmonary embolism which was subsequently negative. There is
also report of an Methicillin resistant Staphylococcus aureus
pneumonia at the outside hospital, although, this was not seen on
the chest CT images. Patient was initially started on
vancomycin, levofloxacin, fluconazole, as well as a heparin drip.
Gastrointestinal was consulted. Because of the persistent
tachycardia and failure to respond to fluid hydration, the
patient was transferred to the [**Hospital Ward Name 332**] Intensive Care Unit. He was
then subsequently volume resuscitated and transferred back out to
the General Medicine Floors. Upon transfer, he had no
complaints.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Glaucoma.
3. Alcohol abuse.
4. Gastroesophageal reflux disease.
5. History of thrush.
ALLERGIES: Primaxin.
MEDICATIONS ON ADMISSION:
1. Xalatan.
2. Alphagan.
3. Prinivil.
4. Protonix.
5. Regular insulin sliding scale.
6. TPN.
7. Ampicillin.
8. Albuterol.
9. Atrovent MDI.
10. Demerol.
11. Tylenol.
SOCIAL HISTORY: Positive for history of alcohol abuse.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Patient's weight was 60 kilograms.
Temperature was 100.9 with a pulse of 109. Blood pressure of
109/60. Respiratory rate of 25. Oxygen saturation of 94% on
three liters nasal cannula. On general exam, the patient was
an ill-appearing male in no apparent distress. Head, eyes,
ears, nose and throat examination revealed extraocular
movements intact, nonicteric sclera and dry mucous membranes.
Neck examination revealed no lymphadenopathy. Cardiac exam
revealed a regular tachycardia normal S1, S2 and no murmurs,
rubs or gallops. Pulmonary exam revealed coarse but clear
lung fields bilaterally. The patient's belly had some slight
tenderness diffusely but was soft with mild distention and
normal bowel sounds. Extremity exam revealed no edema.
Vascular exam revealed good capillary refill.
PERTINENT LABORATORY FINDINGS: The patient had a white blood
cell count of 13.1 with a hematocrit of 24.2 and platelets of
328,000. Patient's creatinine was 0.8. Patient had initial
CK of 9 with a second CK of 10 and a final CK of 20. INR of
1.5 and a PTT of 36.7. Patient had a subclavian line tip
from the outside hospital that grew greater than 15 colonies
of gram negative rods.
Chest x-ray revealed bibasilar linear atelectasis, no
pneumothorax.
CT angiogram: Pseudocyst without pseudoaneurysm in the
pancreas and question of splenic vein occlusion.
Echocardiogram from the outside hospital revealed an ejection
fraction of 60%.
SUMMARY OF HOSPITAL COURSE: The patient is a 65-year-old male
with a history of hypertension, alcohol abuse and
gastroesophageal reflux disease transferred from an outside
hospital for a pancreatic pseudocyst, gallstone pancreatitis
and multiple infections, as well as a left upper extremity deep
vein thrombosis.
1. Gastrointestinal: The patient presented with gallstone
pancreatitis, complicated by a pancreatic pseudocyst. Because of
continuing candidemia, enterotoxemia, as well as febrile
episodes, the patient was transferred to [**Hospital6 649**] for a drainage procedure of his pancreatic
pseudocyst. Patient was evaluated by Gastroenterology, as well
as Surgery regarding the drainage. He was maintained on bowel
arrest, given intravenous fluids and started on TPN. His
antibiotics were changed to levofloxacin, Flagyl and fluconazole.
The Surgery Team did not feel that the patient was a stable
surgical candidate. Infectious Disease was consulted to re-
evaluate the patient's antibiotic regimens. They concurred with
the regimen of levofloxacin, Flagyl and fluconazole. Patient
eventually underwent drainage of his pancreatic pseudocyst by
Interventional Radiology on [**2135-7-7**]. Laboratories from
this drainage were pending at the time of this dictation.
2. Cardiovascular: A patient with tachycardia and a CT
angiogram that was negative for pulmonary embolism. It was
thought that this was secondary to fever or pain. Patient was
volume resuscitated. He had two episodes of supraventricular
tachycardia which could have been atrioventricular node reentry
tachycardia. This was likely secondary to a stress response and
nodal agents were held. Patient was maintained on telemetry.
3. Venous thromboembolism: Patient presented with a left upper
extremity deep vein thrombosis maintained on a heparin drip.
4. Hematologic: Patient with anemia of multifactorial etiology.
He was transfused two units of packed red blood cells within an
appropriate increase in his hematocrit to the high 20s. The
patient also required four units of FFP before his drainage
procedure.
5. Infectious Disease: Patient with history of enterotoxemia,
candidemia and Methicillin resistant Staphylococcus aureus in the
sputum. Multiple cultures were taken upon arrival. He underwent
a drainage procedure to evaluate whether a pseudocyst was
infected. Patient had a line tip from an outside hospital
central venous line which grew Klebsiella. Infectious Disease
did not recommended changing the antibiotic regimen at that
point.
6. Fluid, electrolytes and nutrition: Patient had an
nasogastric tube, was NPO and was started on TPN.
The remainder of this discharge summary will be completed in an
addendum.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2135-7-11**] 11:43
T: [**2135-7-11**] 11:43
JOB#: [**Job Number 43060**]
Name: [**Known lastname 7840**], [**Known firstname 7661**] Unit No: [**Numeric Identifier 7841**]
Admission Date: [**2135-7-2**] Discharge Date: [**2135-8-11**]
Date of Birth: [**2069-11-10**] Sex: M
Service: [**Company 112**]
ADDENDUM:
HOSPITAL COURSE:
1. Gastrointestinal: The patient had a pseudocyst drain
placed which was growing Gram negative rods and Enterococcus.
The patient was placed on Zosyn. At one point during the
admission, the drain was accidentally pulled out by Nursing.
The drain was replaced and drainage continued. Towards the
end of the hospital stay, the drainage had fallen off to less
than 10 cc a day. A CT scan was done where contrast was
injected into the pigtail catheter and a fistula was
discovered between the pancreas and the stomach. No action
was taken on the pseudocyst. The patient was started on
p.o., pureed foods, and still complains of nausea when he
eats.
2. Cardiovascular: The patient was cardiovascularly stable
after two weeks on the floor. He was taken off Telemetry and
did not require any more boluses and was hemodynamically
stable.
3. Venous thromboembolism: The patient developed a left
rectus sheath hematoma and was discontinued on heparin. No
further anti-coagulation was started.
4. Hematologic: The patient was periodically anemic and
heme positive. He did have two unit requirement twice on the
floor but has been hemodynamically stable for the last two
weeks of admission and has required no more blood.
5. Infectious Disease: The patient had a history of
Enterotoxemia, Candidemia and Methicillin resistant
Staphylococcus aureus with enterococcus and Gram negative
growing out of his pigtail catheter. The patient was placed
on a six week course of Zosyn and received ten more days upon
his discharge from the hospital. He has been afebrile for
the past week.
6. Pulmonary: The patient developed a right lower lobe
pneumonia, most likely secondary to aspiration. He was on
Zosyn at the time and we felt coverage was adequate. Upon
discharge, the patient's lungs were clear and he was
breathing adequately and saturating well.
7. Fluids, Electrolytes and Nutrition: The patient is on
TPN and will continue on TPN upon discharge. He is
encouraged to have p.o. although still feels nauseous when
eating. The patient is on Reglan, Droperidol and Zofran.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: To [**Hospital6 7842**].
DISCHARGE DIAGNOSES:
1. Pancreatic pseudocyst.
2. Pancreatitis.
3. Enterotoxemia.
4. Candidemia.
5. Pneumonia.
6. Ascites.
DISCHARGE MEDICATIONS:
1. Zosyn 4.5 mg intravenous q. six times ten days.
2. Insulin sliding scale.
3. Dulcolax 10 mg p.r. q. day.
4. Zofran 8 mg intravenously three times a day.
5. Protonix 40 mg intravenously q. day.
6. Hydromorphone 0.5 to 1.0 mg q. two to four hours p.r.n.
7. Tylenol 650 mg p.o. or p.r. q. four to six hours p.r.n.
8. Atrovent q. four hours p.r.n.
9. Droperidol 0.625 mg intravenously q. eight hours.
DISCHARGE INSTRUCTIONS:
1. The patient also to receive Physical Therapy while in the
hospital.
2. He was walking with assistance here.
3. The patient has also been on TPN and should continue
while at [**Location (un) **]. Notes from Dietary have been included.
[**Doctor Last Name **] [**Name6 (MD) 909**] [**Name8 (MD) **], M.D. [**MD Number(1) 348**]
Dictated By:[**Last Name (NamePattern1) 7843**]
MEDQUIST36
D: [**2135-8-11**] 15:19
T: [**2135-8-11**] 13:48
JOB#: [**Job Number 7844**]
|
[
"507.0",
"285.9",
"996.62",
"998.12",
"577.0",
"453.8",
"577.8",
"112.0",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"52.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2628, 2646
|
9587, 9696
|
9719, 10129
|
2380, 2554
|
7395, 9498
|
10153, 10660
|
4144, 7378
|
2669, 4115
|
9514, 9566
|
146, 170
|
199, 2197
|
2219, 2354
|
2571, 2611
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,697
| 184,537
|
48750+59112
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-10-8**] Discharge Date: [**2128-10-10**]
Date of Birth: [**2054-3-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Trileptal / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64yo man with hx bipolar, HTN, chronic neck/back pain here from
MICU after p/w fall and hypotension. Recently discharged from
psych after inpt stay for hyponatremia, hyperkalemia, diarrhea
then depression. He was in USOH with only new meds of
seroquel/wellbutrin until day of admission he was walking off
the bus and tripped. He hit posterior head but had no LOC.
Denied any fevers, photophobia, CP, SOB, palpitations, abd pain.
He came to ED. VSS initially, head CT neg. Creatinine 3.3 (bl
1.9), potassium 5.1. Received insulin and 2L IVF. Then
developed hypotension with SBP 70s to sent to the ICU.
.
In ICU, BP stabilized with additional 2L. Creatinine improved.
Hct dropped from 30 to 25 (OB neg). Even while hypotensive, he
was assymptomatic. CXR, cx neg to date. No infectious source.
Thought to be [**1-30**] atenolol in setting of ARF, valsartan, and
pain meds causing hypotension. Random cortisol was 2.2.
.
Notably, the patient has q6-12 month steroid injections in
ankles for pain control. He has never taken oral or IV
steroids. He has no change in skin color. He reports fatigue,
depressive sx.
.
ROS and currently: No fevers, chills, HA, vision changes, cp,
sob. Has been compliant with medications. Reports neck and
right shoulder pain s/p fall. Reports bilat ankle pain which is
chronic.
Past Medical History:
1. Chronic renal failure: bl creatinine 1.9
2. Hypertension
3. Hyperlipidemia
4. Mitral regurgitation
5. MGUS
6. Diverticulosis
7. Adenocarcinoma of the prostate s/p radical prostatectomy,
[**2120-6-27**].
8. Depression
9. Bipolar disorder
10. Chronic pain: [**1-30**] cervical/lumbar spine disease
11. Chronic headaches
12. Peptic ulcer disease
13. Tremors
14. Internal Hemmorrhoids
15. Cervical osteoarthritis
16. History of bilateral degenerative joint disease.
17. Glaucoma
18. Palpitations, with a Holter monitor showing sinus
tachycardia
and occasional premature ventricular contractions, but otherwise
negative in [**2120-3-28**].
19. Status post lumbar fusion.
20. h/o "fainting spells" - ?med related
21. s/p Tonsillectomy, adenoidectomy.
22. Recent admission for hyponatremia, hyperkalemia, diarrhea,
fatigue. Source unclear
Social History:
Grew up in [**Location (un) 21601**]. Lives in [**Location **] with his partner,
[**Name (NI) **], of 13years. No tobacco, no etoh. Received a BA and then an
MS in Philosophy from [**University/College 4700**]. He taught at the
college level for 5 years. Worked as contracts specialist for
[**Hospital3 40709**] for about 30 years.
Family History:
- Father: Alcoholic. Died of metastatic melanoma at 67
- Mother: Mother died of CHF and CAD at age 80, with first MI at
57.
Physical Exam:
VS: 100/60 72 18 97.7 97% RA
I/O 2000ml/2000ml
Gen: AAO x3. Fatigued easily arousable. NAD. Able to ambulate
without dizziness. Pos right foot pain with ambulation
Orthostatics neg
Heent: MM dry, JVP flat, OP clear
Cards: RRR nl S1S2 no MGR
Lungs: clear
Abd; BS+ NT ND no organomeg
Ext: no edema or rashes. No darkening of skin noted
Neuro: CN ii-xii intact, strength 4+/5 upper right ex prox.
otherwise full bilat. [**Last Name (un) 36**] intact. romberg neg. gait with
narrow steps.
OB negative
Pertinent Results:
EKG: NSR nl axis intervals. J point inferiorly, TWF aVL
unchanged. More pronounced T waves from prev
Labs:
Hct: 30 -> 26.8 (baseline 33)
Creatinine: 3.3 - 2.7 - 2.3 (bl 1.9)
Hepatic enzymes normal
venous: 7.29/44/74
Lactate 0.5
CK [**Telephone/Fax (3) 102472**]
CKMB 16 - 14 - 14
MBI neg
Trop: 0.03 - 0.04 - 0.02
Urine and serum tox neg
Random cortisol 2.2
[**Last Name (un) **] stim @ time 0: cortisol 15.4, at 60 minutes 33.0
137 109 55
--------------< 105
4.7 18 2.7
WBC: 7.6 (77N, 16L, 5M, 1E)
Plt 284
Hct 27.3
Retic 1.8
EGD [**8-27**]: gastritis
[**Last Name (un) **] [**2125**]:
Diverticulosis of the whole colon
Polyps in the ascending colon
Grade 3 internal & external hemorrhoids
Polyp in the sigmoid colon
.
Head CT: No evidence of intracranial hemorrhage.
CXR: [**10-9**]: No failure. No pneumonia.
Brief Hospital Course:
# Hypotension: Thought to be related to two factors, 1)
hypovolemia from recent diarrheal illness and 2) medication
effect from multiple anti-hypertensives as well as decreased
clearance of atenolol due to Acute on Chronic Renal failure.
Patients was volume resucitated and anti-hypertensives as well
as narcotics were held and his SBP (nadir was 70) increased
eventually to 140 upon discharge. His Diovan was restarted at
half of his home dose (80mg [**Hospital1 **], home dose was 160mg [**Hospital1 **]), his
norvasc was held (normally takes 5mg po daily) and his HCTZ was
also started at half of his home dose (20mg po bid of oxycontin
rather than his normal dose of 40mg po bid). His atenolol was
held, a decision was made to defer beginning a low dose Toprol
XL in the outpatient setting and uptitrating as needed. Adrenal
insufficiency was ruled out with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim from 15 at time 0
and a cortisol of 33 at time 60 minutes.
# ARF- Acute on Chronic renal failure, likely due to pre-renal
causes as patient had a diarrheal illness for 5 days which
resolved a few days prior to admission, and his renal failure
improved with 4 liters of fluid resuscitation- back to his
baseline. Patient will follow up with his renal doctor within
10 days of his discharge.
# Anemia- Slightly worse than previous, retic 1.8%. In the high
20s and stable upon discharge. Iron studies, B12, Folate normal
1 month ago and guiac negative. Would likely benefit from
beginning EPO therapy, the patient should discuss this during
his appointment with his nephrologist.
# Fall- per patient his fall was completely mechanical, his
ankle pain caused his instability. He was not using his cane at
the time. Per PT he should use his cane at all times from this
point forward. He has chronic ankle pain from previous trauma
and is scheduled for surgical correction in roughly 1 week.
Pain medications were decreased to oxycontin 20mg po bid from
40mg po bid, patient's pain was well controlled on this regimen,
he should uptitrate as outpatient with his PCP as his blood
pressure allows if his pain worsens.
# Cardiac: Trop Peak at 0.04, likely insignificant in setting of
renal failure. Ruled out for MI.
# Depression / Suicidal- post discharge from psych facility
patient no longer feels suicidal. Continued Wellbutrin.
# Hyperkalemia- This was in the setting of his acute renal
failure, it resolved and was stable upon discharge, he was
placed on half of his home dose of HCTZ (12.5mg po daily). He
will have his labs checked on [**10-14**] by VNA (K, BUN, Cr) and have
these results called to his PCP.
Medications on Admission:
1. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
2. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID
4. Oxycodone 40 mg Tablet Sustained Release 12 hr [**Hospital1 **]
5. Oxycodone 5 mg Tablet PO Q8H as needed.
6. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY
7. Primidone 50 mg Tablet Sig: 0.5 Tablet PO HS
8. Quetiapine 25 mg PO TID as needed for anxiety.
9. Wellbutrin SR 150 daily
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
3. Primidone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: please do not exceed 4 grams of tylenol per
day.
10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Mechanical Fall
Hypotension
Acute Renal Failure
Secondary Diagnosis:
Chronic Renal Failure
Discharge Condition:
stable, BP well controlled
Discharge Instructions:
You were admitted for a fall related to your ankle pain. You
were found to have a very low blood pressure thought to be
related to your medications as well as your worsening renal
function (one of your medications, Atenolol, is cleared by your
kidney and built up in your system when your kidney function
worsened).
Please call your doctor or go to the emergency room if your
ankle pain worsens, if you feel lightheaded, have chest pain,
shortness of breath or any other concerning symptoms.
Followup Instructions:
Please follow up with your renal (kidney) doctors [**Name5 (PTitle) 176**] 2 weeks
of your discharge. They can check labs and help determine if
you need a medication called 'erythropoetin' or 'EPO' for your
anemia associated with your kidney dysfunction. Also please
follow up with your Primary Care Physician [**Name Initial (PRE) 176**] 4 weeks of
your discharge.
You have the following appointments:
1. [**Name Initial (PRE) **] RM 1 [**Name Initial (PRE) **]-PREADMISSION TESTING Date/Time:[**2128-10-18**] 1:30
2. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2128-10-19**] 10:30
3. DRS. [**Last Name (STitle) **] AND [**Name5 (PTitle) 9529**] Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2128-12-20**]
4:15
Name: [**Known lastname 2836**],[**Known firstname 448**] Unit No: [**Numeric Identifier 16536**]
Admission Date: [**2128-10-8**] Discharge Date: [**2128-10-10**]
Date of Birth: [**2054-3-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Trileptal / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1408**]
Addendum:
Addendum to Discharge summary on [**Known firstname **] [**Known lastname **].
Patient also had an SPEP and UPEP sent. These results were
pending upon discharge.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1410**] MD [**MD Number(2) 1411**]
Completed by:[**2128-10-11**]
|
[
"585.3",
"276.7",
"276.52",
"424.0",
"403.90",
"285.21",
"584.9",
"272.4",
"E888.9",
"V10.46",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10785, 11000
|
4415, 7076
|
315, 322
|
8849, 8878
|
3567, 4296
|
9420, 10762
|
2902, 3027
|
7593, 8614
|
8715, 8715
|
7102, 7570
|
8902, 9397
|
3042, 3548
|
267, 277
|
350, 1675
|
8804, 8828
|
4305, 4392
|
8734, 8783
|
1697, 2537
|
2553, 2886
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,654
| 197,369
|
8233
|
Discharge summary
|
report
|
Admission Date: [**2142-11-18**] Discharge Date: [**2142-12-5**]
Date of Birth: [**2094-1-11**] Sex: F
Service: TRANSPLANT SURGERY
CHIEF COMPLAINT: End stage renal disease and blood loss
anemia.
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old
female with history of end stage renal disease, likely due to
focal segmental glomerulosclerosis, status post living
related renal transplantation in [**2124**], complicated by
rejection, status post cadaveric renal transplantation in
[**2132**] by Dr. [**Last Name (STitle) 15473**], who suffered vaginal bleeding for one
month. The patient did not seek any medical treatment but did
present to [**Hospital1 **] [**Location (un) 47**] complaining of dizziness. The
patient was found to have a hematocrit of 7.9. The patient
was transfused 4 units of blood as her hematocrit rose to
21.8. She was found to have normal INR and no evidence of
coagulopathy. After transfusion of 4 units of blood, the
patient was transferred to the [**Hospital1 188**] due to elevated creatinine level and concern for her
transplanted kidney.
In review the patient had been lost to follow up for over one
year. She has been followed intermittently with her
nephrologist and primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
PAST MEDICAL HISTORY: Focal segmental glomerulosclerosis,
related to history of renal disease, status post living
related renal transplantation in [**2124**], status post cadaveric
renal transplantation [**2132**]. She denies any history of
coronary artery disease or chronic obstructive pulmonary
disease. The patient denies any past medial history of
diabetes.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Sandimmune 100 mg po b.i.d.
2. Prednisone 5 mg po once daily.
3. Lasix 40 mg po b.i.d.
PHYSICAL EXAMINATION: Afebrile. Heart rate 82, blood
pressure 161/79, respiratory rate 27, 97 percent on 30
percent face mask. Alert and oriented x 3 in no apparent
distress.
CARDIOVASCULAR: Rate and rhythm regular, S1, S2.
RESPIRATORY: Clear to auscultation bilaterally.
ABDOMEN: Soft, nondistended, nontender. A well healed
incision.
RECTAL: Guaiac negative.
EXTREMITIES: Right upper extremity swollen, tender and
erythematous.
LABORATORY DATA: Laboratory tests on admission showed white
blood cell count 11.4, hematocrit 21.8, platelet count 259,
sodium 141, potassium 3.5, chloride 104, CO2 22. BUN 88,
creatinine 7.3, glucose 152. AST 15, ALT 4, alkaline
phosphatase 49, total bilirubin 0.7. PT 13.7, PTT 29.5, INR
1.2. Chest x-ray was within normal limits. CT of the chest
on admission showed enlarged heart. No evidence of
pneumothorax. The patient was transferred from [**Hospital1 **]
[**Location (un) 47**] to [**Hospital1 69**] Surgical
Intensive Care Unit. The patient received 4 units of blood
on admission with appropriate rise in hematocrit to 35.6.
The patient made by end of hospital day 2, 1.7 liters of
urine, however her creatinine did not significantly improve.
HOSPITAL COURSE: Given the significant gastrointestinal
bleeding, the patient was seen by GYN consultation. The
patient had vaginal ultrasound which showed calcified
fibroid, thickened endometrium and small blood in the pelvis.
There was question of a 2 cm structure adjacent to the right
ovary, apparently vascular. CT of the abdomen showed small
focus of fluid and no obvious mass and questionable fibroid
in the uterus. The patient was seen by GYN consult. Vaginal
examination showed no evidence of acute bleeders.
The rest of the [**Hospital 228**] hospital course will be summarized
by problems.
VAGINAL BLEEDING - the patient continued to have occasional
vaginal spotting and was seen by GYN consult and follow up.
The patient eventually went to the Operating Room on [**2142-12-4**], hospital day 17 with GYN service during which time
she underwent hysteroscopy and ablation of uterine fibroids
for dysfunctional uterine bleeding.
Throughout the hospital course the patient received 4 units
of packed red blood cells on the first day of admission,
otherwise her hematocrit was relatively well during her
length of stay. As her volume status increased her
hematocrit shifted down, and at discharge home, her
hematocrit was 31.4.
RENAL FAILURE - The patient's creatinine was significantly
higher than her last recorded creatinine on follow up over a
year ago. Because of the concerns of cyclosporin toxicity,
cyclosporin was held for the first 4 hospital days. The
patient was restarted on her home dose cyclosporin on
hospital day 5 and her C2 levels were monitored. She
underwent ultrasound of the transplanted kidney which showed
no evidence of hydro and relatively good flow to the
transplanted kidney. _____________were within normal limits.
The patient eventually underwent biopsy of her transplanted
kidney because of lack of improvement in her serum
creatinine. Biopsy showed evidence of chronic rejection of
kidney. The patient underwent course of high dose steroids
for immunosuppression, total course of 5 days. While she
came off the high dose steroids, she was put back on her
usual home dose of 5 mg of prednisone once a day. The patient
told also to restart her CellCept at 500 mg po b.i.d. for
immunosuppression.
By hospital day 12, biopsy evidence showed chronic rejection
and significant fibrosis, without evidence of significant
viable glomeruli. Cyclosporin was discontinued and with a
lack of improvement in her creatinine, the patient was
started back on dialysis on [**2142-11-30**]. As her urine
continued to decrease, we did try to give her trace amounts
of Lasix to continue to diurese, however she did not respond
to a total daily dose to 140 mg of Lasix to increase her
urine output.
At discharge the patient's creatinine had improved, having
been on dialysis. She was discharged with creatinine of 5.2.
The patient was being followed by transplant nephrologist.
DISCHARGE DIAGNOSIS: Dysfunctional uterine bleeding, likely
from a uterine source, likely due to fibroids. Assess with
hysteroscopy and fibroid ablation [**2142-12-4**].
DISCHARGE CONDITION: Discharge to home.
DISCHARGE FOLLOW UP: The patient is to follow up with Dr.
[**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for hemodialysis and is to see Dr. [**Last Name (STitle) **] as
needed. The patient is to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], nephrologist for follow up of her renal conditions.
DISCHARGE MEDICATIONS: Folate 1 mg po daily.
Vitamin C 500 mg po b.i.d.
Calcium acetate 2 tablets po t.i.d. with meals.
Iron 325 mg po daily.
Pepcid 20 mg po daily
Prednisone 5 mg po daily.
RECOMMENDATIONS: CellCept was also discontinued. Home dose
prednisone of 5 mg po daily.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier 29231**]
Dictated By:[**Last Name (NamePattern1) 12164**]
MEDQUIST36
D: [**2142-12-6**] 22:03:20
T: [**2142-12-6**] 23:53:30
Job#: [**Job Number 29232**]
|
[
"275.3",
"276.6",
"920",
"276.2",
"996.81",
"E878.0",
"280.0",
"682.3",
"218.9",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"68.23",
"38.91",
"55.23",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6204, 6234
|
6627, 7168
|
6031, 6182
|
3107, 6009
|
6246, 6603
|
1916, 3089
|
170, 218
|
247, 1383
|
1406, 1893
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,086
| 106,020
|
33861
|
Discharge summary
|
report
|
Admission Date: [**2178-3-12**] Discharge Date: [**2178-3-20**]
Date of Birth: [**2135-3-22**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
pancreatitis and alcohol withdrawal
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
45 M with history of etoh abuse originally presented to [**Hospital **]
Hospital on [**3-6**] with nausea, vomiting and abdominal pain.
Initial labs showed Lipase of 1678, WBC 13.1 (76%PMNs), Hct
37.8, AP 140, AST 87, ALT 52. Abdominal CT was done and
consistant with pancreatits but no necrosis. Abd ultrasound
showed Gb sludge without stones or ductal dilitation.
His lipase of 1678 on admission trended down to 129 by [**3-9**], but
rose to 282 by [**3-12**]. His Hct drifted down from 37 to 28. Serial
abd CTs ([**3-5**], [**3-7**] and [**3-12**]) showed progression of pancreatitis
involving 50% of the pancreas, specifically the head and
uncinate process with phlegmon formation by the head and severe
inflammation; body and tail are spared. No abscess noted; no
splenic or portal vein thrombosis. On most recent CT [**3-12**], head
of pancreas showed poor/heterogenous enhancement, suspicious for
necrosis. Surgery and ID were consulted. Given CT findings and
Hct drop concerning for necrotizing pancreatitis, cipro and
flagyl were started on [**3-12**].
.
Additionally, his OSH course was complicated by EtOH withdrawal
on [**3-7**] and was transferred to the ICU. He was placed on a CIWA
scale and required large doses of benzos and dilaudid to control
his withdrawal and pain. He was intubated for airway protection
in setting of agitation and obtundation on [**3-9**].
.
Given climbing white count, progression of fluid on CT, possible
phlegmon development at head of the pancreas and anemia, he was
transferred to [**Hospital1 **] for further managment of ?necrotizing
pancreatitis. Presentation labs revealed normal amylase/lipase,
however WBC count elevated to 19K with 1% bands and hct down to
28 (from 38 on admission to OSH).
Past Medical History:
Polysubstance abue (etoh, benzos, opiates)
Bipolar disorder
s/p shoulder surgery [**3-2**] (arthroscopic subacromial
decompression and distal clavicle excision)
s/p appy
Social History:
+etoh abuse, +tobacco use, h/o narcotic abuse
Physical Exam:
VS 100.7 100 (72-100) 149/93 (111-150-60s-90s) O2 sat 96-99%
AC 550x14 (breathing over at 19), 35%, peep 5; I/Os since
midnight 1897/2645.
Gen: Intubated, sedated, somnolent but aroused
HEENT: mmm, op clear, eomi, perrl
CV: Sinus tachy, no mrg appreciated
PULM: CTAB anteriorally
ABD: soft, +moderate epigastric tenderness, no rebound or
guarding, +BS
EXT: no c/c/e, 2+ DP and PT pulses bilaterally
skin: no rash, +tattoo over chest, no Cullen's nor [**Doctor Last Name 27210**] sign
.
DATA:
OSH LABS:
[**3-12**] labs:
141 110 6
-----------<89
3.8 25 0.9 calcium 8.3,
WBC 17.5 (80.7%polys) , Hct: 28.1, Plt 472
.
Lipase trend: 1678->1241->490->294->129->168
WBC trand:
13.1->13->12.1->11.7->15.5->17.8->20.2->17.9->14.6->16.4->16.7
.
Other labs: Iron 9, transferrin 8.6, TIBC 105; retic 2.9, folate
12.4, B12>1000, albumin 2.6, AP 100, Ast 23, ALT 15, TBili 0.4,
TSH 1.93
EtOH [**3-5**]: 49
.
OSH IMAGING:
[**3-5**] Abd U/S: no obvious stones but biliary sludge
Pertinent Results:
[**2178-3-13**] 06:03AM BLOOD WBC-18.8* RBC-2.92* Hgb-9.6* Hct-27.8*
MCV-95 MCH-32.8* MCHC-34.6 RDW-15.0 Plt Ct-543*
[**2178-3-19**] 05:20AM BLOOD WBC-14.3*# RBC-3.09* Hgb-10.1* Hct-29.3*
MCV-95 MCH-32.7* MCHC-34.6 RDW-14.7 Plt Ct-567*
[**2178-3-13**] 12:01AM BLOOD Glucose-84 UreaN-5* Creat-0.8 Na-139
K-3.7 Cl-107 HCO3-24 AnGap-12
[**2178-3-19**] 05:20AM BLOOD Glucose-76 UreaN-6 Creat-1.0 Na-140 K-4.2
Cl-102 HCO3-28 AnGap-14
[**2178-3-16**] 01:03AM BLOOD ALT-13 AST-24 LD(LDH)-242 AlkPhos-95
Amylase-23 TotBili-0.6
[**2178-3-15**] 01:08AM BLOOD Lipase-56
[**2178-3-19**] 05:20AM BLOOD Calcium-9.4 Phos-4.6* Mg-1.7
[**2178-3-13**] 12:01AM BLOOD Triglyc-176*
.
CHEST (PORTABLE AP) [**2178-3-13**] 12:02 AM
HISTORY: 45-year-old man with pancreatitis, intubated, status
post transfer from outside hospital; evaluate for ET tube
placement and pneumonia.
IMPRESSION:
1. Endotracheal tube is in satisfactory location.
2. Small left pleural effusion and smaller left retrocardiac
atelectasis. No pulmonary edema or pneumonia.
.
Cardiology Report ECG Study Date of [**2178-3-15**] 1:30:54 PM
Sinus rhythm. Incomplete right bundle-branch block.
Non-specific ST-T wave
changes. No previous tracing available for comparison.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 152 106 348/428 48 12 47
.
CHEST (PORTABLE AP) [**2178-3-16**] 5:16 AM
As compared to the previous radiograph, the patient is now
extubated. The nasogastric tube has also been removed. The PICC
line is in unchanged position. The pre-described right-sided
parenchymal opacity is no longer visible. There is no evidence
of pleural effusion. The size of the cardiac silhouette is
unchanged.
Brief Hospital Course:
This is a 42 year old man with history of EtOH abuse presents to
OSH with abdominal pain, N/V found to have markedly elevated
lipase and evidence of pancreatitis on CT. Now with fever,
rising WBC count and progressive involvement of pancreas and
concern for necrosis at head of pancreas on repeat CTs at OSH.
Does having rising WBC count and fever currently concerning in
this context; remains HD stable however. Although does have
biliary sludge per OSH RUQ U/S, given h/o heavy EtOH, seems more
likely EtOH pancreatitis. TG mildly elevated, no clear
medication causes as only on pain meds post recent arthroscopic
shoulder surgery. No e/o hemorrhagic pancreatitis thus far on
imaging and exam, no e/o splenic thrombosis, calcium normal.
1. Pancreatitis
His lipase of 1678 on admission trended down to 129 by [**3-9**], but
rose to 282 by [**3-12**]. His Hct drifted down from 37 to 28 (some
dilutional effect). Serial abd CTs ([**3-5**], [**3-7**] and [**3-12**]) showed
progression of pancreatitis involving 50% of the pancreas,
specifically the head and uncinate process with phlgemon
formation by the head and severe inflammation; body and tail are
spared. No abscess or focal fluid collection; no splenic or
portal vein thrombosis. Surgery and ID were consulted. Given CT
findings and Hct drop concerning for necrotizing pancreatitis,
cipro and flagyl were started on [**3-12**].
He continued to receive aggressive IVF hydration.
Once extubated, he was no longer complaining of abdominal pain,
his LFT's, Amylase, Lipase trended down.
We were able to advance his diet and he was tolerating a regular
diet at time of discharge.
2. EtOH withdrawal: He developed acute EtOH withdrawal on [**3-7**]
and was transferred to the ICU. He was placed on a CIWA scale
and required large doses of benzos and Dilaudid to control his
withdrawal and pain ([**Month (only) 16**] not available to verify doses upon
admission). He was intubated for airway protection in setting of
agitation and obtundation on [**3-9**].
Once extubated, he required restraints for agitation. This
passed and he was transferred out to the floor and his
withdrawal symptoms subsided.
He was followed by Psych and we followed their recommendations
as far as weaning benzos and tapering the methadone etc. (please
see full note in OMR). He was set up with serviced (AA, NA)
closer to home in [**Location (un) **], ME.
#Hct drop- likely from pancreatitis and dilutional effect from
IVF. Guiaic negative. He was serially examined and HCT
monitored. His HCT remained stable at 29.
Medications on Admission:
oxycontin, percocet
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea, vomiting and abdominal pain.
Pancreatitis
EtOH withdrawal
Leukocytosis
Discharge Condition:
Good
Discharge Instructions:
You were admitted with nausea, vomiting and abdominal pain,
pancreatitis and alcohol withdrawl.
You required an ICU admission and intubation. You have been
weaned off of narcotics, methadone, and benzodiazapams.
You will need services at home to help stay off of alcohol,
narcotics and other medications.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please take any new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
Followup Instructions:
You have an appointment at 10:30am on Monday [**2178-3-23**] with the
Cottage Program at [**Hospital **] Hospital. Call [**Telephone/Fax (1) 78256**] with an
questions.
Please follow-up with your PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 78257**]. Call to
schedule an appointment
Please follow-up with your Psychiatrist. Call to schedule.
Please call BEST: 1-[**Telephone/Fax (1) 20233**] for urgent care psych issues
24hrs/day
Completed by:[**2178-3-20**]
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41,861
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55173
|
Discharge summary
|
report
|
Admission Date: [**2134-8-18**] Discharge Date: [**2134-8-22**]
Date of Birth: [**2052-10-10**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug-eluting stent placement
Permanent Pace Maker
History of Present Illness:
Mrs. [**Known lastname 3866**] is an 81 y/o female with a h/o HTN, HLD and GERD
who presented on [**2134-8-17**] to the [**Hospital3 26615**] Hospital ED c/o of
chest pressure that radiated to her arms, neck and jaw. The
patient had been at home watching TV and lying down in bed.
After 45 minutes of chest pressure she went to the ED. She
reports a similar episode approximately a week pror that
resolved spontaneously after 2-3 hrs. She reports mild SOB with
exertion, but not at rest and denies diaphoresis, dizziness or
nausea. Of note she had a Cardiolite stress test on [**2134-7-9**]
which was negative for ischemia, at that time she was noted to
have an LVEF of 56% by gated study.
.
Per OSH report her EKG on admission showed left bundle branch
block pattern, heart rate 64 beats a minute (which is her
baseline from prior EKGs). At OSH ED, troponins were initially
.04 (positive at their lab). Pain resolved with SL Nitro and
Morphine. In OSH [**Name (NI) **] Pt received ASA 325, Lovenox 1 mg/kg, and
Statin.
.
Cardiology consulted that interpreted the situation as UA,
recommended trending enzymes, Nitro paste 1 in q4-6H, ASA 325,
Lovenox ppx, Low dose BB, Echo, Losartan 40 daily, Atorva 10
daily, Metop 12.5mg po bid, and Cardiac Cath. - Pt received
Cardiac cath on [**8-17**] revealed LAD mid 75% stenosis and 2+
calcification and D2 ostial 50% stenosis, left circumflex mid
30% stenosis, OM3 proximal 40% stenosis, RCA right dominant
vessel with mid 30% and distal 20% stenosis and subsequent to
cath trop peaked at 0.36. A plan was made to transfer her to
[**Hospital1 18**] for intervention. Overnight on telemetry she was noted to
have multiple pauses (third degree AVB and a 7 second pause
around 4am). The pauses were thought to be complete heart block
and a temporary pacer was placed this morning [**8-18**] via left
femoral vein. It's lower rate limit was 50 with an output of 5.
.
Pt transfered to [**Hospital1 18**] cath lab for PCI of LAD(OSH has no
ability to perform PCI) and EP eval.
.
At OSH, Vital signs: T 97.7, BP 115/63, HR 67, RR 20. O2 sat 98%
on room air.
.
Labs and imaging significant for:
(1st set) CPK 87, MB 3.6, Troponin I less than 0.03.
(2nd set) CPK is 90, MB 8.3, troponin-I 0.04.
(3rd set) Troponin-I 0.36
LDL is 137, Na 139, K 4.3, Cl 99, HCO3 30, glucose 123, BUN 28,
Cr 1.2.
.
CXR: WNL per OSH report
.
EKG (OSH): Sinus arrhythmia with ventricular rate about 64 beats
per minute, axis -45, PR interval 0.20, QRS is 0.16; left axis
deviation is noted; left bundle branch block is noted. No
significant change compared to prior EKGs.
.
On arrival to the CCU patient was hemodynamically stable in no
acute distress: HR = 69, BP = 135/74(90), SaO2 94%
.
REVIEW OF SYSTEMS
On review of systems, she endorses chronic knee pain. She does
complain of some epigastric pain at this time, chronic
neuropathy, hand and foot. She denies any chest pain at this
time, fevers, chills, nausea, vomiting, diarrhea at this time.
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- Dyslipidemia,
- Hypertension
- Myalgia with high dose Simvastatin (will confirm with PCP)
- [**2134-7-9**] Cardiolite stress test at OSH which was negative
for ischemia. She was noted to have an LVEF of 56% by gated
study.
- DJD.
- Lumbar radiculopathy.
- Facet joint hypertrophy.
- Spondylolithiasis, Grade I, L4-L5.
Laminectomy, lumbar.
Trochanteric bursitis.
Osteoarthritis.
Osteopenia.
Herpes Zoster.
Cataracts
Vertigo
GERD
Esophagitis
Hypertension
Hyperlipidemia.
s/p Tonsillectomy.
s/p Hysterectomy
s/p Appendectomy.
Social History:
She is divorced. She lives with a daughter.
CIGS - She is an ex-smoker who quit about 40 years ago. She has
a 20 pack-per-year history.
ETOH - She drinks one glass of alcohol qday.
Family History:
Negative for coronary artery disease.
Physical Exam:
ADMISSION:
GENERAL: WDWN elderly female in NAD. Oriented x3. Mood, affect
appropriate. Comfortable and appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no visible JVP.
CARDIAC: RR, normal S1, S2 is split. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, mild TTP in RUQ. No HSM, No abdominial bruits.
EXTREMITIES: No c/c, trace pitting edema in lower extremities
with mild tenderness in calves bilaterally. No Erythema redness
or palpable cords.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT dopplerable
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT dopplerable
DISCHARGE:
GENERAL: Very comfortable, in chair, tolerating full diet,
communicating appropriately, ambulating on own.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no visible JVP.
CARDIAC: RR, normal S1, S2 is split. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Breathing room air. Resp were unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi. - Pacemaker
sight with bandage, clean/dry/intact.
ABDOMEN: Soft. Feels somewhat "bloated" Non tender, non
distended.
EXTREMITIES: No c/c, no edema in lower extremities, no
tenderness in calves. No Erythema redness or palpable cords.
PULSES: Palpable DP/PT
Pertinent Results:
EKG: 66 bpm, sinus, LAD, PR < .2, QRS ~ .15, LBBB-chronic, I,
aVL, V6
.
Stress test ([**2134-7-9**])
The EKG is negative for ischemia. The test is negative for
angina.
The test is negative for arrhythmia. Cardiolite images have
been reported separately.
COMMENT: The patient received a total of 41.4 mg of IV
Persantine over 4 minutes and followed by an injection of
Cardiolite as per protocol. The patient experienced headache and
nausea during testing which resolved shortly after receiving 100
mg of IV aminophylline. Heart rate and blood pressure
response were appropriate. The patient experienced no chest
pain. There were no arrhythmias noted throughout the study.
Electrocardiogram demonstrates no ST-segment changes to suggest
ischemia.
Cardiolite images have been reported separately.
.
[**2134-8-18**] 08:42PM PT-13.2* PTT-32.5 INR(PT)-1.2*
[**2134-8-18**] 08:42PM PLT COUNT-295
[**2134-8-18**] 08:42PM NEUTS-78.2* LYMPHS-13.5* MONOS-6.9 EOS-0.8
BASOS-0.5
[**2134-8-18**] 08:42PM WBC-9.8 RBC-4.44 HGB-13.8 HCT-40.8 MCV-92
MCH-31.1 MCHC-33.8 RDW-12.9
[**2134-8-18**] 08:42PM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.9
[**2134-8-18**] 08:42PM CK-MB-25* MB INDX-9.7* cTropnT-0.88*
[**2134-8-18**] 08:42PM CK(CPK)-259*
[**2134-8-18**] 08:42PM estGFR-Using this
[**2134-8-18**] 08:42PM GLUCOSE-112* UREA N-12 CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
.
([**8-21**]) CXR: The left-sided pacemaker leads terminate in the
expected location of the right ventricle. There is no evidence
of pneumothorax. Heart size is top normal. Mediastinum is
stable. Large hiatal hernia is projecting at the retrocardiac
location. No pleural effusion is seen.
.
([**8-20**]) ECHO:The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the mid to distal septal segments. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. There is an anterior space
which most likely represents a prominent fat pad.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with mildly depressed left ventricular systolic
dysfunction as described above. Increased left ventricular
filling pressure. Mild tricuspid regurgitation. Mild pulmonary
artery systolic hypertension.
.
DISCHARGE:
[**2134-8-22**] 07:42AM BLOOD WBC-8.5 RBC-4.01* Hgb-12.2 Hct-35.9*
MCV-90 MCH-30.5 MCHC-34.0 RDW-13.3 Plt Ct-288
[**2134-8-22**] 07:42AM BLOOD PT-11.4 PTT-35.3 INR(PT)-1.1
[**2134-8-22**] 07:42AM BLOOD Glucose-100 UreaN-21* Creat-0.9 Na-143
K-4.3 Cl-107 HCO3-29 AnGap-11
[**2134-8-22**] 07:42AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8
Brief Hospital Course:
Mrs. [**Known lastname 3866**] is an 81 y/o lady with a h/o HTN, HLD, who
presented with CP diagnosed as NSTEMI at OSH on [**8-17**] and
developed CHB prior to PCI. She was transfered here with
temporary pacing wire, for PCI and EP consult.
.
# NSTEMI: Pt admitted directly to Cath lab, followed by DES to
mLAD. Chest pain significantly resolved when presented to CCU.
In CCU pt was hemodynamically stable, and in sinus rhythm,
occasionally paced with temp transvenous pacer. Patient
presented to OSH with CP that resolved with SL Nitro no ST
changes on EKG and subsequently ruled in with elevated
Troponins. Pt has no prior cardiac interventions and recent
negative stress test. Pt has chronic LBBB, and on our EKG did
not meet SG criteria. At the [**Hospital1 **] cath lab pt received a DES to
the mLAD and bivalrudin 126 mg/hr in addition to aspirin 325 mg,
plavix 75 mg NAC 600 mg and zofran 4 mg. For the NSTEMI, she
was discharged on ASA 325, Plavix 75, Metoprolol tartrate 12.5
mg TID, Atorvastatin 80 mg and Losartan. Repeat Echo here showed
LVEF 45%, anterolateral as well as inferolateral walls at base
and mid level with hypokinesis. On day of discharge pt was
without chest pain, no SOB, ambulating on her own, and cleared
by PT for home PT. Pt was tolerating a full diet, moving her
bowels, and no difficulty urinating.
.
# Complete Heart Block: Pt was found to be in CHB at OSH, temp
transvenous pacer was placed while at OSH, then transferred here
for EP consult in addition to therapeutic Cath. In CCU pt was in
sinus rhythm and using the pacemaker frequently. Received
permanent pacemaker on [**8-21**]. The procedure was without
complications.
.
# PUMP: No s/s of CHF currently or in the past. Euvolemic on
exam. Although on Lasix per outpatient records. Per report,
Cardiolite stress test on [**2134-7-9**] at OSH was negative for
ischemia. She was noted to have an LVEF of 56%. Repeat Echo
here showed LVEF 45%, anterolateral as well as inferolateral
walls at base and mid level with hypokinesis. She did not
require diuresis while inpatient and was euvolemic to slightly
negative during this hospitalization.
.
# Hypertension: Pt was normotensive during this admission. At
home on lasix, which was not given during this admission. She
was continued on Metoprolol tartrate 12.5 mg TID, and Losartan
was restarted prior to discharge.
.
#GERD: we continued home omeprazole while hospitalized.
.
#[**Last Name (un) **]: Cr 1.2 at OSH. Cr was .8-.9 during entire course here.
.
#Depression: Stable on citalopram 20mg daily which was continued
while inpatient.
.
TRANSITIONAL:
- Cardiologist Dr. [**Last Name (STitle) 112538**]
- f/u in device clinic in 1 week
- Pt at high risk of sCHF given Anterior Lateral MI with EF 45%.
- FULL CODE
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Losartan Potassium 50 mg PO DAILY
hold for sbp < 100, hr < 55
2. Omeprazole 20 mg PO DAILY
3. Furosemide 40 mg PO DAILY
hold for sbp < 100, hr < 55
4. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
hold for sbp < 100, hr < 55
3. Omeprazole 40 mg PO BID
4. Aspirin EC 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
5. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
6. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
7. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
NSTEMI (Heart attack)
Complete Heart Block (abnormal Hearth Rhythm)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 3866**],
You were admitted to [**Hospital1 69**] after
presenting with complaints of chest pain. You were found to be
having a heart attack and were taken urgently to the
catheterization lab where it was found that one of the arteries
supplying blood to the heart muscle was blocked. This was
treated by placing a stent in the artery to keep it open. You
were started on a medication call Plavix which is similar to a
"super aspirin" that helps to keep the artery open after having
a stent placed. It is very important that you take this new
medication daily until instructed to stop by your cardiologist,
Dr. [**Last Name (STitle) 77919**].
In addition, you were also found to have a abnormal heart rhythm
called "heart block" which prevented your heart from beating
normally and required a permanent pace maker which was placed
during this admission.
It was a pleasure taking care of you, we hope that you have
speedy recovery!
Followup Instructions:
Since we are discharging you on a Sunday, we are unable to
schedule follow-up appointments for you. However, it is
imperative that you be seen for follow-up from your recent
hospitalization with the following providers:
1) Please schedule an appointment to see your primary care
physician within one week from discharge for routine follow-up
for your recent hospitalization.
Name: NASEER,SAIRA
Location: [**Location (un) **] INTERNAL MEDICINE
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 13312**]
Fax: [**Telephone/Fax (1) 112539**]
2) Please schedule an appointment to see your Cardiologist Dr.
[**Last Name (STitle) 77919**] within the next month to follow-up with him regarding
your recent heart attack:
NAME: [**Last Name (STitle) **], [**Last Name (un) **]
ADDRESS: [**Last Name (NamePattern1) **] Suite A
[**Location (un) 5028**], [**Numeric Identifier 12023**]
PHONE: ([**Telephone/Fax (1) 110136**] (Office)
3) Please make an appointment with Cardiology at [**Hospital1 18**] to set
up an appoinmtent to have your pacemaker checked in the device
clinic in 7 days:
NAME: [**Last Name (LF) **], [**Name8 (MD) **] MD / OR ANYONE AT THE DEVICE CLINIC
Office Location: [**Location (un) **] 418, [**Hospital Ward Name 23**] Clinical Center
PHONE: ([**Telephone/Fax (1) 20575**]
Completed by:[**2134-8-23**]
|
[
"780.4",
"733.90",
"272.4",
"241.0",
"530.81",
"530.10",
"V15.82",
"726.5",
"E942.2",
"410.71",
"721.3",
"426.0",
"311",
"414.01",
"401.9",
"715.90",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"37.22",
"00.66",
"37.71",
"37.82",
"99.69",
"36.07",
"00.40",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13222, 13271
|
9490, 12251
|
280, 360
|
13382, 13382
|
6229, 9467
|
14553, 15940
|
4592, 4631
|
12585, 13199
|
13292, 13361
|
12277, 12562
|
13565, 14530
|
4646, 6210
|
230, 242
|
388, 3784
|
13397, 13541
|
3806, 4376
|
4392, 4576
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,918
| 110,876
|
9929
|
Discharge summary
|
report
|
Admission Date: [**2119-7-13**] Discharge Date: [**2119-7-18**]
Date of Birth: [**2038-12-16**] Sex: F
Service: SURGERY
Allergies:
Macrodantin / Fentanyl / Dilaudid
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic right foot
Major Surgical or Invasive Procedure:
Right femoral above-knee popliteal bypass with 6 mm PTFE graft.
History of Present Illness:
This 80-year-old lady with extensive peripheral [**First Name3 (LF) 1106**] disease
status post a failed graft in her left leg and a below-the-knee
amputation. She has also had iliac artery angioplasties in the
past. She has developed ischemic rest pain in her right foot. An
arteriogram showed that she had a superficial femoral artery
occlusion with reconstitution of the diseased above-knee
popliteal artery
with 2-vessel runoff distally. She has no usable conduit left.
Past Medical History:
HTN
spinal stenosis
PVD, s/p L CFA-BK [**Doctor Last Name **] [**7-16**], R CEA, s/p angioplasty R CIA/L
fempop graft [**11-15**] c/b CIA disruption requiring covered stent,
repeat angioplasty/stent of distal bpg anastamosis, thrombectomy
of L PT [**2118-3-16**]
Social History:
Smoker
No alcohol
Family History:
Non contributary
Physical Exam:
a/o x 3
nad
grossly intact
cta
rrr
abd - benign
surgical inc c/d/i
dopplerable DP/PT
Pertinent Results:
[**2119-7-18**] 06:06AM BLOOD
WBC-9.9 RBC-3.57* Hgb-10.5* Hct-31.3* MCV-88 MCH-29.5 MCHC-33.6
RDW-15.4 Plt Ct-517*
[**2119-7-18**] 10:40AM BLOOD
PT-33.5* PTT-37.2* INR(PT)-3.6*
[**2119-7-18**] 06:06AM BLOOD
Glucose-89 UreaN-29* Creat-1.3* Na-142 K-4.2 Cl-108 HCO3-26
AnGap-12
[**2119-7-18**] 06:06AM BLOOD
Calcium-9.4 Phos-3.5 Mg-1.9
[**2119-7-18**] 06:06AM BLOOD
WBC-9.9 RBC-3.57* Hgb-10.5* Hct-31.3* MCV-88 MCH-29.5 MCHC-33.6
RDW-15.4 Plt Ct-517*
Brief Hospital Course:
Mrs. [**Known lastname **],[**Known firstname **] T was admitted on [**2119-7-13**] with an ischemic
right foot. Sheagreed to have an elective surgery.
Pre-operatively, she was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
It was decided that she would undergo a Right femoral above-knee
popliteal bypass with 6 mm PTFE graft
.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She as then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care.When stable she wa
delined. His diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status.
While in VICU coumadin was started. Her INR was followed in the
usual manner.
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. Shecontinues to make steady progress
without any incidents. She was discharged home with vna
To note she has been set up to have her inr checked by her PCP.
[**Name10 (NameIs) **] DC her inr is 3.6 / down from 4.1.
Medications on Admission:
gaba 400''',plavix 75',furosemide 20',lipitor 40' ecotrin 81',
lisinopril 5', lopressor ?
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Warfarin 1 mg Tablet Sig: half of tablet Tablet PO HS (at
bedtime): your goal INR is [**1-14**]. You must have your INR checked
by your PCP this has been arranged.
Disp:*30 Warfarin (Oral) 1 mg Tablet* Refills:*2*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed. Tablet(s)
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
Ischemic right foot.
Discharge Condition:
Good
Discharge Instructions:
Division of [**Month/Day (3) **] and Endovascular Surgery Lower Extremity
Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-14**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
COUMADIN (WARIFIN)
What is warfarin?
Warfarin is the generic name for Coumadin?????? (brand or trade
name).
Warfarin belongs to a class of medications called
anticoagulants, which help prevent clots from forming in your
blood and or keep grafts open.
Why am I taking warfarin?
You are taking warfarin because you have a medical condition
that puts you at risk for forming dangerous blood clots, or to
keep open vessels that have stents and or vessels that allow
blood to flow for ischemic leg symptoms.
How do I take warfarin?
Warfarin is taken once daily at the same time every day,
preferably in the evening, with or without food.
If you miss a dose of warfarin, take the missed dose as soon as
possible on the same day. If you forget, do not double up the
next day! Write the day of your missed dose on your calendar and
let your health care provider know at your next visit.
Why is warfarin use monitored so carefully?
Warfarin is a medication that requires careful and frequent
monitoring to make sure that you are being adequately treated,
but not over- or under-treated. If you have too much warfarin in
your body, you may be at risk for bleeding. If you have too
little warfarin in your body, you may be at risk for forming
dangerous blood clots. Medications, food and alcohol can also
interfere with warfarin, making close monitoring even more
important.
What is INR?
INR, which stands for International Normalized Ratio, is a blood
test that helps determine the right warfarin dose for you.
The INR tells us how much warfarin is in your bloodstream and is
a measure of how fast your blood clots.
A high INR means you are more likely to bleed (your blood does
not clot very fast).
A low INR means you are more likely to form a clot (your blood
clots very fast).
All patients will have an INR goal depending on their medical
condition(s), yours is [**1-14**].
What are the possible side effects of warfarin?
The major side effect of warfarin is bleeding (especially when
your INR is too high). Here are some symptoms of bleeding to
look for and to report to your health care provider:
[**Name10 (NameIs) 33276**] bruising or bruises that won't heal
Bleeding from your nose or gums
Unusual color of urine or stool (including dark brown urine, or
red or black/tarry stools)
What do I need to know about drug interactions with warfarin?
Many drugs can potentially interfere with warfarin and may cause
your INR to change, putting you at risk for bleeding or a clot.
These drugs include prescription medications, over-the-counter
medications (like aspirin, ibuprofen, naproxen), and dietary and
herbal supplements. They should be avoided unless otherwise
directed by health provider. [**Name10 (NameIs) **] should take your Aspirin as
directed.
What role does my diet play?
The amount of vitamin K in your diet may affect your response to
warfarin. Certain foods (like green, leafy vegetables) have high
amounts of vitamin K and can decrease your INR. You do not have
to avoid foods high in vitamin K, but it is very important to
try to maintain a consistent diet every week.
What about alcohol?
Alcohol use also may affect your response to warfarin. Excessive
use can lead to a sharp rise in your INR. It is best to avoid
alcohol while you are taking warfarin.
Safety Tips
Carry a wallet ID card and/or wear an emergency alert bracelet
Tell all health care providers (physicians, nurses, pharmacists,
dentists, etc.) that you are taking warfarin, especially if you
have any planned surgeries or procedures.
Alert your health care provider if you are pregnant or become
pregnant while taking warfarin.
Plan ahead when traveling by having enough warfarin and arrange
for follow-up blood tests. It is also important to keep your
diet consistent.
Avoid any sport or activity that may result in a serious fall or
injury.
Use a soft-bristled toothbrush to protect your gums.
Use an electric razor if you are prone to cut yourself when
shaving.
Call Dr[**Name (NI) 5695**] office if you have any questions regarding
your new medication.
Followup Instructions:
Call Dr [**Last Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 3121**] and schedule an
appointment for two weeks.
YOU HAVE BEEN SET UP TO HAVE YOUR INR CHECKED. THIS IS VERY
IMPORTANT FOR COUMADIN CAUSES BLEEDING. YOUR GOAL INR IS [**1-14**].
YOUR INR ON DISCHARGE IS 4.1. THIS IS HIGH. YOUR COUMADIN DOSE
HAS BEEN LOWERED. VNA WIIL COME TO YOUR HAOUSE AND DRAW YOUR
INR, THEY WILL DR [**First Name (STitle) **] OFFICE KNOW. HE WILL ADJUST YOUR
COUMADIN FROM THERE. PHONE NUMBER IS [**Last Name (LF) **],[**First Name3 (LF) 2671**] T.
[**Telephone/Fax (1) 33277**].
Completed by:[**2119-7-18**]
|
[
"440.22",
"428.0",
"V49.75",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
4312, 4360
|
1842, 3297
|
314, 380
|
4425, 4432
|
1360, 1819
|
11333, 11947
|
1221, 1239
|
3437, 4289
|
4381, 4404
|
3323, 3414
|
4456, 6855
|
6881, 11310
|
1254, 1341
|
255, 276
|
408, 883
|
905, 1169
|
1185, 1205
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,823
| 112,546
|
49774
|
Discharge summary
|
report
|
Admission Date: [**2124-10-4**] Discharge Date: [**2124-10-9**]
Date of Birth: [**2045-11-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
recurrent mass
Major Surgical or Invasive Procedure:
Craniotomy with resection mass
History of Present Illness:
The patient is a 78-year-old female who is well-
known to neurosurgery service from previous hospitalizations as
well as from
surgery in [**2121**]. The patient had been diagnosed with an
atypical meningioma. The patient was previously irradiated
and underwent a gross total resection, [**Doctor Last Name 18741**] grade 2, in
[**2123-3-20**]. The patient has been followed sequentially with
MRI scans. The patient now re-presents with an enlarging
recurrent tumor on the left side posterior to the resection
bed and abutting the falx. The lesion causes significant mass
effect as well as perifocal edema. The patient has shown
progressive weakening on the right side. The patient was,
therefore, extensively counseled. Since conservative means
are rather exhausted in her case, the family agreed to
proceed with a second resection. The patient was extensively
counseled. The patient was consented. The patient was aware
of the risks and benefits of the procedure. The patient was
then taken electively to the operating room on [**2124-10-4**].
Past Medical History:
Parasagittal meningioma
HTN
Glaucoma
Right wrist fracture
Recent dental tooth extraction
Left rotator cuff repair with LUE weakness
Pelvic prolapse repair
Cataract extraction
Soft diet
.
Past Surgical History:
Pelvic prolapse repair
Cyberknife [**9-22**]
cataract resection
s/p bifrontal craniotomy and resection of parasagittal
meningioma [**2123-4-15**]
Social History:
Originally from [**Location (un) 3156**], lives w/husband (who recently had a
mild stroke) in [**Location (un) **]; one son, no [**Name2 (NI) **]/etoh/drugs. Not
working, no prior career.
Family History:
No illnesses per patient
Physical Exam:
Exam After Patient Medically clear for discharge.
T:97.7 P:96.9 HR:64 BP:96/52 RR:18 SaO2:97%RA
Awake alert oriented x3
Eyes open
Follows commands.
Articulate, intelligent, appropriate.
No dysarthria.
Strength is likely full but the exam is limited by poor effort.
Weakness in the right lower extremity greater than the left but
strength exam is limited by patient effort. Has at least [**12-24**]
strength in the IP, Quad, and hamstring on the right. Strength
is [**3-23**] in the IP and quad on the left.
Senation intact to light touch.
Reflexes symmetrical.
Toes upgoing on the right, mute on the left.
Pertinent Results:
[**2124-10-4**] 03:05PM GLUCOSE-159* UREA N-14 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13
[**2124-10-4**] 11:41AM GLUCOSE-100 LACTATE-1.1 NA+-132* K+-3.7
CL--102
[**2124-10-4**] 10:17AM HGB-11.7* calcHCT-35 O2 SAT-99
[**2124-10-8**] 08:10AM BLOOD WBC-9.9 RBC-3.87* Hgb-11.5* Hct-34.0*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.6 Plt Ct-265
[**2124-10-8**] 08:10AM BLOOD Glucose-96 UreaN-20 Creat-0.7 Na-140
K-4.3 Cl-103 HCO3-31 AnGap-10
[**2124-10-6**] 05:00AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.8
CT-Head without contrast: [**2124-10-4**]: IMPRESSION: Status post left
frontal craniotomy, with post-procedural changes seen at the
vertex, likely a small amount of hemorrhage at the resection
site. No shift of midline structures identified. Expected
pneumocephalus seen, as noted above.
CXR [**2124-10-4**]: IMPRESSION: Right subclavian line entering the
internal jugular. ET tube at the carina. An NG tube in the
distal esophagus.
MR [**Name13 (STitle) 430**] With Contrast [**2124-10-4**]:
IMPRESSION: Relatively unchanged (or very slightly larger) left
parasagittal enhancing meningioma and postoperative sequela.
MR [**Name13 (STitle) 430**] with and without contrast [**2124-10-5**]:
IMPRESSION: Anticipated post-surgical changes. No definite
abnormal enhancement to indicate residual tumor. Bilateral
parietal T2 hyperintensities, secondary to vasogenic edema, are
unchanged.
Brief Hospital Course:
78 Russian woman with recurrent meningioma admitted for surgical
resection.
PRINCIPAL PROCEDURE PERFORMED on [**2124-10-4**]:
1. Bifrontal redo craniotomy for resection of predominantly left
recurrent meningioma.
2. Intraoperative image guidance.
3. Microscopic dissections.
4. Duraplasty.
5. Central line placement.
Patient was given Dexamethasone post operatively.
Patient started on Cipro for urinary tract infection.
Patient recovered very well after the operation. She complained
of zofran responsive nausea on the day of discharge.
Medications on Admission:
This list was obtained from prior Neuro-oncology note.
AFO --R afo qd while walking pt with r foot drop, please fit new
r afo
ARTHROTEC 50 50 mg-0.2 mg--one tablet(s) by mouth three times a
day as needed for as needed for pain
DARVOCET-N 50 50 mg-325 mg--one tablet(s) by mouth three times a
day as needed for for pain
KEPPRA 250 mg--1 tablet(s) by mouth twice a day increase as
directed to 4 tabs [**Hospital1 **]
MOBIC 7.5 mg--1 tablet(s) by mouth [**Hospital1 **] start at 1 tab [**Last Name (LF) **], [**First Name3 (LF) **]
increase to 2 tabs after one week if not enough effect.
PAMELOR 10 mg--1 capsule(s) by mouth at bedtime increase by 1
tab qweek to a max dose of 4 tabs qhs. hold increase if enough
effect at a lower dose or excess sedation
No medications DC'd on [**2124-9-8**].
Medications prescribed on [**2124-9-8**]:
DEXAMETHASONE 2 mg--2 tablet(s) by mouth twice a day
DILANTIN 100 mg--1 capsule(s) by mouth at bedtime
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Meningioma
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? 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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN ____________DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN _______WEEKS.
YOU WILL / WILL NOT NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT
CONTRAST
YOU WILL/WILL NOT NEED AN MRI OF THE BRAIN WITH OR WITHOUT
GADOLIDIUM
Completed by:[**2124-10-9**]
|
[
"225.2",
"729.89",
"780.39",
"401.9",
"599.0",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
5691, 5770
|
4156, 4700
|
334, 367
|
5825, 5849
|
2716, 4133
|
7219, 7605
|
2045, 2071
|
5791, 5804
|
4726, 5668
|
5873, 7196
|
1675, 1823
|
2086, 2697
|
280, 296
|
396, 1443
|
1465, 1652
|
1839, 2029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,907
| 165,405
|
39222
|
Discharge summary
|
report
|
Admission Date: [**2133-1-24**] Discharge Date: [**2133-1-31**]
Date of Birth: [**2056-12-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
septic shock, respiratory failure
Major Surgical or Invasive Procedure:
see hospital course
History of Present Illness:
This is a 76yoF, who was admitted to an OSH for a lap chole on
[**2133-1-22**]. Post-op, she complained of abdominal pain, later
developing peritonitis, hypotension and respiratory failure. CT
scan abdomen showed excessive free fluid in the abdomen, ?
portal venous gas and ? leakage of contrast. She returned to the
OR on [**2132-1-25**] for exploratory laparatomy, and was found to have
turbid, cloudly abdominal free fluid (appearing to be succus
mixed with bile) with a small area of bile leakage from the
cystic duct with displacement of one of the clips. The abdomen
was irrigated. Additionally a portion of the small bowel was
noted to be dusky, and this portion was resected with a side to
side functional end to end anastomosis. At transfer back to the
ICU, the patient was hypotensive, and was started on leveophed,
vasopressin and norepinephrine. She was noted to be acidemic
with a PH of 7.2, base deficit of 15 and hypoxic on 100% FiO2
and PEEP 6. She was started on a bicarb drip. She was given
hydrocortisone 100mg IV for possible hypoadrenalism. She was
subsequently transfered to [**Hospital1 18**] for additional management.
Past Medical History:
PMH: HTN, depression, hypothyroidism, choledocholithiasis
PSH: ERCP with sphincterotomy
Social History:
no EtOH, tobacco. Married w. two daughters.
Family History:
non-contributory.
Physical Exam:
On admission:
VS: T 93.3 HR 76 BP 115/64 RR 22 O2sat 99% on CMV/AC
ventilation: FiO2 100% TV 500 PEEP 12
Gen: intubated, sedated, ill-appearing, mottled skin
Pulm: fairly CTA bilat
CV: RRR no murmurs, palpable fem and PT pulses
Abd: distended, hypoactive BS, dressings in places, wounds c/d/i
Ext: 1+-trace edema
Pertinent Results:
02/13/[**Numeric Identifier 86816**]:33p
pH 7.08 pCO2 37 pO2 80 HCO3 12 BaseXS -18
Glu:90
freeCa:1.05
Lactate:12.9
140 104 35 AGap=32
-------------99
4.8 9 1.9
CK: 703 MB: Pnd Trop-T: Pnd
Ca: 7.3 Mg: 1.5 P: 6.2
ALT: 1467 AP: 79 Tbili: 1.0 Alb: 1.7
AST: 2139 LDH: Dbili: 0.8 TProt:
[**Doctor First Name **]: Lip: 20
9.8
5.2 --- 110
32.5
N:53 Band:25 L:15 M:4 E:0 Bas:1 Metas: 2
Hypochr: OCCASIONAL Poiklo: 2+ Polychr: OCCASIONAL Burr: 2+
PT: 26.7 PTT: 61.8 INR: 2.6
Fibrinogen: 337
Rads:
OSH CT abd [**2133-1-23**]: portal venous air pneumatosis and abnormal
distension of loops of small bowel c/f ischemia; increased
density ascites around liver and lower pelvis c/f extravasated
oral contrast. Oral contrast in CBD and gallbladd fossa probably
the source of extrav. Heterog collection of air anterior to the
left pericardial fat pad superior to the diaphragm. Possibly
post-surgical.
OSH CXR [**2133-1-24**]: no PTX s/p subclav line placement, unilateral
hazy opacity of R lung possibly due to patient position, unilat
CHF or R-sided infiltrates. Tip of ETT in satisfactory position.
OSH echo [**2133-1-24**]: LVEF 20-25%. LV normal size. Mildly thickened
aortic valve. Mild to mod mitral regurg. Small pericardial
effusion. bilat pleural effusion. Right vent global systol fxn
is
mod reduced. The free wall of the r vent appears hypkinetic. R
atrium is mildly dilated. R vent syst poresure calc at 17mmhg.
Brief Hospital Course:
Patient was transfered to [**Hospital1 18**] TSICU on [**2133-1-24**] where she
was fluid resuscitated, and maintained on pressors and bicarb
drip. She was intubated with a PEEP of 20. During her hospital
stay she developed Afib and was treated with an amiodarone drip.
She was in renal and hepatic failure on presentation; her
initial lactate peaked at 20.7. She received FFP, packed red
blood cells, albumin, and started on CVVH.
On the day of arrival ([**2133-1-24**]) She went to the OR for ex-lap
and washout. Her splenic flexure was found to be necrotic and
was resected without re-anastomosis, leaving a Hartmann's pouch.
The TI was noted to be ischemic, but not necrotic. Uterus, and
bilateral tubes/ovaries were ischemic. The abdomen was left open
for planned second look on [**1-25**].
[**2133-1-25**], patient returned to the OR for completion colectomy
and TI resection due to persistent ischemia with necrosis. The
abdomen was left open for planned third look on [**1-26**].
[**2133-1-26**], patient returned to the OR for resection of necrotic
uterus and ovaries. And ileotomy was created, and a J tube and G
tube were placed. A leak was noted at the anastomosis site from
her initial bowel resection at [**Location (un) **], and the anastomosis site
was resected, and the bowel was re-anastomosed. Abdomen was
closed using [**State 19827**] patch of facia.
Following these surgeries pressor requirements, and PEEP
initially decreased. Lactate fell to a low of 3.4. LFTs improved
throughout her hospital course. Patient was empirically treated
with Vancomycin, Meropenem, and Ciprofloxacin. Cultures of
blood, and urine were positive for [**Female First Name (un) **], and negative for
bacterial growth. Micafungin was added to cover [**Female First Name (un) **].
On [**2133-1-29**] pressor requirements increased, and PEEP was
increased. Patient was noted to have thigh erythema bilaterally,
with extension into abdominal wall. Abdominal wall fasia became
rapidly necrotic consistent with necrotizing fasciitis.
On [**2133-1-30**] a family meeting was held where the decision was
made to maintain the patient on care measures only. IV morphine
was started. All pressors and antimicrobials were discontinued,
amiodarone was held, CVVH was discontinued; the family decided
to keep the patient intubated.
Medications on Admission:
lisinopril
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock
Discharge Condition:
same
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"567.29",
"785.52",
"997.4",
"E878.8",
"614.0",
"728.86",
"584.5",
"276.2",
"998.59",
"311",
"112.2",
"401.9",
"112.5",
"995.92",
"244.9",
"615.0",
"557.0",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"65.61",
"39.95",
"46.39",
"45.76",
"38.91",
"45.75",
"43.19",
"38.95",
"38.93",
"45.62",
"96.72",
"45.73",
"68.39",
"46.21",
"45.74"
] |
icd9pcs
|
[
[
[]
]
] |
5988, 5997
|
3569, 5895
|
347, 368
|
6053, 6059
|
2106, 3546
|
6115, 6125
|
1732, 1751
|
5956, 5965
|
6018, 6032
|
5921, 5933
|
6083, 6092
|
1766, 1766
|
274, 309
|
396, 1544
|
1780, 2087
|
1566, 1655
|
1671, 1716
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,162
| 194,362
|
33435
|
Discharge summary
|
report
|
Admission Date: [**2189-3-12**] Discharge Date: [**2189-3-17**]
Date of Birth: [**2171-11-23**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall from moving vehicle
Major Surgical or Invasive Procedure:
None
History of Present Illness:
17 yo female who was brought to [**Hospital1 18**] Emergency room
on [**2189-3-12**] at ~1130 am shortly after falling out of a convertible
travelling at ~50 mph while riding in the back sitting on the
trunk. On arrival she was able to give her first name, moving
all four extremities reportedly without focality. However, she
was agitated and combative. She was noted to be hypertensive
and bradycardic and was intubated as a result. CT head
reportedly showed a SDH and a neurosurgical consult was called.
Past Medical History:
ADHD
Social History:
High school student
Lives with her mother
Family History:
Noncontributory
Physical Exam:
Upon admission to ED:
T: 97.5 P: 83 R: 14 BP: 121/64 Sp02: 100% NRB
Gen: Oriented to person, mildly agitated, combative
HEENT: scalp hematoma, blood and ? csf from L ear. Airway
patent. PERRLA 4->2
Neck: trachea midline, no masses
Chest: Lungs CTA, RRR
Abd/Pelvis: soft, NT, ND. Pelvis stable
Extremities: LUE with forearm/hand abrasion
Neuro: GCS initially 12 (E3V3M6), changed to 8 (E2V1M5) while in
ED.
Pertinent Results:
CT HEAD #1 IN ED HD #0 11:55AM: 1. Right-sided subdural hematoma
with associated contusion/intraparenchymal hemorrhage within the
right temporal lobe and slight shift of normally midline
structures leftward. 2. Longitudinal fractures through left
temporal bone with extension into the middle ear. 3. Left
parietal scalp hematoma.
CT HEAD #2 IN TSICU HD#0 4:12PM: 1. Unchanged appearance of
right-sided subdural hematoma. 2. Increased size of subjacent
right intraparenchymal hematoma/hemorrhagic contusion, with
increased surrounding edema. However, effacement of nearby
sulci, and mass effect on the frontal [**Doctor Last Name 534**] of the right lateral
ventricle is unchanged, and slight leftward subfalcine
herniation is also unchanged.
3. Unchanged appearance of longitudinal fractures through left
temporal bone, extending into the left middle ear. Ossicles on
the left are poorly
visualized.
CT HEAD #3 IN TSICU HD#1 4:11AM: Essentially unchanged
examination of right intraparenchymal hemorrhage with
accompanying right-sided subdural hematoma compared to
examination 12 hours prior. Unchanged mass effect as noted.
CT ABD PELVIS IN ED: No evidence of traumatic injury in the
abdomen and
pelvis.
CT C-SPINE IN ED: No CT evidence of fracture or subluxation.
CXR IN ED: No acute cardiopulmonary process.
[**2189-3-12**] 03:07PM TYPE-[**Last Name (un) **] PH-7.30*
[**2189-3-12**] 03:07PM LACTATE-2.6*
[**2189-3-12**] 03:07PM freeCa-1.07*
[**2189-3-12**] 02:23PM GLUCOSE-138* UREA N-7 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-21* ANION GAP-15
[**2189-3-12**] 02:23PM ALBUMIN-3.6 CALCIUM-7.7* PHOSPHATE-1.1*
MAGNESIUM-1.6
[**2189-3-12**] 02:23PM PHENYTOIN-15.6
[**2189-3-12**] 02:23PM NEUTS-92.0* BANDS-0 LYMPHS-5.8* MONOS-1.8*
EOS-0.3 BASOS-0.1
[**2189-3-12**] 02:23PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2189-3-12**] 02:23PM PLT SMR-NORMAL PLT COUNT-271
[**2189-3-12**] 11:45AM URINE HOURS-RANDOM
[**2189-3-12**] 11:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2189-3-12**] 11:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2189-3-12**] 11:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2189-3-12**] 11:34AM PH-7.34* COMMENTS-GREEN TOP
[**2189-3-12**] 11:34AM GLUCOSE-172* LACTATE-2.9* NA+-139 K+-3.5
CL--105 TCO2-21
[**2189-3-12**] 11:34AM HGB-14.1 calcHCT-42 O2 SAT-96 CARBOXYHB-4 MET
HGB-0
[**2189-3-12**] 11:34AM freeCa-1.10*
[**2189-3-12**] 11:05AM UREA N-9 CREAT-0.7
[**2189-3-12**] 11:05AM AMYLASE-88
[**2189-3-12**] 11:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-3-12**] 11:05AM WBC-9.1 RBC-4.62 HGB-13.5 HCT-37.7 MCV-82
MCH-29.2 MCHC-35.7* RDW-12.9
[**2189-3-12**] 11:05AM PLT COUNT-293
[**2189-3-12**] 11:05AM PT-13.2 PTT-26.0 INR(PT)-1.1
[**2189-3-12**] 11:05AM FIBRINOGE-203
Brief Hospital Course:
She was admitted to the Trauma Surgery Service and taken to the
Trauma ICU for close monitoring. Neurosurgery was consulted
given her injuries; she was loaded with Dilantin and serial head
CT scans were followed. She remained intubated for the first
several days; her sedation was weaned and she did awaken and was
eventually extubated. She was later transferred to the floor;
her mental status continued to improve significantly; she is
awake and alert, cooperative and conversant. On HD#5 she
complained of left ear pain (noted with longitudinal temporal
bone fracture extending into the left middle ear). ENT was
consulted as a result. She was started on Floxin ear drops and
will require an outpatient audiogram in the next 2 weeks.
Physical and Occupational therapy were consulted and have
recommended home. She is being discharged to home with her
mother. She will follow up with Neurosurgery in 4 weeks, for
repeat head imaging; the Dilantin will continue for a month.
Follow up also with Behavioral Neurology and ENT in the next 2
weeks.
Medications on Admission:
Fluoxetine 30'
Strattera 100'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Fluoxetine 20 mg Tablet Sig: 1 [**1-7**] Tablet PO once a day.
3. Strattera 100 mg Capsule Sig: One (1) Capsule PO once a day.
4. Dilantin Infatabs 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO every eight (8) hours.
Disp:*90 Tablet, Chewable(s)* Refills:*0*
5. Ofloxacin 0.3 % Drops Sig: Two (2) Otic TID (3 times a day):
instill in left ear.
Disp:*1 bottle* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Fall
Right-sided subdural hematoma with associated
contusion/intraparenchymal
hemorrhage within the right temporal lobe
Longitudinal fractures through left temporal bone with extension
into the
middle ear.
Left parietal scalp hematoma
Discharge Condition:
Good
Discharge Instructions:
RETURN TO THE EMERGENCY ROOM IMMEDIATELY IF YOU EXPERIENCE ANY
OF THE FOLLOWING:
?????? New onset of tremors or seizures
?????? Increased confusion or changes 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, drainage
?????? Fevers/chills
And for any other symptoms that are concerning to you.
It is not uncommon for you to experience intermittent headaches,
dizziness and problems with short term memory because of your
head injury.
CONTINUE the Dilantin for 1 month until follow up with
Neurosurgery.
Continue with the Floxin medication for your ear as directed by
ENT until follow up appointment in the next 2 weeks.
You may resume your home medications.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Neurosurgery, in 4 weeks. Inform the
office that you will need a repeat head CT scan for this
appointment. Call [**Telephone/Fax (1) 1669**] for an appointment.
Follow up in Behavioral [**Hospital 878**] Clinic with either Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next 2-3 weeks. Call
[**Telephone/Fax (1) 1690**].
Follow up with Dr. [**First Name (STitle) **], ENT for an Audiogram (hearing test)
within the next 2 weeks, call [**Telephone/Fax (1) 2349**] for an appointment.
Completed by:[**2189-3-17**]
|
[
"801.16",
"314.01",
"E849.5",
"E818.1",
"920"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6124, 6130
|
4490, 5538
|
344, 351
|
6413, 6420
|
1453, 4467
|
7329, 7994
|
995, 1012
|
5618, 6101
|
6151, 6392
|
5564, 5595
|
6444, 7306
|
1027, 1434
|
276, 306
|
379, 892
|
914, 920
|
936, 979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,633
| 178,630
|
53431
|
Discharge summary
|
report
|
Admission Date: [**2148-8-14**] Discharge Date: [**2148-8-21**]
Service: [**Hospital1 **] MEDICINE
HISTORY OF PRESENT ILLNESS: This is an 89-year-old female
with history of hypertension, who is admitted postfall on her
knees secondary to questionable dizzy spell with no loss of
consciousness. She was admitted for dehydration and elevated
CKs to rule out myocardial infarction, but now also being
worked up with findings consistent with rabdo picture and
treated with IV fluids.
In ED her vitals were temperature of 97.0, blood pressure of
182/99, heart rate of 96, respiratory rate of 34, and O2
saturation of 92% on room air. Patient in the ED was given
Aldomet 250 mg, aspirin, Lopressor, and 1.5 liters of normal
saline. She also got a CT without contrast, which was
negative. A chest x-ray and plain films and bilateral hips
were negative.
HOME MEDICATIONS:
1. Aldomet 1.5 tablet t.i.d.
2. Vasotec 5 mg q.d.
3. Maxzide half a tablet q.d.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Eye implants in [**2134**].
3. History of DVT, which she was treated for six months with
Coumadin in [**2142**].
SOCIAL HISTORY: No tobacco, no ethanol, and no drugs. Lives
alone in [**Location (un) **] Senior Center. No stairs, housebound.
Son and daughter live in [**Name (NI) 1411**] and [**Name (NI) 745**] respectively. He
was born in [**Country 4754**].
On admission, her T max was 98, T current was also 98, BP was
133-145/75-77, heart rate was 76-80, respiratory rate was 16,
O2 saturation was 96% on 2 liters.
PHYSICAL EXAM: She was lying down in no acute distress,
appeared to be comfortable. HEENT: Slightly dry membrane
mucosa. Eyes: Her pupils were sluggishly reactive to light
and her extraocular movements were not intact and with
questionable visual changes, decreased vision in both eyes.
Neck: No LAD, no JVD noted, no carotid bruits. Thyroid was
not palpable. Respiratory: She had these high-pitched
expiratory wheezes bilaterally, no rales or rhonchi.
Cardiovascular: Regular, rate, and rhythm, normal S1, S2, no
S3, S4. Abdomen: Nondistended, nontender, soft, plus bowel
sounds in all quadrants, no hepatosplenomegaly. Extremities:
2+ pitting edema in the lower extremities, no clubbing or
cyanosis. Pulses were palpable 1+. Neurologically, she was
alert and oriented times three. Cranial nerves III, IV, and
VI slow for extraocular motors, not fully intact. Other
cranial nerves were intact. Her deep tendon reflexes were
intact. Her motor strength was [**3-23**] throughout. Sensation to
touch was intact. Speech was normal.
LABORATORIES ON ADMISSION: Cardiac enzymes: She had a CK of
1759, CK MB of 52, index of 3.0, troponin-T of 0.21. The
repeat CK was 1491, CK MB 44, index 3.0, troponin-T of 0.23
and the one after that, eight hours after was also negative.
UA showed small blood, trace protein, trace ketone,
occasional bacteria, 0-2 epi, 0-2 red blood cells, 0-2 white
blood cells. Her PTT was 29.1. INR 1.2.
Chest x-ray showed cardiomegaly, basilar bilateral linear
atelectasis with a calcified aorta, no effusion and no
pneumothorax.
Head CT further verification still showed no evidence of
intracranial hemorrhage and no acute brain infarct.
Patient was admitted for evaluation of dehydration, which
received normal saline since admission. Also getting normal
saline secondary to presumed rhabdomyolysis with elevated CKs
which were trending down with normal saline IV fluid
hydration. She was ruled out for myocardial infarction given
normal index of MB.
HOSPITAL COURSE: Since she was admitted, her rabdo was
improving daily. She was ruled out for myocardial
infarction, but on day two of hospital admission, she
developed shortness of breath, and she was slightly
refractory to O2 treatments. An ABG was retained, which
showed a CO2 of 108 with good pO2. She was then transferred
to the MICU for further evaluation secondary to CO2
retention. She stayed in the MICU for three days. Patient's
blood gas was repeated and over time, blood gas gradually
improved. Although when readmitted to the floor, still the
bicarb for ........... were a mechanism was still elevated,
although decreasing each day.
For the past three days, the bicarb has been decreasing. It
has gone from 50 to 48 to 44 and today's is pending. Patient
is still on face mask today, but says that everything is
feeling better, and her extraocular motors are now back and
she notes that she is going back to her old self, although
still has some respiratory distress and is still currently on
BiPAP machine intermittently with nasal cannula. Her lower
edema, she is wearing her stockings and since wearing the
stockings, had been feeling better. Her rhabdomyolysis has
been improved and the last CK was dramatically improved from
the over 1,000 CK that was on admission, it was 300 and
today's CK pending.
CONDITION ON DISCHARGE: Stable, some respiratory distress.
Continues to be on O2.
DISCHARGE STATUS: Patient is planning on being discharged to
rehab center today.
DISCHARGE MEDICATIONS:
1. Ipratropium nebulizer IH q.6h.
2. Albuterol nebulizer one inhaled q.6h. prn.
3. Bisacodyl 10 mg p.r. prn.
4. Thiamine 100 mg p.o. q.d.
5. Bacitracin ointment TP b.i.d. apply to lumbar sore.
6. Heparin 5,000 units subQ q.12h.
7. Docusate sodium 100 mg p.o. b.i.d. prn.
8. Aspirin 81 mg p.o. q.d.
FOLLOWUP: Patient is to followup with PCP early next week.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (STitle) 109878**]
MEDQUIST36
D: [**2148-8-21**] 08:27
T: [**2148-8-21**] 08:36
JOB#: [**Job Number 109879**]
cc:[**CC Contact Info **]
|
[
"428.0",
"276.5",
"428.31",
"424.0",
"E888.8",
"584.9",
"518.81",
"728.89",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5094, 5749
|
3591, 4904
|
1586, 2634
|
883, 1002
|
2667, 3573
|
140, 865
|
2649, 2649
|
1024, 1158
|
1175, 1570
|
4929, 5071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,417
| 100,223
|
53906
|
Discharge summary
|
report
|
Admission Date: [**2162-3-29**] Discharge Date: [**2162-4-19**]
Date of Birth: [**2075-12-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
1. Intubation and mechanical ventilation.
2. Placement of 2 pleurex catheters
History of Present Illness:
86F history of DM2, HTN, HLD, cardiac problem, transferred from
[**Name (NI) **]. Pt presented with one month of breathing difficulty,
weight loss, cough, decreased apetite getting progressively
worse over time. Family trie to bring pt in earlier but she
refused to go to hospital. Last night pt became acute more SOB
and family called ambulance and pt brought to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At
[**Hospital1 **] found to have WBC 44, HR 170's in A fib, lactate=4;
concern for possible malignant process and ? PE. Got dilt 30mg
PO and 10mg IV for HR, which improved. Also got 4L IVF. LENI
showed R DVT. Got head CT which showed nothing acute. Deferred
CTA chest due to elevated Cr (Cr 1.8). Started on heparin gtt
for DVT and concern for PE. Got azithro and ceftriaxone at
[**Hospital1 **].
During transport pt developed worsened rales/crackles possibly
secondary to 4 L IVF given.
.
In the [**Hospital1 18**] ED, initial VS were: 65, RR 32, 128/59, 97% 15L
NRB. ECG showed AFib with RVR. Patient was started on a nitro
gtt, heparin gtt, given vancomycin/zosyn, and placed on BiPAP
for resp distress which didnt tolerate. Labs were notable for a
lactate of 8.5, WBC count 49.3, INR 1.6 and Cr of 1.8. CXR: air
fluid level abscess in lung. Patient was initially trialed on
BiPAP, did not tolerate, and thus was intubated (straight
forward intubation).
Placed R IJ. CVP=13.
Lactate rose to 10 and concern for gut ischemia.
CTA chest and torso: No PE, revealed multiple abscess in L lung-
Rim enhancing fluid collection. Multiple hypodensisities in
kidney and liver suggestive of embolic infectious process.
in ED given: Vanco, zosyn, flagyl.
Thoracics consult: Poor surgical candidate. Recc drainage per IR
right now.
K=6-->insulin/D50, Kayexlate.
Gave 1 UPRBC for elevated lactate.
ED attempted to call family several times to give update, never
got through.
.
On arrival to the MICU, pt is intubated, sedated, on Levo 0.2
and Dopamine 8. Had family meeting with son and 3 grandchildren.
Family very tearful, as of now they request FULL code but will
continue to discuss goals of care. They report this pt is usualy
active at baseline, ambulatory, takes care of her great
grandchildren.
Past Medical History:
Dm2
HTN
HLD
Cardiac process- seen at [**Hospital 1263**] hospital, family is not sure
what process this is.
Social History:
Lives with son, normally active at baseline and babysits
grandchildren. Ambulatory. Rarely admitted to the hospital. No
history of smoking or drug use.
Family History:
no cancers.
Physical Exam:
Vitals:T 98.1, HR 83, BP 110/51, A fib, 98% on AC FiO2 40, TV
350, F 20, PEEP 5, MV 8.2. IVF in: 6L plus 1 PRBC. UO: 230 in
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and 180 in [**Hospital1 18**] ED.
General: sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregular rate, no mrg.
Lungs: anterior breath sounds, no crackles, few ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated
Pertinent Results:
Cytology [**2162-3-29**]
NEGATIVE FOR MALIGNANT CELLS.
Acellular specimen with bacterial overgrowth;
Correlate with microbiology report.
ECG Study Date of [**2162-3-29**] 2:29:44 AM
The rhythm is regular and most likely a junctional escape rhythm
at 60 beats per minute without clear atrial activity. Delayed R
wave transition. No previous tracing available for comparison.
Possible prior anteroseptal
myocardial infarction.
CHEST (PORTABLE AP) Study Date of [**2162-3-29**] 2:45 AM
FINDINGS:
There is extensive opacification of the left hemithorax with an
air-fluid
level identified superiorly. These findings are representative
of a large
mass, possibly abscess in a fissure. Less likely would be a
large hiatal
hernia. There is rightward shift of normally midline structures.
Otherwise, the right hemithorax appears clear. No acute
fractures are identified. A dedicated chest CT is recommended
for further evaluation
Portable TTE (Complete) Done [**2162-3-29**] at 12:03:01 PM FINAL
The left atrium is elongated. No thrombus/mass is seen in the
body of the left atrium. The right atrium is markedly dilated.
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
mildly dilated with normal free wall contractility. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The ascending aorta is 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. 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. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. Significant pulmonic regurgitation is seen.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade
CT ABD & PELVIS WITH CONTRAST Study Date of [**2162-3-29**] 3:05 AM
IMPRESSION:
1. Multilobulated large left hemithorax pleural empyema with
foci of gas
noted. Given the foci of gas the differential includes recent
instrumentation
versus infection with a gas-forming organism versus a
bronchopleural fistula.
2. Multiple hypodense areas are also visualized throughout
bilateral
nonenlarged kidneys. These findings may be representative of
multiple cysts but a superinfectious process with multiple
abscesses cannot be excluded.
3. Small subsegmental right upper lobe pulmonary emboli.
4. There is mild gallbladder wall edema and mottled apparance of
the liver
are likely due to congestive hepatopathy.
5. Endotracheal tube with the tip at the level of the carina.
Retraction by
2cm is recommended.
6. Bilateral small pleural effusions.
7 . Severe cardiomegaly.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2162-3-29**]
3:05 AM
IMPRESSION:
1. Multilobulated large left hemithorax pleural empyema with
foci of gas
noted. Given the foci of gas the differential includes recent
instrumentation
versus infection with a gas-forming organism versus a
bronchopleural fistula.
2. Multiple hypodense areas are also visualized throughout
bilateral
nonenlarged kidneys. These findings may be representative of
multiple cysts
but a superinfectious process with multiple abscesses cannot be
excluded.
3. Small subsegmental right upper lobe pulmonary emboli.
4. There is mild gallbladder wall edema and mottled apparance of
the liver
are likely due to congestive hepatopathy.
5. Endotracheal tube with the tip at the level of the carina.
Retraction by
2cm is recommended.
6. Bilateral small pleural effusions.
7 . Severe cardiomegaly.
Multiple CXR performed, representative reads shown.
CHEST (PORTABLE AP) Study Date of [**2162-3-31**] 2:17 AM
FINDINGS: The left pigtail catheter is unchanged in position.
The right IJ
and ET tubes terminate in the standard position. The NG tube
terminates
outside the field of view. Compared to [**3-30**], there are
increasing
bilateral pleural effusions, pulmonary vascular congestion, and
parenchymal opacities suggesting developing pulmonary edema.
Cardiomegaly is unchanged. Tere is no pneumothorax.
Findings were discussed by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) **] by
phone at 11:45
a.m. on [**2162-3-31**].
CT CHEST W/O CONTRAST Study Date of [**2162-3-31**] 9:08 AM
IMPRESSION:
Interval resolution of a dominant gas/fluid collection within
the left
hemithorax, and near-resolution of an adjacent medial
collection. There remains a loculated posterior collection that
does not appear tocommunicate with the catheter. 2. Adjacent
severe left lower lobe atelectasis with a consolidative
component. Slightly enlarged small right pleural effusion.
Trace pericardial effusion. New moderate anasarca. Increased
caliber of the main pulmonary artery likely reflects chronic
pulmonary hypertension.
.
CT Torso [**4-4**]
IMPRESSION:
1. Reaccumulation of left sided localized hydropneumothorax s/p
pigtail
catheter removal.
2. Bilateral peribronchial ground glass opacity and patchy
opacities which
are a non-specific finding.
3. Slight decrease in size of right pleural effusion.
4. Stable increased diameter of the main pulmonary artery likely
due to
pulmonary hypertension.
5. Persistent non-mobile 1.3cm filling defect within the left
main bronchus which is suspicious for polyp, neoplasm or mucus
plug.
.
CT Chest [**4-6**]
IMPRESSION:
1. Mid-esophageal soft tissue mass severly narrows and may
invade left main bronchus.
2. Interval placement of a second left lower lung drain with
interval
decrease in size of the air and fluid collection. Persistent
left lower lung consolidation is either pneumonia or
atelectasis.
3. Markedly enlarged right atrium.
4. Thinning of the renal cortices with hyperdensity which could
represent
retained contrast or nephrocalcinosis.
.
ECHO [**4-6**]
The left atrium is elongated. The right atrium is markedly
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is 5-10 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. with borderline normal free wall
function. There is abnormal septal motion/position consistent
with right ventricular pressure/volume 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 masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. An eccentric, posteriorly directed jet
of mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a very small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. Compared with the prior study (images
reviewed) of [**2162-3-29**], the degree of TR and pulmonary
hypertension have increased.
..
INDICATIONS: 86-year-old female with esophageal cancer, lung
empyema and
ischemic right foot.
Bilateral lower extremity ABIs, Doppler waveforms, and PVRs were
performed at
rest.
FINDINGS:
RIGHT: The right ABI is 0.65 at DP. There is no signal present
at PT.
Doppler waveforms are biphasic to the level of the popliteal
artery.
Posterior tibial waveform is absent. The dorsalis pedis waveform
is
monophasic. PVRs are artifactually diminished proximally and
aphasic at the
metatarsal level suggesting severe tibial disease.
The left ABI is 0.61 at DP. The PT waveform is absent.
Left-sided Doppler
waveforms are triphasic at the popliteal level and monophasic at
the dorsalis
pedis. PVRs show significant dropoff between calf and ankle and
again between
ankle and metatarsal level suggesting severe tibial occlusive
disease.
IMPRESSION: ABIs are likely falsely elevated. Based on Doppler
waveforms and
PVRs, there is severe tibial disease bilaterally.
.
COMPARISON: CT [**4-4**] and [**2162-4-6**].
TECHNIQUE: MDCT data were acquired through the chest without
intravenous
contrast. Images were displayed in multiple planes.
FINDINGS: There are two pigtail catheters at the left lung base.
A
small-to-moderate effusion layers posteriorly. There is no large
air-fluid
collection in communication with the anterior or posterior
drain. Moderate
left basilar atelectasis and/or consolidation is unchanged. A
moderate right
effusion is slightly larger.
No new consolidation, nodule, or pneumothorax is present. Since
the prior
exam, an esophageal catheter has been removed. The boundaries of
a large mid
esophageal mass are hard to delineate without contrast. The
lesion measures
approximately 1.9 x 3.4 cm (2:20). Since the preceding exam five
days ago,
the left main bronchus has become completely effaced (2:20) by a
combination
of mass effect from the thickened esophagus, and bronchial
secretions. There
are extensive secretions in the distal left lower lobe segmental
bronchus at
(2:25). A tracheo-esophageal connection is not directly
visualized but would
not be suprising given the appearence.
The non-contrast appearance of the heart and great vessels shows
cardiomegaly,
massive right atrial enlargment, and minimal aortic arch
calcification. The
tip of a right subclavian line terminates in the low SVC. The
thyroid has
normal attenuation. No mesenteric, hilar or axillary adenopathy
is present.
There is residual renal excretion of contrast from [**3-29**].
There are
peripheral hyperdense foci in the visualized portions of both
kidneys.
Previously, the cortices of both kidneys were uniformly
hyperdense.
Residual oral contrast is seen in nondistended loops of large
bowel.
BONES AND SOFT TISSUES: There are no concerning lytic or
sclerotic lesions.
Bilateral lower old rib fractures. There is diffuse soft tissue
edema.
IMPRESSION:
1. Large mid esophageal soft tissue mass with now complete
opacification of
the left main bronchus either by invasion, hemorrhage, and/or
secretions.
Persistent post-obstructive left lower lobe consolidation and
bronchial
secretions.
2. Improving small-to-moderate left pleural effusion. No large
collection at
the site of two pigtail catheters.
3. Increasing moderate right effusion.
4. Stable right atrial enlargement.
Final Report
CHEST RADIOGRAPH
INDICATION: Query pneumothorax, 86-year-old woman with large
esophageal
neoplasm extending into the left mainstem.
TECHNIQUE: Portable upright chest view was read in comparison
with multiple
prior radiographs with the most recent from [**2162-4-13**].
FINDINGS:
Lower lung opacity due to a combination of effusion and
atelectasis now
involves the entire left hemithorax suggestive of an increased
large left
pleural effusion. Two pleural pigtail catheters in the left
lower hemithorax
are unchanged in position. Increase in the left pleural
effusion. There has
not been much change in the position of the mediastinum probably
due to
associated left lung volume loss. Moderate right pleural
effusion and right
basilar atelectasis is similar. Upper lung is clear.
IMPRESSION: Left pleural effusion has progressed over last two
days. Two
left pleural pigtail catheters are in unchanged position and
moderate right
pleural effusion and bibasilar atelectasis is unchanged.
The study and the report were reviewed by the staff radiologist.
Microbiology:
[**2162-4-15**] 8:12 pm URINE Source: Catheter.
**FINAL REPORT [**2162-4-16**]**
URINE CULTURE (Final [**2162-4-16**]): NO GROWTH.
[**2162-4-5**] 6:36 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2162-4-5**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2162-4-8**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2162-4-11**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2162-4-6**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2162-3-29**] 4:40 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Site: PLEURAL
**FINAL REPORT [**2162-4-2**]**
Fluid Culture in Bottles (Final [**2162-4-2**]):
GRAM NEGATIVE ROD(S). REFER TO SPECIME # 343-4776A
[**2162-3-29**].
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP.
SENSITIVITIES PERFORMED ON CULTURE # 343-4776A
[**2162-3-29**].
GRAM POSITIVE RODS. REFER TO SPECIMEN # 343-4776A
[**2162-3-29**].
Anaerobic Bottle Gram Stain (Final [**2162-3-29**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
GRAM POSITIVE ROD(S).
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27395**] ON [**2162-3-29**] @
740 PM.
Aerobic Bottle Gram Stain (Final [**2162-3-29**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
GRAM POSITIVE ROD(S).
[**2162-3-29**] 3:30 am BLOOD CULTURE # 2.
**FINAL REPORT [**2162-4-4**]**
Blood Culture, Routine (Final [**2162-4-4**]): NO GROWTH.
[**2162-4-16**] 04:08AM BLOOD WBC-11.3* RBC-3.46* Hgb-10.0* Hct-33.9*
MCV-98 MCH-28.9 MCHC-29.6* RDW-22.8* Plt Ct-270
[**2162-4-15**] 03:04AM BLOOD WBC-11.2* RBC-3.57* Hgb-10.2* Hct-34.7*
MCV-97 MCH-28.5 MCHC-29.3* RDW-22.6* Plt Ct-286
[**2162-4-14**] 05:06AM BLOOD WBC-8.9 RBC-3.28* Hgb-9.3* Hct-33.9*
MCV-103* MCH-28.3 MCHC-27.3* RDW-23.0* Plt Ct-262
[**2162-4-12**] 03:03PM BLOOD WBC-10.5 RBC-3.60* Hgb-10.1* Hct-33.0*
MCV-91 MCH-28.1 MCHC-30.7* RDW-22.6* Plt Ct-304
[**2162-4-12**] 06:00AM BLOOD WBC-10.4 RBC-3.71* Hgb-10.6* Hct-34.8*
MCV-94 MCH-28.5 MCHC-30.4* RDW-23.1* Plt Ct-299
[**2162-4-10**] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4*
MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292
[**2162-4-11**] 03:42AM BLOOD WBC-11.6* RBC-3.78* Hgb-10.4* Hct-34.4*
MCV-91 MCH-27.4 MCHC-30.1* RDW-22.6* Plt Ct-305
[**2162-4-10**] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4*
MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292
[**2162-4-9**] 02:57AM BLOOD WBC-14.2* RBC-3.62* Hgb-10.1* Hct-33.7*
MCV-93 MCH-28.0 MCHC-30.1* RDW-23.5* Plt Ct-265
[**2162-4-8**] 03:48AM BLOOD WBC-20.4* RBC-3.62* Hgb-10.3* Hct-32.8*
MCV-91 MCH-28.5 MCHC-31.4 RDW-22.2* Plt Ct-247
[**2162-4-7**] 02:27AM BLOOD WBC-22.8* RBC-3.41* Hgb-9.6* Hct-30.1*
MCV-88 MCH-28.1 MCHC-31.8 RDW-19.8* Plt Ct-226
[**2162-4-6**] 02:20AM BLOOD WBC-23.5* RBC-3.86* Hgb-10.9* Hct-35.7*
MCV-93 MCH-28.2 MCHC-30.5* RDW-19.6* Plt Ct-206
[**2162-4-5**] 01:57AM BLOOD WBC-20.3* RBC-3.76* Hgb-10.6* Hct-34.2*
MCV-91 MCH-28.1 MCHC-30.9* RDW-19.2* Plt Ct-180
[**2162-4-4**] 03:04AM BLOOD WBC-22.3* RBC-3.85* Hgb-10.7* Hct-34.7*
MCV-90 MCH-27.7 MCHC-30.7* RDW-18.6* Plt Ct-165
[**2162-4-3**] 02:56AM BLOOD WBC-27.4* RBC-3.94* Hgb-11.4* Hct-35.6*
MCV-90 MCH-29.0 MCHC-32.1 RDW-17.7* Plt Ct-175
[**2162-4-2**] 03:22AM BLOOD WBC-24.2* RBC-4.21 Hgb-11.7* Hct-38.3
MCV-91 MCH-27.8 MCHC-30.5* RDW-17.4* Plt Ct-204
[**2162-4-1**] 03:34AM BLOOD WBC-24.2* RBC-3.99* Hgb-11.2* Hct-35.4*
MCV-89 MCH-28.2 MCHC-31.8 RDW-17.6* Plt Ct-212
[**2162-3-31**] 01:10PM BLOOD WBC-27.0* RBC-4.15* Hgb-11.4* Hct-37.2
MCV-90 MCH-27.4 MCHC-30.6* RDW-16.8* Plt Ct-310
[**2162-3-31**] 04:24AM BLOOD WBC-24.9* RBC-3.96* Hgb-11.0* Hct-34.9*
MCV-88 MCH-27.8 MCHC-31.6 RDW-17.2* Plt Ct-264
[**2162-3-30**] 11:17PM BLOOD WBC-23.3* RBC-3.85* Hgb-10.3* Hct-33.1*
MCV-86 MCH-26.8* MCHC-31.2 RDW-16.3* Plt Ct-288
[**2162-3-30**] 07:07PM BLOOD WBC-28.8* RBC-3.31* Hgb-9.3* Hct-28.8*
MCV-87 MCH-28.0 MCHC-32.3 RDW-16.0* Plt Ct-408
[**2162-3-29**] 11:58PM BLOOD WBC-36.1* RBC-4.10* Hgb-11.0* Hct-36.1
MCV-88 MCH-26.7* MCHC-30.3* RDW-15.9* Plt Ct-425
[**2162-3-29**] 01:37PM BLOOD WBC-48.5* RBC-3.99* Hgb-10.5* Hct-35.7*
MCV-90 MCH-26.3* MCHC-29.3* RDW-15.4 Plt Ct-541*
[**2162-3-29**] 10:41AM BLOOD WBC-46.5* RBC-3.79* Hgb-9.8* Hct-34.3*
MCV-91 MCH-25.9* MCHC-28.6* RDW-15.0 Plt Ct-501*
[**2162-3-29**] 08:20AM BLOOD WBC-44.7* RBC-3.74* Hgb-9.9* Hct-34.6*
MCV-93 MCH-26.5* MCHC-28.7* RDW-15.0 Plt Ct-514*
[**2162-3-29**] 02:45AM BLOOD WBC-49.3* RBC-3.71* Hgb-9.7* Hct-33.7*
MCV-91 MCH-26.2* MCHC-28.8* RDW-15.2 Plt Ct-589*
[**2162-3-29**] 02:45AM BLOOD Neuts-85* Bands-3 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2162-3-29**] 08:20AM BLOOD Neuts-95.9* Lymphs-2.5* Monos-1.2* Eos-0
Baso-0.4
[**2162-4-1**] 03:34AM BLOOD Neuts-90.9* Lymphs-8.1* Monos-0.5*
Eos-0.2 Baso-0.2
[**2162-4-2**] 03:22AM BLOOD Neuts-93.0* Lymphs-5.2* Monos-1.0*
Eos-0.2 Baso-0.6
[**2162-4-16**] 04:08AM BLOOD PT-15.7* PTT-103.7* INR(PT)-1.5*
[**2162-4-15**] 03:04AM BLOOD PT-14.4* PTT-33.5 INR(PT)-1.3*
[**2162-4-14**] 05:06AM BLOOD PT-15.4* PTT-150* INR(PT)-1.4*
[**2162-4-6**] 02:20AM BLOOD PT-14.4* PTT-87.4* INR(PT)-1.3*
[**2162-4-1**] 09:30PM BLOOD PT-12.8* PTT-103* INR(PT)-1.2*
[**2162-4-1**] 05:10PM BLOOD PT-12.6* PTT-150* INR(PT)-1.2*
[**2162-3-29**] 01:37PM BLOOD PT-18.0* PTT-28.7 INR(PT)-1.7*
[**2162-4-16**] 04:08AM BLOOD Glucose-115* UreaN-32* Creat-1.4* Na-141
K-4.3 Cl-113* HCO3-25 AnGap-7*
[**2162-4-15**] 03:04AM BLOOD Glucose-228* UreaN-33* Creat-1.4* Na-143
K-4.1 Cl-114* HCO3-25 AnGap-8
[**2162-4-14**] 09:52AM BLOOD Glucose-145* UreaN-34* Creat-1.5* Na-145
K-3.4 Cl-115* HCO3-24 AnGap-9
[**2162-4-14**] 05:06AM BLOOD Glucose-826* UreaN-30* Creat-1.5* Na-133
K-6.5* Cl-105 HCO3-21* AnGap-14
[**2162-4-10**] 02:59PM BLOOD Creat-1.8* Na-146* K-3.8 Cl-114* HCO3-22
AnGap-14
[**2162-4-9**] 02:57AM BLOOD Glucose-119* UreaN-54* Creat-2.2* Na-146*
K-3.6 Cl-114* HCO3-24 AnGap-12
[**2162-4-8**] 03:48AM BLOOD Glucose-201* UreaN-61* Creat-2.6* Na-143
K-4.1 Cl-114* HCO3-20* AnGap-13
[**2162-4-6**] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139
K-4.2 Cl-106 HCO3-20* AnGap-17
[**2162-4-6**] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139
K-4.2 Cl-106 HCO3-20* AnGap-17
[**2162-4-5**] 01:57AM BLOOD Glucose-182* UreaN-51* Creat-2.7* Na-142
K-3.8 Cl-110* HCO3-21* AnGap-15
[**2162-4-2**] 03:22AM BLOOD Glucose-146* UreaN-43* Creat-1.9* Na-143
K-3.4 Cl-113* HCO3-19* AnGap-14
[**2162-3-31**] 04:24AM BLOOD Glucose-208* UreaN-48* Creat-1.7* Na-139
K-3.5 Cl-111* HCO3-16* AnGap-16
[**2162-3-29**] 10:41AM BLOOD Glucose-128* UreaN-56* Creat-1.7* Na-142
K-4.8 Cl-112* HCO3-15* AnGap-20
[**2162-3-29**] 02:45AM BLOOD Glucose-141* UreaN-60* Creat-1.8* Na-138
K-6.5* Cl-109* HCO3-13* AnGap-23*
[**2162-4-13**] 05:32AM BLOOD ALT-12 AST-16 AlkPhos-73 TotBili-0.5
[**2162-4-12**] 03:03PM BLOOD ALT-15 AST-18 LD(LDH)-261* Amylase-129*
[**2162-4-1**] 03:34AM BLOOD ALT-88* AST-76* LD(LDH)-246 AlkPhos-201*
TotBili-0.8
[**2162-3-31**] 04:24AM BLOOD ALT-119* AST-206* LD(LDH)-320*
AlkPhos-116* TotBili-0.8
[**2162-3-29**] 10:41AM BLOOD ALT-111* AST-600* LD(LDH)-1689*
AlkPhos-119* TotBili-0.6
[**2162-4-12**] 03:03PM BLOOD CK-MB-4 cTropnT-0.04*
[**2162-3-29**] 01:37PM BLOOD CK-MB-4 cTropnT-0.04*
[**2162-3-29**] 10:41AM BLOOD CK-MB-4 cTropnT-0.03*
[**2162-3-29**] 08:20AM BLOOD cTropnT-0.03*
[**2162-3-29**] 02:45AM BLOOD cTropnT-0.04*
[**2162-4-16**] 04:08AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
[**2162-4-15**] 03:04AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
[**2162-3-29**] 02:45AM BLOOD Albumin-2.3*
[**2162-3-29**] 08:20AM BLOOD Calcium-7.0* Phos-6.6* Mg-2.1
[**2162-3-29**] 10:41AM BLOOD Albumin-1.8* Calcium-6.9* Phos-5.1*
Mg-1.9
[**2162-3-29**] 01:37PM BLOOD Calcium-7.4* Phos-5.2* Mg-2.1
UricAcd-10.6*
[**2162-3-29**] 01:37PM BLOOD Hapto-326*
[**2162-3-30**] 10:02AM BLOOD Vanco-9.5*
[**2162-3-31**] 06:04PM BLOOD Vanco-15.4
[**2162-4-1**] 07:07PM BLOOD Vanco-20.5*
[**2162-4-2**] 08:10AM BLOOD Vanco-18.5
[**2162-4-8**] 05:43AM BLOOD Vanco-22.8*
[**2162-4-9**] 05:57AM BLOOD Vanco-20.4*
[**2162-4-12**] 06:00AM BLOOD Vanco-18.9
[**2162-4-13**] 05:32AM BLOOD Vanco-24.9*
[**2162-3-29**] 02:58AM BLOOD Lactate-8.5* K-6.5*
[**2162-3-29**] 04:44AM BLOOD Glucose-124* Lactate-9.6* K-6.2*
[**2162-3-29**] 04:53AM BLOOD Lactate-9.3*
[**2162-3-29**] 06:22AM BLOOD Lactate-9.6*
[**2162-3-29**] 08:48AM BLOOD Glucose-205* Lactate-7.0* Na-139 K-5.4*
Cl-113* calHCO3-13*
[**2162-3-29**] 11:12AM BLOOD Lactate-4.7*
[**2162-3-29**] 11:53PM BLOOD Lactate-2.9*
[**2162-3-30**] 12:27PM BLOOD Lactate-2.7*
[**2162-3-31**] 12:52AM BLOOD Lactate-2.2*
[**2162-3-31**] 09:16AM BLOOD Lactate-2.7*
[**2162-3-31**] 04:23PM BLOOD Lactate-2.4*
[**2162-3-31**] 06:14PM BLOOD Lactate-2.1*
[**2162-4-1**] 03:17PM BLOOD Lactate-1.7
[**2162-4-2**] 03:37AM BLOOD Lactate-1.5
[**2162-4-4**] 04:17AM BLOOD Lactate-2.1*
[**2162-4-6**] 02:28AM BLOOD Lactate-3.8*
[**2162-4-6**] 10:01AM BLOOD Lactate-5.4*
[**2162-4-6**] 02:18PM BLOOD Lactate-4.4*
[**2162-4-14**] 10:33AM BLOOD Lactate-1.7
[**2162-4-5**] 06:36PM PLEURAL WBC-[**Numeric Identifier 110572**]* RBC-[**Numeric Identifier 28746**]* Polys-98*
Lymphs-0 Monos-1* Meso-1*
[**2162-4-3**] 06:21PM PLEURAL WBC-1700* RBC-800* Polys-75* Lymphs-20*
Monos-0 Baso-1* Meso-1* Other-3*
[**2162-3-29**] 02:45AM estGFR-Using this
Brief Hospital Course:
86 yo F with no known medical problems admitted shortness and
breath cough. Hospital course was notable for admission to the
ICU where she was found to have lung and renal abscesses, septic
shock requiring vasopressor support, DVT and PE, and difficult
to control atrial fibrillation. She was also noted to have a
large esophageal mass suggestive of esophageal cancer with
compression of the left main stem bronchus causing intermittent
lung collapse and esophageal compression with
dysphagia/aspiration. Patient had a long ICU course and
transferred from the floor to the ICU multiple times.
Ultimately, given the patient's multiple significant and severe
medical problems, age, and progressively declining course
despite maximal medical care, a discussion was held with the
family and the decision was to transition the patient's care to
comfort centered care and the patient passed away [**2162-4-19**] at
2:10AM.
#Septic shock/Lung and renal abscesses:
Patient presented in septic shock from pneumonia with empyema
and was found to have lung and renal abscesses. She required
multiple pressors and intubation. Her lactate peaked at 10. CT
demonstrated multiple fluid collections as well as an esophageal
mass (see below) that was compressing the L mainstem bronchus
that was believed to be predisposing to her polymicrobial
infection. Interventional pulmonology placed two chest tubes to
drain the fluid collections. Gram stain showed GPCs, GNRs and
gram positive rods. Cultures only grew strep angionosis. She was
initially treated with broad spectrum antibiotics but was weaned
down to vancomycin and flagyl per ID recommendations for a
planned course of four weeks from the date of her last chest
tube placement (day one [**4-5**]). She was weaned off pressors and
succesfully extubated. She was treated with vanc/flagyl until
she was made CMO on [**2162-4-16**].
#DVT/PE: Patient was found to have DVT on lower extremity
ultrasound. CTA showed small subsegmental RLL PE. Patient was
placed on heparin gtt. After her goals of care discussion
anticoagulation was held on [**2162-4-16**].
#Esophageal Mass, likely esophageal cancer, with bronchial and
esophageal obstruction:
CT showed large mid esophageal soft tissue mass with now
complete opacification of the left main bronchus either by
invasion, hemorrhage, and/or secretions.
There was persistent post-obstructive left lower lobe
consolidation and bronchial secretions and patient did suffer
collapse of her left lung. It was believed that this mass was
the etiology of her polymicrobial septic shock, as well as
persistent pleural effusions and left sided atelectatsis.
Secondary to the obstruction of the esophagus and risks for
aspiratoin, the patient was made NPO. She did transiently
receive TPN, but this was discontinued when care was
transitioned to comfort centered care.
#Atrial fibrillation: Unclear if patient has history of afib,
but this was likely exacerbated or caused by infection/sepsis.
There may also have been contribution of irritation by
esophageal mass. After hypotension resolved patient was managed
on the medical floor with IV betablockers but required transfer
back to the ICU for rapid atrial fibrillation and low blood
pressures in the 90s. She was subsequently rate controlled with
IV amiodarone drip in the ICU and transferred back to the
medical floor. After family discussion regarding overall goals
of care amiodarone was eventually discontinued.
# Acute Renal failure: Creatinine 1.8 with unclear baseline. Her
creatinine later increased to a peak of 2.8 which was believed
to be ATN from septic shock. Her creatinine trended back down to
1.8. On the floor her creatinine remained at baseline.
# Anemia: She required 3 UPRBC in setting of elevated lactate
and septic shock. Hct stabilzed in mid 30s.
#Goals of care discussion:
Throughout hospitalization multiple family meetings/updates were
held with multiple providers/teams. Palliative care was involved
as were the social work and case management teams. With the
patient's age of >80 years and multiple medical problems that
continued to progress despite medical care (including IV
amiodarone drip, TPN, antibiotics, and IV anticoagulation), the
family decided to focus on comfort centered care on [**2162-4-16**]. The
patient passed away on [**2162-4-19**] at 2AM.
Medications on Admission:
None
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Esophageal neoplasm
2. Septic shock
3. Atrial fibrillation
4. Deep venous thrombosis
5. Pulmonary Emboli
6. Digital necrosis of [**3-8**] metatsarsals
7. Occlusive narrowing of tibial arteries bilaterally
8. Pleural effusions
9. Pulmonary empyema
Discharge Condition:
expired
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63,062
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37358+58145
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-1-21**] Discharge Date: [**2195-1-26**]
Date of Birth: [**2116-3-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
black stool; transfer from [**Location (un) 620**] for GI bleed
Major Surgical or Invasive Procedure:
ERCP [**2195-1-21**]
History of Present Illness:
Ms. [**Known lastname **] is a 78 yo woman with h/o gastric ulcer in the setting
of NSAID use who presented to [**Location (un) 620**] [**1-20**] with melena and HCT
drop from baseline and is now being transferred to [**Hospital1 18**] for GI
evaluation.
The patient reports black stools for the last one month. She was
seen in her PCP's office last week, and her hematocrit was down
to 27 from a recent baseline of 39. Her primary doctor had
difficulty contacting her because she was away from her home
baby-sitting. When patient received voicemail message from her
doctor on [**1-20**], he referred her to the ED.
Upon presentation to [**Location (un) 620**], her VS were BP 152/81 with a HR of
75. BUN and Cr were 17 and 0.9 and her Hct was 22.4. She was
transfused 2 units of pRBCs with improvement in Hct to 27. An
EGD was done at [**Location (un) 620**]. It was difficult to completely
visualize, but the team thought there was some duodenal
ulceration as well as active oozing from the duodenal papilla.
Upon arrival to the ICU, she is comfortable and without
complaints aside from fatigue. Notes intermittent
lightheadedness in last month. Denies syncope. Denies chest pain
or confusion. No shortness of breath.
REVIEW OF SYSTEMS:
(+)ve: black stool, lightheadedness, unsteady when first
standing, right foot numbness
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, dysuria, urinary frequency, urinary urgency, focal
weakness, myalgias, arthralgias
Past Medical History:
1) Hypertension
2) Diabetes mellitus
3) Hyperlipidemia
4) Anemia with baseline Hct 39 in [**2194-8-6**]
5) h/o Gastric ulcer in [**2190**] in setting of alleve use, f/u EGD 3
months later showed healing of ulcers, gastric Bx was negative
for H pylori
6) Hiatal hernia
7) Osteoarthritis
8) h/o Motor vehicle accident resulting in partial splenectomy
and nephrectomy in [**2176**]
9) Urinary incontinence
Social History:
Lives at home with her son; independent in ADLs and IADLs.
Still drives.
Tobacco: None
EtOH: None
Illicits: None
Family History:
Lung cancer in her brother.
Two nieces with breast cancer.
No history of heart disease or sudden cardiac death.
Physical Exam:
VS: T 99.7, HR 79, BP 143/69, RR 13, O2Sat 98% RA
GEN: NAD
HEENT: PERRL, EOMI, bilaterally equal arcus senilis, no scleral
icterus, partial dentures in place, oral mucosa moist,
oropharynx without erythema or exudates
NECK: Supple, no [**Doctor First Name **] or thyromegaly
PULM: CTAB, no wheezes, crackles, rhonchi
CARD: RR, nl S1, nl S2, no M/R/G
ABD: Multiple surgical scars with visible abnormalities of
anatomy, BS+, soft, non-tender, non-distended
EXT: No C/C/E
SKIN: No rashes
NEURO: Oriented x 3, CN II-XII intact,
PSYCH: Mood and affect appropriate
Pertinent Results:
LABS from [**Location (un) 620**]:
CBC: 9>/28<263, MCV 77. N65, L28, M5
ALT 37
AST 27
Alk Phos 69
Tbili 0.6
TP 6.7
Alb 3.5
[**1-21**]: 139/3.4, 107/23, 16/0.8, 140, Ca 7.7, Mg 1.8
STUDIES:
EGD from [**3-13**]: 6 gastric ulcers, no H pylori on Bx
EGD from [**6-10**]: Healed ulcers with scarring.
Labs at admission:
[**2195-1-21**] 03:42PM BLOOD WBC-PND RBC-3.88* Hgb-10.0* Hct-29.9*
MCV-77* MCH-25.9* MCHC-33.5 RDW-20.8* Plt Ct-308
ERCP [**1-21**]:
-The major papilla was prominent and bulging. Fresh blood was
seen oozing from the major papilla just superior to the opening
of the common bile duct.
-Cannulation of the biliary and pancreatic ducts was performed
with a sphincterotome using a free-hand technique.
-The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized. The course and caliber of the
structures are normal with no evidence of extrinsic compression,
no ductal abnormalities, and no filling defects.
-Given that the oozing was seen just superior to the opening of
the bile duct, a 10FR by 7cm biliary stent was placed
successfully using a Oasis 10FR stent introducer kit to protect
the biliary opening prior to BiCap therapy. Given the fresh
blood, biopsies were not performed on today's exam.
-A mild dilation of the pancreas duct to 5mm was seen at the
head of the pancreas and body of the pancreas. There was an
abrupt cutoff of the PD at the body of the pancreas consistent
with the known distal pancreatectomy.
[**Hospital1 **]-CAP Electrocautery was applied for hemostasis successfully to
the major papilla at the site of oozing after placement of the
CBD stent.
[**1-22**] CT Pancreas: Pending
[**2195-1-22**] 03:03PM BLOOD WBC-17.8* RBC-3.53* Hgb-9.4* Hct-28.2*
MCV-80* MCH-26.6* MCHC-33.4 RDW-21.3* Plt Ct-287
[**2195-1-22**] 03:03PM BLOOD WBC-17.8* RBC-3.53* Hgb-9.4* Hct-28.2*
MCV-80* MCH-26.6* MCHC-33.4 RDW-21.3* Plt Ct-287
Brief Hospital Course:
# GI bleed: 78 year old woman with h/o NSAID-induced gastric
ulcers who was transferred from [**Location (un) 620**] for evaluation of GI
bleed. Her lower GI bleed was thought to be related to active
bleeding from the duodenal papilla per upper endoscopy performed
at [**Hospital1 **] [**Location (un) 620**]. She underwent ERCP directly after admission
which showed a prominent duodenal papilla that was bleeding. The
papilla was cauterized and a common bile duct stent was placed.
A biopsy was not taken because she was actively bleeding, but
she will need a follow-up ERCP in one month for biopsies and
stent removal. She remained hemodynamically stable and her
hematocrit remained stable. She was placed on an IV and then
oral PPI. To rule out papillary or pancreatic carcinoma, she had
a CT of her pancreas which showed no evidence of cancer.
However, it showed a gallbladder wall thickening that was
followed with ultrasound of the gallbladder. Based on both the
CT and the RUQ ultrasound this gallbladder wall thickening was
consistent with adenomyomatosis and does not require further
work up at this time. Patient will be scheduled for repeat ERCP
in one month to have the CBD stent removed and have a biopsy
performed. Patient was counseled to continue taking
pantoprazole after discharge and to refrain from the use of
NSAIDS to reduce risk of rebleeding. She was instructed to hold
her daily aspirin 81 mg for one week after her procedure to
reduce the risk of bleeding. She will likely need to stop this
medication one week before her next ERCP. Recommend monitoring
patient's HCT by her PCP within one week of discharge.
.
# Leukocytosis: Patient developed a leukocytosis (WBC 17) and
low grade fevers (100 F) after her ERCP. Patient denied any
localizing symptoms with the exception of a dry nonproductive
cough. UA was performed due to recent use of foley catheter. UA
was negative. CXR was performed which showed only atelectasis.
Patient was encouraged to increase her ambulation and use
incentive spirometry. The leukocytosis and low grade fevers
resolved on their own without antibiotics or intervention.
Patient is instructed to follow up with her PCP should her cough
continue or she develops chest pain or shortness of breath to
have CXR imaging repeated.
.
# Acidosis: Patient was also found to have a mixed anion gap and
non anion gap metabolic acidosis on presentation to [**Hospital1 18**]
without clear explanation. Once patient started po intake and
was tolerating a regular diet the acidosis resolved.
.
# Hypertension: Patient's antihypertensives were held during
admission. Her blood pressure remained low throughout
admission. She was instructed to hold her valsartan and
amlodipine until her blood pressure could be monitored in the
outpatient setting by her PCP. [**Name10 (NameIs) **] was instructed not to
restart these medications until instructed to do so by a
physician.
.
# Diabetes mellitus: Her ASA was initially held. Glipizide was
also held and she was managed with an insulin sliding scale.
Glipizide was restarted prior to discharge.
.
# Arthritis: She had no acute pain complaints and was given
acetaminophen for pain. She was counseled not to take any
NSAIDs in the future for pain. She was started on acetaminophen
at the time of discharge to use as needed for pain control.
.
# Urinary incontinence: Her home solifenacin was initially held.
She was permitted to restart this medication on discharge.
.
# Health care maintenance: She received pneumococcal vaccine ~3
years ago and does not need revaccination. She was given the
seasonal flu vaccine on admission.
.
# Code Status: She was FULL code during this admission.
Medications on Admission:
HOME MEDICATIONS:
1) ASA 81mg daily
2) Diovan 30mg daily
3) Amlodipine 5mg daily
4) Glipizide 10mg daily
5) Simvastatin 40mg daily
6) Vesicare 5mg daily
7) Clonazepam 5mg QHS
8) Advil 600mg [**Hospital1 **]
9) Vitamin D 600 units daily
10) Boniva monthly
11) Fish oil daily
12) Multivitamin
13) Vitamin E
14) Stool softener
MEDS ON TRANSFER:
Esomeprazole 40 mg IV BID
ALLERGIES:
Sulfa -- (history of GI bleed and rash, no anaphylaxis)
Discharge Medications:
1. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: Do not exceed 4 grams of
acetaminophen per 24 hours.
Disp:*90 Tablet(s)* Refills:*0*
8. Clonazepam Oral
9. Vesicare 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Vitamin E Oral
11. Fish Oil Oral
12. Boniva Oral
13. Vitamin D Oral
14. Outpatient Lab Work
Please have your CBC and Chem 7 monitored before [**2195-2-2**]. The
results should be faxed to your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 26317**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 26329**].
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Metabolic Acidosis
Leukocytosis
Atelectasis
DM2
Discharge Condition:
Afebrile, hemodynamically stable, tolerating po diet and
medications, ambulating without assistance.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for further evaluation of your GI
bleed. You were found to have bleeding in your intestines near
the opening of you bile duct. Cautery was performed to stop the
bleeding and a stent was placed to keep the bile duct open. You
tolerated the procedure well.
.
The following changes were made to your home medications:
.
1) STOP Advil/Ibuprofen/Motrin/Aleve as these medications can
cause GI bleeding.
2) STOP Valsartan (Diovan) as your blood pressure was low during
your admission. Please do not restart this medication until
instructed to do so by your primary care physician.
3) STOP Amlodipine (Norvasc) as your blood pressure was low
during your admission. Please do not restart this medication
until instructed to do so by your primary care physician.
4) STOP Aspirin as this can cause increased bleeding. You can
restart this medication one week after your procedure. You will
likely need to stop this medication 1 week before your next
procedure (ERCP).
5) START Pantoprazole 40 mg by mouth twice a day.
6) START Acetaminophen 325 mg tablets, 2 tablets by mouth every
6 hours as needed for pain.
7) START Senna 8.6 mg tablet, 1 tablet by mouth twice a day as
needed for constipation.
Followup Instructions:
You should have a repeat ERCP with Dr. [**Last Name (STitle) **] in 4 weeks for a
biopsy of your small intestine and removal of the stent that was
placed. They will be calling you with your appointment in the
next week or two. If you have any problems, please call Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 2799**].
.
Please go to the lab at your physician's office to have your
blood counts monitored before your appointement with Dr. [**First Name (STitle) **].
.
Please follow up with Dr. [**First Name8 (NamePattern2) 26317**] [**Last Name (NamePattern1) **] on Monday [**2195-2-2**] at 9:45 am to have your blood pressure and lab work
reviewed.
Name: [**Known lastname **],[**Known firstname **] R Unit No: [**Numeric Identifier 13362**]
Admission Date: [**2195-1-21**] Discharge Date: [**2195-1-26**]
Date of Birth: [**2116-3-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4842**]
Addendum:
RESULTS (continued):
.
[**2195-1-23**] RUQ Ultrasound:
1. Cholelithiasis without cholecystitis.
2. Focal thickening of the fundus of the gall bladder may
represent adenomyomatosis but is not well evaluated. This could
be followed up with a repeat ultrasound after resolution of
pneumobilia.
2. Echogenic liver with focal areas of fatty sparing. Other
forms of liver disease and more advanced liver disease such as
cirrhosis/fibrosis cannot be excluded in the areas of fatty
infiltration.
.
[**2195-1-24**] CXR (PA and lateral): No evidence of acute process.
Minimal atelectasis in the left lower lobe that should be
further followed to exclude the remote possibility of developing
infection.
.
Left apical nodular opacity projecting over the first rib, 5 mm
in diameter. Further evaluation of the patient with lordotic
views is recommended to exclude the possibility of pulmonary
nodule.
.
[**2195-1-24**] CXR (lordotic view): The left upper lung field nodule
demonstrated on the prior study is not seen
on the current view most likely representing bone island. The
lungs are
unremarkable. The cardiomediastinal silhouette is unchanged. No
evidence of acute cardiopulmonary process is present.
.
DISCHARGE LABS:
.
WBC 8.2
HGB 8.8
HCT 27
PLT 379
Na 140
K 4.0
Cl 108
HCO3 24
BUN 16
Cr 0.8
Glu 135
.
BRIEF HOSPITAL COURSE:
.
Patient's prescription of pantoprazole 40 mg po bid was changed
to omeprezole 40 mg po bid on discharge as she stated she's had
difficulty with filling pantoprazole [**Hospital1 **] in the past. [**Location (un) 13363**] was called and they recommended omeprazole as there is
a generic form that will likely be approved [**Hospital1 **] without prior
authorization.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4843**] MD [**MD Number(2) 4844**]
Completed by:[**2195-1-26**]
|
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"250.00",
"V45.73",
"276.2",
"285.1",
"788.30",
"715.90",
"553.3",
"562.02",
"401.9",
"272.4",
"518.0",
"V12.71",
"V04.81",
"577.8",
"V45.79",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
14918, 15081
|
14525, 14895
|
356, 378
|
10786, 10889
|
3364, 5325
|
12173, 14399
|
2656, 2769
|
9521, 10650
|
10700, 10765
|
9060, 9060
|
10913, 11255
|
14415, 14502
|
2784, 3345
|
11273, 12150
|
1650, 2084
|
252, 318
|
406, 1631
|
2106, 2510
|
2526, 2640
|
9403, 9498
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,230
| 107,336
|
51861
|
Discharge summary
|
report
|
Admission Date: [**2200-7-10**] Discharge Date: [**2200-7-22**]
Date of Birth: [**2140-1-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p fall down stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
60 yo male s/p fall down stairs. Taken to an area hospital where
found to have right subdural and subarachnoid hemorrhages. He
was then transfered ti [**Hospital1 18**] for continued trauma care.
Past Medical History:
Hypertension
Anxiety
Depression
Irritable Bowel Syndrome
Sciatica
Chronic Back pain
"Breathing problems"
Social History:
Married, lives with wife and 2 small children
Family History:
Noncontributory
Pertinent Results:
[**2200-7-10**] 08:00PM GLUCOSE-113* LACTATE-0.7
[**2200-7-10**] 07:45PM GLUCOSE-111* UREA N-24* CREAT-1.3* SODIUM-135
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2200-7-10**] 07:45PM CALCIUM-7.7* PHOSPHATE-1.7* MAGNESIUM-2.8*
[**2200-7-10**] 07:45PM WBC-12.2* RBC-3.78* HGB-11.0* HCT-30.7*
MCV-81* MCH-29.0 MCHC-35.7* RDW-13.7
[**2200-7-10**] 07:45PM PLT COUNT-279
[**2200-7-10**] 07:45PM PT-14.0* PTT-29.7 INR(PT)-1.2*
MR HEAD W/O CONTRAST [**2200-7-12**] 1:00 AM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: 60 M s/p fall-4 days ago, not waking up appropriately-
neuro
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with
REASON FOR THIS EXAMINATION:
60 M s/p fall-4 days ago, not waking up appropriately-
neurosurgery would like to evaluate for diffuse axonal injury
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI brain.
CLINICAL INFORMATION: Patient with status post fall four days
ago, not waking up appropriately, neurosurgery would like
further evaluation to exclude diffuse axonal injury.
TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion
axial images of the brain were obtained. Three time-of-flight
MRA of the circle of [**Location (un) 431**] was acquired. Correlation was made
with CT of [**2200-7-10**].
FINDINGS: There are several areas of T2 hyperintensity with
associated low signal on susceptibility images seen in both
frontal region at the [**Doctor Last Name 352**]-white matter junction. Additional
area of signal abnormality and blood products is seen in the
inferior right frontal lobe. Subtle increased signal in the
sylvian fissures indicate associated subarachnoid hemorrhage.
There is widening of the subdural space in both frontal region
measuring approximately 1 cm with CSF intensities indicative of
bilateral subdural effusions. There is no evidence of acute
infarct seen. No midline shift or hydrocephalus identified.
Evaluation of the brainstem demonstrate no focal abnormalities
or blood products to indicate brain stem injury. The corpus
callosum also demonstrate no focal abnormalities.
Extensive soft tissue changes are seen in the paranasal sinuses,
which could be related to intubation.
Multiple small white matter hyperintensities seen indicative of
small vessel disease.
There is a tiny left parietal subdural collections seen
measuring 2-3 mm. No associated mass effect seen.
IMPRESSION: 1. Bilateral frontal lobe [**Doctor Last Name 352**]-white matter junction
abnormalities with blood products are suggestive of diffuse
axonal injury. 2. Inferior right frontal lobe abnormality could
be due to hemorrhagic contusion. 3. Bilateral frontal subdural
effusions and probable subarachnoid hemorrhage in the right
sylvian fissure. 4. No evidence of brain stem injury. No
evidence of acute infarct.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2200-7-11**] 10:36 AM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: S/P FALL, EVAL FOR FRACTURES
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p fall w/ multiple facial fractures.
REASON FOR THIS EXAMINATION:
fractures?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Multiple facial fractures.
COMPARISON: CT head from [**2200-7-10**].
TECHNIQUE: Non-contrast axial CT imaging of the facial bones
with multiplanar reformats was reviewed.
FINDINGS: There are multiple displaced fractures including
fractures of the anterior, medial, and lateral wall of the left
maxillary sinus. There is also a fracture of the left lateral
anterior inferior orbital rim that extends posteriorly into the
left orbital floor. There is no evidence for displacement of
this fracture, and there is an no herniation of orbital fat.
There is also a fracture of the right posterior maxillary sinus
and nondisplaced fracture of the right zygoma. A small minimally
displaced left nasal bone fracture is also present. The globes
appear normal and there is no evidence for intra or extraconal
abnormalities. There is near total opacification of the left
maxillary sinus and both ethmoid sinuses from a combination of
blood and mucous. Lobulated mucosal thickening in addition to
fluid is present within the right maxillary sinus as well. The
lamina propecia appear intact, there is mild mucosal thickening
of the frontal sinuses. The patient is intubated, and an NG tube
is present.
IMPRESSION: Multiple facial fractures including both maxillary
sinuses and right zygoma, and left nasal bone, as well is a
nondisplaced fracture from the lateral inferior orbital rim
extending posteriorly into the left orbital floor without
evidence for fat herniation or orbital abnormality.
CHEST (PORTABLE AP) [**2200-7-16**] 9:55 AM
CHEST (PORTABLE AP)
Reason: STAT X RAY RESP DISTRESS
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p fall, wbc elevation, s/p intubation
REASON FOR THIS EXAMINATION:
STAT X RAY RESP DISTRESS
CHEST ONE VIEW PORTABLE
INDICATION: 60-year-old man status post fall.
COMMENTS: Portable erect AP radiograph of the chest is reviewed,
and compared with the previous study of yesterday.
The previously identified mild congestive heart failure has been
improving. There is also gradual improvement of the multifocal
pneumonia, possibly due to aspiration. The heart is normal in
size. There is continued tortuosity of the thoracic aorta. No
evidence for pneumothorax is identified.
Brief Hospital Course:
Patient admitted to the trauma service. Neurosurgery was
consulted because of his head bleed. Serial head CT scans were
followed and were stable; an MRI of the brain also revealed
Diffuse Axonal Injury ([**Doctor First Name **]). He was started on Dilantin which
will need to continue until follow up with Neurosurgery. His
Dilantin dose has been adjusted several times because of
subtherapeutic levels; these levels will need to rechecked in
the next several days. Plastics was consulted as well because of
his facial fractures; these were non operative.
Behavioral Neurology was consulted because of the behavioral
issues associated with his head injury; he was started on
Olanzapine standing dose; a prn dose was added for episodes of
increased agitation. Trazodone was also added to help regulate
his sleep/wake cycle. He initially required 1:1 sitters because
of his increased agitation; these have been discontinued. His
mental status has improved, although there are still problems
with decreased short term memory; there have been no further
episodes of agitation.
He had episodes of loose stool during his hospital stay; a stool
for C-Diff was obtained and was negative. His WBC was also
elevated; thought to be related to a small aspiration pneumonia
noted on chest radiograph. His white count has trended downward
over the past several days.
Speech and Swallow were consulted to evaluate for dysphagia
given his head injury and altered mental status; initially he
did not pass the bedside evaluation. As his mental status
improved his diet was upgraded to regular with thin liquids.
Physical and Occupational therapy were consulted and have
recommended rehab for improving function and cognitive
abilities.
Medications on Admission:
Neurontin
Nortriptyline
Albuterol MDI
Lisinopril
Lorazepam
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/wheeze.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for HR <55 and/or SBP <110.
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q 5PM (): Notify MD for increased sedation.
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO TID (3 times a day) for 4 weeks.
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Right Subdural and subarachnoid hemorrhages
Multiple facial fractures
Discharge Condition:
Good
Discharge Instructions:
Follow up with Neurosurgery in 4 weeks.
Continue with the Dilantin until follow up with Neurosurgery.
Follow up with Behavioral Neurology in [**2-28**] weeks.
Followup Instructions:
Call [**Telephone/Fax (1) 9986**] for an appointment with Neurosurgery to be
seen in 4 weeks. Inform the office that you will need a repeat
head CT for this appointment.
Call [**Telephone/Fax (1) 1690**] for an appointment with Behavioral Neurology
to be seen in 2 weeks. You may also choose to contact Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the number he provided to you to schedule an appointment.
Completed by:[**2200-7-21**]
|
[
"428.0",
"518.5",
"802.8",
"787.2",
"507.0",
"401.9",
"E880.9",
"564.1",
"599.7",
"724.3",
"801.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9379, 9449
|
6308, 8032
|
335, 342
|
9572, 9579
|
810, 1419
|
9788, 10254
|
774, 791
|
8141, 9356
|
5691, 5747
|
9470, 9551
|
8058, 8118
|
9603, 9765
|
275, 297
|
5776, 6285
|
370, 567
|
3635, 3882
|
589, 695
|
711, 758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,380
| 158,054
|
54869+59636
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-7-22**] Discharge Date: [**2174-8-22**]
Date of Birth: [**2098-7-10**] Sex: F
Service: SURGERY
Allergies:
Bactrim / diltiazem / hydrochlorothiazide
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Symptomatic Abdominal Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2174-7-22**] Open Abdominal Aortic Aneurysm Repair
History of Present Illness:
76F with a history of COPD on prednisone and multiple medical
problems presents to an OSH with three weeks of abdominal pain.
She states that the pain has no exacerbating or alleviating
factors but has been persistent over this period of time. A
non-contrast CT was obtained and revealed growth of her aneurysm
from 3 cm in [**2172**] to 5.4 cm. There was no fat stranding but
given these findings she was transferred to [**Hospital1 18**] for further
care.
Past Medical History:
PMH: CRI, CAD, a fib, RBBB, cor pulmonale, DM, diverticulosis,
GI bleed, hyperlipidemia, HTN, fibromylgial, polymyalgia
rheumatica, asthma, COPD on steroids, varicose veins, c.diff.
Social History:
Recently in rehab post-discharge from LGH for UTI. Previously
lived with her son in [**Name (NI) 7661**]. History of smoking quit sixteen
years ago, denies etoh
Family History:
Non-contributory
Physical Exam:
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP difficult to assess secondary to
extraneous neck tissue and recent CVL. Normal carotid upstroke
without bruits. No thyromegaly.
CV: PMI in 5th intercostal space, mid clavicular line. RRR.
normal S1,S2. No murmurs, rubs, clicks, or [**Last Name (un) 549**]
LUNGS: Poor air movement. Inspiratory crackles at bases with
rhonchi and wheeze.
ABD: NABS. Soft, tenderness near incision, ND. No HSM. Abdominal
aorta not palpated [**2-10**] recent surgery.
EXT: LE edema R>L. Full distal pulses bilaterally.
SKIN: No rashes/lesions
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**1-10**]+ reflexes, equal BL.
Gait assessment deferred
PSYCH: Mood was pleasant and affect was appropriate.
Sacral Skin Decub
She has and area of skin breakdown that appears to be partial
thickness with few areas of increased depth. Shallow stage 3
breakdown. Wound bed with 70% red, 30% yellow. Total area
measures 7 x 5 cm. Appears jagged with attached edges. The
periwound tissue is blanching purple tissue, very fragile.
Drainage moderate serosang without odor.
Pertinent Results:
[**2174-8-17**] 04:09AM BLOOD WBC-10.6 RBC-3.28* Hgb-9.2* Hct-29.9*
MCV-91 MCH-27.9 MCHC-30.7* RDW-19.4* Plt Ct-260
[**2174-8-17**] 04:09AM BLOOD Plt Ct-260
[**2174-8-22**] 12:20PM BLOOD Glucose-214* UreaN-54* Creat-1.7* Na-138
K-4.8 Cl-95* HCO3-37* AnGap-11
[**2174-8-22**] 12:20PM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2174-7-21**] 10:59 PM
CTA ABD W&W/O C & RECONS; -59 DISTINCT PROCEDURAL SERVIC; CTA
PELVIS W&W/O C & RECONS Clip # [**Clip Number (Radiology) 112099**]
Reason: define AAA
Field of view: 34 Contrast: OMNIPAQUE Amt: 90
[**Hospital 93**] MEDICAL CONDITION:
History: 76F with AAA
REASON FOR THIS EXAMINATION:
define AAA
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: [**First Name9 (NamePattern2) 85409**] [**Doctor First Name **] [**2174-7-21**] 11:59 PM
1. Saccular infrarenal AAA up to 48 mm in diameter (400b:22). no
extravasation. focus of calcific irregularity along the right
aspect of the
aneurysmal sac is stable since the 6:18 reference examination.
2. Severe right femoralacetabular osteoarthritis.
Final Report
INDICATION: AAA.
COMPARISON: Reference CT is available from [**2172-5-13**] and [**7-21**], [**2174**].
TECHNIQUE: MDCT-acquired 2.5-mm axial images of the abdomen and
pelvis were
obtained prior to and following the uneventful administration of
90 cc of
Visipaque intravenous contrast. Coronal and sagittal
reformations were
performed at 5-mm slice thickness.
CT OF THE ABDOMEN WITH IV CONTRAST:
Included views of the lung bases demonstrate mild dependent
atelectasis.
There is no pericardial or pleural effusion. The heart size is
top normal.
The liver, stomach, pancreas, adrenal glands, kidneys, and
intra-abdominal
loops of small bowel are normal. There is no mesenteric or
retroperitoneal
lymphadenopathy, and no free air or free fluid. The patient is
post left
colectomy with a right lower quadrant loop ileostomy, with no
evidence of
obstruction. Extensive colonic diverticulosis is present, with
no evidence of
diverticulitis.
CT OF THE PELVIS WITH IV CONTRAST:
The rectum is normal. No adnexal masses are present. A Foley
catheter
resides within the bladder, containing a small amount of air
(3:40). There is
no intrapelvic free fluid or lymphadenopathy.
OSSEOUS STRUCTURES:
There is no acute fracture. Severe osteoarthritic changes are
seen within the
right femoroacetabular joint (3:131, 400B:23), where there is
complete loss of
joint space with extensive sclerosis and subchondral cystic
change. There are
no bony lesions concerning for malignancy or infection. Grade I
anterolisthesis of L4 over L5 is present. There is loss of the
L5-S1 disc
space with vacuum phenomenon and posterior osteophytosis with
mild thecal sac
narrowing.
CTA:
A saccular infrarenal aortic aneurysm measures up to 48 mm in
diameter
(400B:22), measuring approximately 44 mm in length. The
aneurysmal sac arises
from the right side of the aorta and demonstrates peripheral
coarse
calcifications, with focal area of calcific irregularity at the
lateral-most
edge (3:52), with no neighboring stranding to suggest an active
rupture. The
appearance of the aneurysmal sac is unchanged in comparison to
the 8:19 p.m.
reference examination, but is markedly enlarged since [**2172-5-13**] reference
exam. Moderate atherosclerotic calcifications extend throughout
the abdominal
aorta and iliac branches.
IMPRESSION:
1. 48-mm right saccular infrarenal AAA, markedly increased in
size since
[**2172**], with mild irregularity of the lateral-most calcific
borders placing this
at high risk for rupture. No active rupture is detected.
2. Severe right femoroacetabular osteoarthritis.
3. Post-left colectomy and right lower quadrant loop ileostomy,
with no
evidence of obstruction.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: FRI [**2174-7-22**] 5:27 PM
Brief Hospital Course:
76 year old female with a history of CAD, HTN, atrial
fibrillation, RBBB diverticulitis status post left colectomy
with loop ileostomy and oxygen-dependent
COPD on steroids who presented on [**2174-7-21**] with progressive
abdominal pain over the past few weeks. She went to an outside
hospital where CT with oral contrast only demonstrated an
expansion of an infrarenal abdominal aortic aneurysm that was
saccular in shape without an adequate neck for endovascular
repair. She was transferred to our hospital for further
evaluation where she was found to be hemodynamically stable.
However, she was complaining of significant pain and was
tender over her aneurysm. A CT angiography was obtained, despite
an elevated creatinine, that did demonstrate concerning
expansion of her aneurysm without any evidence of rupture.
However, it was felt with her progressive pain and tenderness
over the aneurysm and the saccular shape that she was at
incredibly high risk for imminent rupture. We therefore admitted
her for urgent repair of her juxtarenal
AAA. On HD 2 she underwent open retroperitoneal juxtarenal
abdominal aortic
aneurysm repair with tube graft which she tolerated well. For
full details of the procedure please see the operative report
dated [**2174-7-22**]. Postoperatively she was transferred in stable
condition to the CVICU on a ventilator. On POD #1 she was
extubated but required NIV for a short period. She was noted to
have a metabolic acidosis with a lactate of 2.3 and a WBC of 14
and [**First Name8 (NamePattern2) **] [**Last Name (un) **] with a creatinine on 1.6. She appeared hypovolemic
intravascularly and was treated with albumin with improvement in
UOP. On POD 3 she had bursts of Afib overnight which was rete
controlled with lopressor. Over the next several days she was
restarted on prednisone and was diuresed with lasix. On POD 4 PT
recommended [**Hospital 112100**] rehab. Her white count remained elevated and
UA was positive so she was started on cipro. On POD 9 her foley
was discontinued. On POD 10 her WBC increased to 21. She was pan
cultured and started on vancomycin and flagyl in addition to
cipro. The following day her CVL was removed and the tip was
cultured. C. diff was negative and a PICC line was placed. On
POD 12 her urine culture grew pseudomonas and she was noted to
be incontinent so her foley was replaced. Infectious disease
recommended cefepeme for her pseudomonal UTI so she was started
on cefepime and continued on flagyl. On POD 13 her pseudomonal
UTI was noted to be pan resistant and suspectable to meropenem.
Cardiology was consulted for two episodes of bradycardia to the
30's associated with SOB. These episodes were felt to be vagally
mediated, and her betablocker was stopped. She continued to have
episodic bradycardia and on POD 14 had multiple episodes of
bradycardia associated with brief loss of consciousness. The
patient was transferred to the CCU where review of the telemetry
strips revealed prolongation of the P-P interval with eventual
sinus arrest and slow junctional escape leading to asystole, and
then recovery of sinus node activity within a few seconds
consistent with increased vagal tone. She was started on
theophylline with complete resolution of these episodes, and
pacemaker placement was felt to not be indicated. Her
theophylline was tapered from q6H to q8H to q12H, and then was
discontinued on the morning of POD 19. Additionally on POD 18
she was noted to have right arm swelling and an UE US revealed a
partially occlusive thrombus surrounding the PICC line. She was
also noted to be hyperkaelemic from an unknown origin with a K
of 6. There were no EKG changes and over the next several days
she required multiple rounds of therapy with insulin, D50,
Ca-gluconate and lasix for persistently elevated potassium
levels. The administration of kaexylate was differed in the
setting of her end ileostomy with a concern for potential
ischemia. On POD 20 her meropenem was discontinued and she was
restarted on metoprolol 12.5 mg [**Hospital1 **]. That evening she again had
2 episodes of bradycardia to the 20's consistent with elevated
vagal tone which resulted on very transient loss of
consciousness. She was felt unstable for the floor and on POD 21
was transferred to the CVICU for further management. On POD 22
she was restarted on theophylline and metoprolol. Over the next
several days she continued to have short lived, asymptomatic
episodes of tachycardia to the 130's which resolved
spontaneously. By POD 23 her potassium had stabilized. On POD 24
her theophylline was decreased from TID to [**Hospital1 **] and On POD 27 her
theophylline was decreased to Qday. Since that time her heart
rate has remained stable. At the time of discharge she was
tolerating a regular diet, she was afebrile and she was not
tachycardic.
Medications on Admission:
Proair INH, Compazine PRN, Vitamin D, Calcitonin-Salmon 200U 1
spray alternating nostrils daily, Polystyrene Sulf 15gm/60 cc 5X
weekly (Tues, Wed, Thurs, Sat, Sun), Atenolol 25 daily,
omeprazole 20 mg daily, Zocor 40 mg daily, Citalopram 10 mg
daily, Lasix 20 mg daily, Prednisone 20 mg daily, Oxycodone 5 mg
q 4 hrs PRN, Lantus 8 units QHS, Novolog SS, MVI, Vit C, Zinc
Sulfate, Combivent MDIPRN, Acidophilus
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN fever, pain
RX *acetaminophen 500 mg [**1-10**] tablet(s) by mouth Q6hrs Disp #*30
Not Specified Refills:*0
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
3. Albuterol Inhaler [**2-12**] PUFF IH Q6H:PRN wheezing
4. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*30 Not
Specified Refills:*0
5. Albuterol-Ipratropium [**1-10**] PUFF IH QID wheezing
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL [**1-10**]
Puffs inhaled four times a day Disp #*2 Not Specified Refills:*0
6. Citalopram 10 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Not Specified Refills:*0
8. Furosemide 20 mg PO DAILY
9. Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 Neb Inhaled Q6hrs
Disp #*10 Not Specified Refills:*0
11. Metoprolol Tartrate 12.5 mg PO BID
hold for HR < 60 or SBP < 90
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Not Specified Refills:*0
12. Omeprazole 20 mg PO DAILY
13. PredniSONE 20 mg PO DAILY
14. Simvastatin 40 mg PO DAILY
15. Senna 1 TAB PO BID
RX *senna 8.6 mg 1 tab by mouth twice a day Disp #*60 Not
Specified Refills:*0
16. Theophylline (Oral Solution) 100 mg PO DAILY
RX *theophylline 80 mg/15 mL 100 mg by mouth Daily Disp #*10 Not
Specified Refills:*0
17. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth Q4hrs Disp #*60 Not
Specified Refills:*0
18. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 7661**] health & Rehab center
Discharge Diagnosis:
Expanding Abdominal Aortic Aneurysm, sp repair.
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were transferred to [**Hospital1 18**] after a CT scan, to evaluate your
complaints of abdominal pain, showed growth your abdominal
aortic aneurysm. It was felt that the aneurysm was causing your
pain and at risk of bursting so you were brought to the
operating room immediately for repair. You were treated for a
UTI and were found to have a low heart rate because of increased
vagal tone and are being sent home with a medication to help
control your heart rate.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-9-1**] 9:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2174-8-22**] 2:50
Name: [**Known lastname 18414**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 18415**]
Admission Date: [**2174-7-22**] Discharge Date: [**2174-8-22**]
Date of Birth: [**2098-7-10**] Sex: F
Service: SURGERY
Allergies:
Bactrim / diltiazem / hydrochlorothiazide
Attending:[**First Name3 (LF) 726**]
Addendum:
While in the CVICU on [**2174-8-6**] her symptoms were thought to be
likely the result of acute diastolic CHF exacerbation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 7571**] health & Rehab center
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]
Completed by:[**2174-8-29**]
|
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"E941.3",
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"441.4",
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"707.03",
"E878.2",
"V58.67",
"041.7",
"599.0",
"250.00",
"V46.2",
"453.81",
"403.90",
"276.7",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
15277, 15508
|
6634, 11459
|
339, 395
|
13776, 13891
|
2532, 3126
|
14447, 15254
|
1286, 1305
|
11919, 13588
|
3166, 3188
|
13705, 13755
|
11485, 11896
|
13952, 14424
|
1320, 2513
|
262, 301
|
3220, 6611
|
423, 883
|
13906, 13928
|
905, 1091
|
1107, 1270
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,453
| 148,979
|
18682+18683+18684
|
Discharge summary
|
report+report+report
|
Admission Date: [**2174-7-22**] Interim Date: [**2174-8-9**]
Date of Birth: [**2174-7-22**] Sex: M
Service: NEONATOLOGY
This is an interim summary covering the dates, [**2174-7-22**] to
[**2174-8-11**].
HISTORY OF THE PRESENT ILLNESS: Baby boy [**Known lastname **] [**Known lastname 51236**]
is an 811 gram 26 [**1-18**] week gestation infant born to a
33-year-old gravida I, para 0 now I mother with prenatal
screens as follows: O negative, antibody negative, hepatitis
B surface antigen negative, RPR nonreactive, rubella immune,
GBS unknown. Maternal history was significant for
pregnancy-induced hypertension on [**2174-7-20**] and was
admitted to [**Hospital6 256**]. She was
treated with magnesium sulfate, labetalol, hydralazine, and
bed rest as well as betamethasone.
Fetal testing revealed a BPP [**8-19**] and estimated fetal weight
of 793 grams. On the morning of delivery, fetal heart rate
decelerations were noted and the decision was made to deliver
via emergent cesarean section. The baby emerged with some
tone and grimace. He was treated with bulb suction and
bag-mask ventilation with good response of crying and
spontaneous respirations. Apgar scores were six, seven, and
eight at one, five, and ten minutes respectively. The baby
was intubated at four to five minutes of life and treated
with surfactant.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 811 grams
(40th to 50th percentile), length 33 cm (25th percentile),
head circumference 25.5 cm (50th to 60th percentile). The
anterior fontanelle was soft and flat, sutures mobile, eyes
fused, palate intact, lungs clear and equal, occasional
scattered rales, mild retractions. Cardiovascular: Normal
S1, S2, no murmur, perfusion good. Abdomen: Soft with no
distention, no organomegaly, three vessel cord. Normal
genitalia for gestational age. Testes not descended.
Neurologic: Tone appears normal for gestational age.
Symmetrical movement of upper and lower extremities. Hips
stable. Skin appropriate for gestational age, red and
translucent. No areas of significant bruising or breakdown.
LABORATORY/RADIOLOGIC DATA: Initial chest x-ray revealed
bilateral granular hazy lung fields. Heart size appeared to
be upper limits of normal.
Baby's initial D stick was 30s on admission and required two
boluses of D10W.
ASSESSMENT: [**Known lastname **] is a 26 week gestation, preterm male,
infant with clinical picture consistent with surfactant
deficiency. He was admitted to the NICU for further
management.
HOSPITAL COURSE: 1. RESPIRATORY: [**Known lastname **] received a total
of two doses of Surfactant with initial improvement of
respiratory distress and weaning of ventilatory settings.
However, he developed acidosis and increased work of
breathing on day of life number one and two due to his patent
ductus arteriosus. His ventilatory settings were increased
and he remained on SIMV since that time for evolving chronic
lung disease. He is currently on SIMV settings of 22/6 at a
rate of 24, FI02 anywhere between 25-40%. He has not been
started on caffeine. His chest x-rays in the interim have
revealed shifting atelectasis, most often seen in the right
upper lobe area. With the persistence of right lungs findings,
increasing ventilatory support, and a respiratory culture
revealing staph aureus, he was treated for presumptive pneumonia.
2. CARDIOVASCULAR: [**Known lastname **] developed clinical signs and
symptoms consistent with PDA on day of life number one with
persistent acidosis, pulse pressures and a new murmur. He
was treated with Indomethacin times three doses and follow-up
echocardiogram on day of life number four revealed no PDA
even though a soft murmur persisted.
Given the persistence of the soft murmur as well as
persistent acidosis, a follow-up echocardiogram was done on
day of life number 13 which again revealed no PDA, some small
PFO and PPS were seen. He has otherwise remained
hemodynamically stable.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: [**Known lastname **] was
started on parenteral nutrition on day of life number zero.
His blood glucoses have remained stable after the initial
hypoglycemia requiring two D10W boluses. He was started on
enteral feeds on day of life number nine and has been
advanced gradually in volume at 10 cc per kilogram b.i.d. He
is currently at total fluids of 250 cc per kilogram per day,
breast milk 20 at 70 cc per kilogram per day, advancing 10 cc
per kilogram b.i.d. His birth weight was 811 grams and his
weight on day of life number 18 is 903 grams.
4. GASTROINTESTINAL: [**Known lastname **] bilirubin level peaked on
day of life number one at 5.3, at which time phototherapy was
started. Phototherapy was discontinued on day of life number
seven with a rebound bilirubin level of 2.8 on day of life
number ten. He does not appear to be jaundiced at the time
of dictation.
5. INFECTIOUS DISEASE: [**Known lastname **] completed 48 hours of
ampicillin and gentamicin for initial rule out sepsis course.
On day of life number 13 he had become lethargic with a
left shift on his CBC with a white count of 19.1, 30 polys,
32 lymphs and 6 meta. A blood culture and tracheal
culture were sent at that time and he was started on
vancomycin and gentamicin. His blood cultures so far remain
no growth to date and his trach culture is showing
methicillin-sensitive Staphylococcus aureus. Around this time
he developed a leak around his PICC line. The possibility of
line sepsis, potentially with staph epidermidis, was also
entertained. He is currently completing a course of vancomycin
and gentamicin, now day number five out of ten. The plan is to
switch vancomycin to Oxacillin at day number seven and completing
a full ten day course of antibiotics with Oxacillin and
gentamicin. A LP was performed on day of life number 14 which was
negative for meningitis.
6. NEUROLOGY: [**Known lastname **] had a screening head ultrasound on
day of life number four which revealed a small echogenic
focus in the occipital [**Doctor Last Name 534**] on the right. A follow-up head
ultrasound on day of life number 11 revealed negative
findings and no bleed.
7. HEMATOLOGY: [**Known lastname **] initial hematocrit was 48.9 and
had dropped down to 34.2 on day of life number five given
blood laboratories. He was transfused with 20 cc per
kilogram of packed red cells at that point. His hematocrit
on day of life number 13 was again low at 32.9, at which time
he was transfused again with 20 cc per kilogram of packed red
blood cells.
8. OPHTHALMOLOGY: [**Known lastname **] eyes have not been examined at
this time. He is due for a first examination at corrected
gestational age of 33 weeks.
9. PSYCHOSOCIAL: [**Hospital1 18**] Social Work is involved with the
family. The contact social worker is [**Name (NI) 36130**] [**Name (NI) 36527**], and
she can be reached at [**Telephone/Fax (1) **].
10. AUDIOLOGY: Hearing screening will be performed prior to
discharge.
CONDITION AT THE TIME OF DICTATION: [**Known lastname **] has been stable
on the current ventilatory settings and has been tolerating
advancement in his enteral feeds.
NAME OF PRIMARY PEDIATRICIAN: Undetermined.
CURRENT MEDICATIONS:
1. Vancomycin to be changed over to oxacillin.
2. Gentamicin.
HEALTH CARE MAINTENANCE: State newborn screen has been sent.
[**Known lastname **] had not received any immunizations during this
interim.
DIAGNOSIS:
1. Prematurity at 26 2/7 weeks.
2. Respiratory distress syndrome.
3. Patent ductus arteriosus, status post medical treatment.
4. Evolving chronic lung disease.
5. Presumed staph aureus pneumonia.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Name8 (MD) 47634**]
MEDQUIST36
D: [**2174-8-9**] 01:46
T: [**2174-8-9**] 14:39
JOB#: [**Job Number 51237**]
Admission Date: [**2174-7-21**] Discharge Date: [**2174-10-12**]
Date of Birth: [**2174-7-22**] Sex: M
Service: NEONATOLOGY
Note: This is an interim summary from [**2174-9-12**], to
[**2174-10-11**].
For history and admission exam, please see original admission
summary.
HOSPITAL COURSE: 1. Respiratory: The infant is now 82 days
old. He continues to have chronic lung disease. He came off
CPAP on [**2174-9-10**], onto nasal cannula oxygen. He
initially required high flow at 40 cc/min of oxygen for
increased work of breathing. Following fluid restriction to
130 cc/kg on [**2174-9-22**], his oxygen requirement
gradually came down, and he went into room air on [**2174-10-9**].
He also had apnea of prematurity for which he been on
Caffeine. This was discontinued on [**2174-9-28**]. He
has had no apnea of prematurity since [**2174-9-22**].
As he is progressing so well, we decided to stop his chronic
diuretic therapy, and sodium, potassium and chloride
supplementation on [**2174-10-10**].
We will continue to monitor his progress closely and evaluate
him to see whether he requires reinstatement of his chronic
diuretic therapy or supplemental oxygen requirement.
2. Cardiovascular: He continues to have an intermittent
grade 1-2/6 ejection systolic murmur consistent with
peripheral pulmonic stenosis which was diagnosed on
echocardiogram on [**2174-8-4**].
He has remained hemodynamically stable during this interim.
3. Fluids, electrolytes and nutrition: His weight at the
beginning of the month was 1550. His weight on [**2174-10-11**], was [**2196**]. He was initially 150 cc/kg, and as mentioned
we briefly restricted him in view of his chronic lung disease
on [**2174-9-22**].
In view of metabolic bone disease, he has required
adjustment of his breast milk supplementation. He was noted
to have a mildly elevated calcium, mildly depressed
phosphorus, and elevated alkaline phosphatase. His last labs
were on [**2174-10-4**], when his calcium was 12.4,
phosphorus 4.9, and alkaline phosphatase 791.
He is currently on breast milk 20 ad lib and manages to take
at least 130 cc/kg/day. He has doubled the regular amount of
Promote added to his formula, as well as corn oil and HMS and
Enfamil.
We reduced his calories from 32 kcal to 20 kcal on [**2174-10-9**], and in anticipation of him possibly going home some
time in the near future, we will continue to monitor his
weight gain closely and will increase his calorie requirement
if required.
He will continue to have his metabolic bone disease monitored
at regular intervals.
3. Gastrointestinal: The infant has had alternating
hydroceles since the beginning of the month. On [**2174-9-22**], he was noted to have a left-sided reducible
inguinal hernia. He went to the Operating Room on [**2174-10-8**], when he had a bilateral inguinal hernia repair and
circumcision. He subsequently developed a mild wound
infection and was commenced on a five-day course of Keflex.
4. Hematology: His hematocrit on [**2174-9-20**], was
30.4. He has not required any blood transfusions during this
admission.
5. Infectious disease: He underwent sepsis evaluation on
[**2174-9-15**], in view of increased work of breathing and
desaturations. His antibiotics were discontinued after 48
hours when his blood cultures were negative. Apart from the
surgical wound infection, he has not had any other infectious
disease issues.
6. Neurology: His 60-day head ultrasound revealed no
evidence of white matter disease.
7. Auditory: He has passes his hearing screening.
8. Ophthalmology: His initial eye exam on [**2174-9-14**], revealed retinopathy of prematurity with Stage I, Zone
II on the right and Stage II, Zone II on the left. His most
recent exam on [**2174-10-3**], revealed bilateral
premature retina in Zone III with no evidence of
................. disease or ROP.
9. Immunizations received: He received his two-month
immunizations, i.e., hepatitis B, DTAP, HIP, IPV, and
..............
INTERIM SUMMARY DIAGNOSIS:
1. Chronic lung disease.
2. Apnea of prematurity.
3. Peripheral pulmonic stenosis.
4. Metabolic bone disease.
5. Left inguinal hernia.
6. Circumcision.
7. Sepsis evaluation.
8. Surgical wound infection.
9. Retinopathy of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Doctor Last Name 50143**]
MEDQUIST36
D: [**2174-10-12**] 19:51
T: [**2174-10-12**] 23:48
JOB#: [**Job Number 51238**]
Admission Date: [**2174-7-22**] Discharge Date: [**2174-10-15**]
Date of Birth: [**2174-7-22**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 51236**] is
an 811 gm, 26 [**1-18**] week gestation infant male born to a 33
year old gravida 1, para 0 to 1 mother with prenatal screens
as follows: 0 negative, antibody negative, hepatitis B
surface antigen negative, RPR nonreactive, Rubella immune
Group B Streptococcus unknown. Maternal history is
significant for pregnancy-induced hypertension on [**2174-7-20**] prompting admission to [**Hospital6 2018**]. She was treated with Magnesium Sulfate, Labetalol,
Hydralazine and bedrest as well as betamethasone. Fetal
testing revealed a biophysical profile of 8 out of 8 and an
estimated fetal weight of 792 gm. On the morning of delivery
fetal heartrate decelerations were noted and the decision was
made to deliver by emergent cesarean section. The baby
emerged with some tone and grimace. He was treated with bulb
suction and bag mask ventilation with good response of crying
and spontaneous respirations. Apgars scores were 6, 7 and 8
at one, five and ten minutes respectively. The patient was
intubated at four to five minutes of life and was treated
with Surfactant.
PHYSICAL EXAMINATION: Physical examination on admission
revealed birthweight 811 gm, 40th to 50th percentile, length
33 cm, 25th percentile, head circumference 25.5 cm, 50th to
60th percentile. The anterior fontanelle was soft and flat,
sutures mobile. Eyes fused. Palate intact. Lungs clear and
equal, occasional standard rales, mild retractions.
Cardiovascular, normal S1 and S2, no murmurs. Perfusion
good. Abdomen soft with no distention, no organomegaly,
three vessel cord, normal genitalia for gestational age.
Testes were not distended. Neurological: Tone appears
normal for gestational age. Symmetric movements of upper and
lower extremities. Hips stable. Skin, appropriate for
gestational age, red and translucent. No areas of
significant bruising or breakdown.
HOSPITAL COURSE: 1. Respiratory - [**Known lastname **] received a total
of two doses of Surfactant with initial improvement of
respiratory distress and weaning of ventilator settings.
However, he developed acidosis and increased work of
breathing on day of life #1 and 2 due to a patent ductus
arteriosus. This required increase in his ventilator
settings. He self-extubated on day of life #39 ([**8-30**])
and successfully remained on CPAP. He came off of CPAP on
[**2174-9-10**], on to nasal cannula oxygen. He weaned down
on his nasal cannula oxygen and went into room air on
[**2174-10-9**]. He subsequently remained stable in room
air. The patient was started on Aldactone and Diuril for
chronic lung disease during his hospitalization. These were
discontinued on [**10-10**] and the patient has tolerated
this well. He also apnea of prematurity and was started on
caffeine. Caffeine was discontinued on [**2174-9-28**],
last episode of apnea of prematurity was [**2174-9-22**].
2. Cardiovascular - [**Known lastname **] developed clinical signs and
symptoms consistent with a patent ductus arteriosus on day of
life #1. He received one course of Indomethacin with no
residual patent ductus arteriosus on follow up
echocardiograms. He has an intermittent murmur consistent
with peripheral pulmonic stenosis. His last echocardiogram
was on day of life #13 which revealed no patent ductus
arteriosus, a small patent foramen ovale and peripheral
pulmonic stenosis were seen.
3. Fluids - [**Known lastname **] was started on parenteral nutrition on
day of life #0, enteral feeds were started on day of life #9.
He advanced up to full feeds and caloric density was
gradually increased. He was advanced to breastmilk 32
kcal/oz. He was also started on sodium chloride and [**Doctor First Name 233**]-Ciel
supplements. His calories were reduced from 32 kcal/oz to 28
kcal/oz on [**10-9**] in anticipation for his discharge.
He continued to gain well on this regimen. His sodium and
[**Doctor First Name 233**]-Ciel supplements were also discontinued prior to his
discharge and his electrolytes remained stable. He is
currently on breastmilk 28 kcal/oz with 8 kcal/oz by NeoSure
powder, p.o. adlib feeds, taking greater than 120 cc/kg/day.
Weight on discharge 2125 gm.
4. Gastrointestinal - The patient's bilirubins were
followed. Bilirubin peaked oat 5.3 on day of life #1 and
phototherapy was initiated. Phototherapy was continued until
day of life #7 and rebound bilirubin following
discontinuation of phototherapy was 2.8. The patient had
bilateral inguinal hernias and then underwent bilateral
inguinal hernia repair on [**2174-10-8**] along with a
circumcision. He subsequently developed a mild wound
infection and was treated with a five day course of Keflex.
5. Infectious disease - [**Known lastname **] completed 48 hours of
Ampicillin and Gentamicin for initial rule-out sepsis. There
was also the concern for the possibility of line sepsis with
Staphylococcus epidermidis around day of life #13 which was
treated with a ten day course of Vancomycin and Gentamicin.
6. Hematology - [**Known lastname **] received multiple transfusions.
His last transfusion was on [**8-25**]. He was treated during
his hospitalization with iron and Vitamin D. He continues on
iron supplementation at the time of discharge.
7. Neurology - [**Known lastname **] had screening head ultrasounds on
day of life #4 and day of life #11 which revealed no evidence
of interventricular hemorrhage. His 60 day head ultrasound
revealed no evidence of white matter disease.
8. Ophthalmology - [**Known lastname **] initial eye examination on
[**9-14**] revealed retinopathy of prematurity with Stage 1,
Zone 2 on the right and Stage 2, Zone 2 on the left. His
retinopathy of prematurity did not progress and his most
recent examination on [**10-3**] revealed bilateral
premature retina in Zone 3 with no evidence of retinopathy of
prematurity.
9. Audiology - He passed his hearing screen bilaterally.
10. Immunizations - [**Known lastname **] received his two month old
immunizations including hepatitis B, DTAP, HIB, ITV and
Prevnar. Synagis respiratory syncytial virus prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
who meet any of the following three criteria: 1. Born at
less than 32 weeks; 2. Born between 32 and 35 weeks with
plans for daycare during respiratory syncytial virus season,
with a smoker in the household or with preschool siblings; or
3. With chronic lung disease. [**Known lastname **] meets the criteria
for Synagis and received his first dosage of Synagis prior to
discharge. Influenza immunization should be considered
annually in the fall for preterm infants with chronic lung
disease once they reach six months of age. Before this age
the family and other caregivers should be considered for
immunization against influenza to protect the infant.
11. Social - [**Hospital6 256**] Social Work
was involved with the family with contact social worker,
[**Name (NI) 36130**] [**Name2 (NI) 36527**], she can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with Mom. Name of
primary care pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital **]
Pediatrics, phone [**Telephone/Fax (1) 43116**].
CARE RECOMMENDATIONS:
Feeds at discharge - Breastmilk 28 with 8 kcal/oz of NeoSure
powder.
Medications on discharge - Iron supplements and Poly-Vi-[**Male First Name (un) **].
Carseat testing - Passed carseat test prior to discharge.
Newborn state screens - All within normal limits.
Immunizations - Two month old immunizations have been given
as well as first dose of Synagis for this season.
Follow up appointments - Scheduled with [**Hospital **] Pediatrics on
Monday, [**10-17**].
DISCHARGE DIAGNOSIS:
1. Prematurity at 26 weeks gestational age
2. Chronic lung disease
3. Status post apnea of prematurity
4. Peripheral pulmonic stenosis
5. Status post patent ductus arteriosus
6. Bilateral inguinal hernias, status post repair
7. Circumcision
8. Staphylococcus epidermidis sepsis
9. Surgical wound infection
10. Retinopathy of prematurity
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 50027**]
MEDQUIST36
D: [**2174-10-16**] 01:16
T: [**2174-10-16**] 07:19
JOB#: [**Job Number 51239**]
|
[
"746.02",
"482.41",
"774.2",
"771.81",
"765.13",
"769",
"998.59",
"770.7",
"V30.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"38.91",
"38.92",
"99.83",
"93.90",
"53.10",
"96.72",
"99.55",
"96.04",
"03.31",
"64.0"
] |
icd9pcs
|
[
[
[]
]
] |
19823, 20026
|
20533, 21168
|
14625, 19765
|
20048, 20512
|
13845, 14607
|
7242, 8228
|
12675, 13822
|
1395, 2532
|
19790, 19799
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,917
| 194,216
|
3371
|
Discharge summary
|
report
|
Admission Date: [**2125-10-15**] Discharge Date: [**2125-11-12**]
Date of Birth: [**2046-3-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Senna / Iodine / Optiray 350
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2125-10-22**]:
1. Redo sternotomy.
2. Bentall procedure with a 21 mm [**Company 1543**] Freestyle
bioprosthesis, serial number [**Serial Number 15632**].
3. Redo coronary artery bypass grafting with reverse
saphenous vein graft from the [**Company 1543**] Freestyle graft
to the existing reverse saphenous vein graft to the
distal right coronary artery.
4. Epiaortic duplex scanning.
5. Endoscopic left greater saphenous vein harvesting.
[**2125-10-26**]
1. Mediastinal re exploration.
2. Repair of vein graft tear.
3. Placement of Cormatrix.
History of Present Illness:
Ms. [**Name14 (STitle) 15633**] is a 79 yo female with a complex medical history
including severe aortic stenosis, s/p bioprosthetic
AVR/CABG([**2118**]-F [**Doctor Last Name **]) now with bioprosthetic restenosis and
recurrent systolic heart failure requiring multiple
hospitalizations, Patient also s/p CABG x1([**2118**]) and
PCI-LAD([**2119**]). Cardiac status further complicated by mitral
regurgitation, pulmonary hypertension and complete heart block
s/p pacemaker([**2120**]), hypertension, and insulin-dependent
diabetes. Last month, patient was admitted for severe
hypertension and
resultant pulmonary edema. She was treated with IV Lasix and a
repeat TTE showed progression of the restenosis of her
bioprosthetic valve. At that point her beta-blocker was
increased to carvedilol 25 mg twice a day, her Diovan was
decreased from 120 mg twice a day to 120 mg once a day and
diltiazem XR was started. She was seen by Dr. [**Last Name (STitle) 914**] for
surgical evaluation. The patient refused surgery at that time.
On [**2125-10-12**], pt saw Dr. [**Last Name (STitle) **] in cardiology clinic on
[**2125-10-12**] where she reported progression of her symptoms. She was
not compliant wtih her diet, PCP had increased her diovan to
160mg daily because her BPs at home had been high. Her dose of
lasix was increased. She was subsequently admitted to CCU with
congestive heart failure placed on BiPap and Lasix gtt. Cardiac
surgery was reconsulted for surgical evaluation
Cardiac Echocardiogram: [**2125-10-16**]:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-10mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. with mild global free wall hypokinesis.
A bioprosthetic aortic valve prosthesis is present. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to
moderate ([**12-16**]+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is severe mitral annular
calcification. Moderate to severe (3+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Past Medical History:
1. Aortic stenosis s/p Aortic valve replacement with [**Company 1543**]
mosaic valve, 19mm([**2118**])-Dr [**Last Name (STitle) **]
2. Acute Congestive Heart Failure with numerous hospitalizations
3. CAD - CABG x 1 with SVG to PDA in [**2118**], PCI to LAD [**2119**]
4. HTN
5. DM2
6. DDD-Pacemaker for complete heart block-[**2118**]
7. History of left atrial appendage thrombus on coumadin
8. Schwanomma T11 to T12 s/p resection ([**2-16**]).
9. Anemia.
10. PVD with bilateral subclavian stenosis.
11. History of subdural hemorrhage after motor vehicle accident.
12. Depression
Past Surgical History:
- s/p AVR #19 Porcine/CABG x1(SVG-PDA)[**2118**]
- s/p Schwannoma s/p resection [**2119**]
Social History:
Lives with Husband. Adult [**Name2 (NI) **] Care.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Brother MI [**79**]
Father/Mother HTN
Physical Exam:
HR 62-AVpaced, RR 28 O2sat 94% on RA
B/P Right: 131/45
Height: Weight:
General: NAD-lying in bed
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] anicteric, MMM-benign oropharynx
Neck: Supple [x] Full ROM [x] No lymphadenopathy, JVP 9 cm
Chest: Scattered crackles in lower bases bilaterally
Heart: RRR [x] Murmur: 4/6 SEM
Abdomen: Soft[x] non-distended[x] non-tender[x] +bowel sounds
[x]
Extremities: Warm [x], well-perfused [x] Edema- 2+ bilat
Varicosities: mild
Neuro: Alert and interactive, MAE-follows commands. Non focal
exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit: transmitted murmur
Pertinent Results:
[**2125-11-12**] 05:53AM BLOOD WBC-9.6 RBC-3.90* Hgb-11.6* Hct-34.4*
MCV-88 MCH-29.6 MCHC-33.6 RDW-16.2* Plt Ct-337
[**2125-11-12**] 05:53AM BLOOD Glucose-84 UreaN-66* Creat-2.8* Na-142
K-3.7 Cl-107 HCO3-25 AnGap-14
[**2125-11-11**] 07:04AM BLOOD Glucose-76 UreaN-70* Creat-2.9* Na-142
K-3.7 Cl-106 HCO3-24 AnGap-16
[**2125-11-11**] 07:04AM BLOOD WBC-8.3 RBC-3.82* Hgb-11.3* Hct-33.7*
MCV-88 MCH-29.5 MCHC-33.5 RDW-16.0* Plt Ct-329
[**2125-11-5**] 10:38AM BLOOD ALT-62* AST-52* AlkPhos-179* TotBili-2.5*
[**2125-11-12**] 05:53AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.7*
[**2125-10-23**]:
The left atrium is elongated. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity size is
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with trivial mitral
stenosis. Mild to moderate ([**12-16**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The left ventricular
inflow pattern suggests impaired relaxation. The pulmonary
artery systolic pressure could not be determined. There is a
partially echodense pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
The patient was brought to the operating room on [**2125-10-22**] where
the she underwent a redo sternotomy with a Bentall procedure
with a 21 mm [**Company 1543**] Freestyle bioprosthesis with coronary
button reimplantation, as well as redo coronary artery bypass
grafting with reverse saphenous vein graft from the [**Company 1543**]
Freestyle graft
to the existing reverse saphenous vein graft to the distal right
coronary artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU on Epinephrine,
Neo-Synephrine, Propofol and Dobutamine in stable condition for
recovery and invasive monitoring. She had been doing well on
[**2125-10-24**] and had her chest tube removed earlier in the day when
she suddenly had arrhythmia issues and became hypotensive. An
echocardiogram was performed which showed tamponade. She was
brought to the operating room emergently for mediastinal
exploration. She had multiple clots evacuated and a repair for
bleeding coming from a hole in the vein graft proximally. A
sheet of Cormatrix was used to cover the vein graft repair and 2
chest tubes were placed. See operative note for full details.
She tolerated the procedure well and was transferred to the ICU
in stable condition. She did go into rapid atrial fibrillation
post operatively and was bolused with Amiodarone and loaded with
a drip. She had an attempted cardioversion postoperatively
which was unsuccessful and EP was consulted to adjust her PPM.
She was started on Coreg and Amiodarone was changed to Maltaq
and she was in sinus rhythm under her AV pacing at the time of
discharge. She was on Coumadin preoperatively for atrial
fibrillation but this was held per Dr [**Last Name (STitle) 914**] due to post
operative bleeding. Resumption of Coumadin is to be decided at a
later date. Pacing wires were discontinued without complication
and permanent pacemaker was interrogated by EP.
She was weaned slowly from the ventilator with copious
secretions initially. Once CVVH was started and fluid was
removed she was able to be extubated on [**2125-11-4**] without
complications. She was started on Vancomycin/Zosyn while
awaiting sputum cultures and these were discontinued once
cultures came back negative. Initially after extubation she
failed her speech and swallow but later tolerated a full po
diet. She was cleared by speech and swallow for a regular diet
with thin liquids at discharge.
On [**2125-10-26**] the renal team was consulted for oliguria. It was
thought that her renal failure was a combination of acute
tubular necrosis and renal hypoperfusion in the setting of
decompensated congestive heart failure causing poor forward
flow. CVVH was started for volume removal and she tolerated a
negative fluid balance. She was eventually weaned off CVVH and
transitioned to HD. She was producing adequate urine with stable
electrolytes and the HD was discontinued at the time of
discharge and her HD line was pulled. She is to have daily Chem
10 labs checked to monitor renal function closely. She is on a
low phosphorus diet. An ACE-I was not initiated due to her
elevated creatinine. Her renal function labs were stable at the
time of discharge. Renal recommended no standing Lasix dose and
follow up Friday [**11-16**] with renal labs. Foley was reinserted
for urinary retention and she will be discharged with Foley
catheter in place.
The patient spiked a temperature of 101 and blood cultures form
[**11-3**] came back with SERRATIA MARCESCENS. The infectious
disease team was consulted and recommended Ciprofloxacin for a
14 day course from [**11-5**] (Blood cultures negative x 2 on [**11-5**])
Ciprofloxacin is to be continued until [**2125-11-19**]. Urine culture
was pending and needs to be followed up. She was afebrile and
WBC was normal at the time of discharge.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD the patient was ambulating with assistance, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to [**Location (un) 583**] House rehab in good condition
with appropriate follow up instructions. She did have a
moderate left effusion seen on discharge CXR and the CXR will be
repeated on Friday [**11-16**] before follow up clinic appointment.
Medications on Admission:
Carvedilol 25mg [**Hospital1 **]
Diltiazem 180mg HCl daily
Donepezil 10mg daily
Ezetimibe 10mg daily
Lasix 120mg [**Hospital1 **]
Glargin 23 U daily
Lispro- dosage uncertain
Pantoprazole DR 40mg daily
Potassium chloride 20 Meq daily
Risperidone 0.25mg daily at bed time
Simvastatin 40mg every morning
Sertraline 100mg every morning
Valsartan 40mg- 4 tablets daily
Coumadin 4mg daily
Acetaminophen
ASA 81mg daily
Docusate 100 mg daily
Fererous sulfate 325mg daily
Omega 3 Fatty Acid 1000mg daily
Discharge Medications:
1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. 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.
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/t>101.
12. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day for 7 days: Stop [**11-19**].
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) for 2 weeks.
16. insulin glargine 100 unit/mL Solution Sig: One (1) 40 Units
Subcutaneous Q Breakfast.
17. insulin lispro 100 unit/mL Solution Sig: One (1) Sliding
Scale Subcutaneous four times a day: Sliding Scale. Check FS QID
0-70 - Hypoglycemic protocol
BS 71-110 - O units.
BS 111-140 - Breakfast 2 units, Lunch 2 units, Dinner 2 units,
Bedtime 0 units.
BS 141-180 Breakfast 4 units, Lunch 4 units, Dinner 4 units,
Bedtime 2 units.
BS 181-220 Breakfast 6 units, Lunch 6 units, Dinner 6 units,
Bedtime 4 units.
BS 221-260 Breakfast 8 units, Lunch 8 units, Dinner 8 units,
Bedtime 6 units.
BS >260 - [**Name8 (MD) 138**] MD.
18. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
19. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
1. Prosthetic valve aortic stenosis.
2. Moderate to severe mitral regurgitation.
3. Moderate tricuspid regurgitation.
4. Coronary artery disease status post coronary artery
bypass grafting with a vein graft to the distal right
coronary artery.
5. Multiple persisted bouts of congestive heart failure
necessitating admission to the hospital over the last 2
months (total of 4 admissions).
6. Severely calcified ascending aorta.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. No 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 are scheduled for the following appointments
**cardiac surgery clinic [**Hospital **] medical building [**Hospital Unit Name **]
[**Telephone/Fax (1) 170**] -please go to lab in [**Hospital Ward Name **] [**Location (un) 448**] and xray
clinical center [**Location (un) 470**] for PA/LAT prior to appointment at
1:00 PM on Friday [**11-16**]
Surgeon: Dr [**Last Name (STitle) 914**] [**11-27**] at 1:45 PM
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] [**11-26**] at 2:20 PM
Renal: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],[**Telephone/Fax (1) 721**] Date/Time:[**2125-11-26**] 1:00 -
please have son accompany you to appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 3357**] in [**3-19**] weeks [**Telephone/Fax (1) 4606**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2125-11-12**]
|
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20,263
| 122,249
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54218
|
Discharge summary
|
report
|
Admission Date: [**2198-8-14**] Discharge Date: [**2198-8-28**]
Date of Birth: [**2132-7-5**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / vancomycin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Central venous line placement
Cardiac catheterization
Swan Ganz catheter placement
PICC placement
Intubation and extubation
Arterial line placement
History of Present Illness:
Mrs. [**Known lastname **] is a 66 year old woman with a history of COPD on
home O2 2-4LNC, bronchiechtasis with multiple recurrent
pneumonias, dCHF, a fib not on coumadin, AS s/p balloon
valvuloplasty who presents with acute shortness of breath and
[**Known lastname **] with green/yellow sputum. Of note, she was recently
admitted to [**Hospital1 18**] from [**Date range (2) 111100**] for acute dCHF, acute COPD
and treated with diuresis and steroids with improvement in her
symptoms. She grew pan-resistant pseudamonas but was thought to
be a colonizer per ID c/s. She was discharged on a long steroid
taper, starting at prednisone 5 daily x 1 week, followed by
prednisone 2.5 daily x 1 week, then to stop. She was still
taking 5 a day when her symtptoms began 3 days prior to
presentation. She first noted increasing [**Date range (2) **] with heavy
green/yellow sputum that was new. She also noted associated
dyspnea worsening with the [**Date range (2) **]. Within 1-2 days prior to
presentation she noticed increasing wheezing, orthopnea, mild
weight gain (4lbs from 266->270lbs in 24 hours), pedal edema.
She also complained of generalized malaise and weakness. Due to
this constellation of symptoms, she decided to come to the ED
for further evaluation.
.
In the ED, her initial vitals were 99 131/99 100 18 94%3L.
She was thought to be in hypercarbic respiratory failure
requiring bipap with her initial ABG 7.33/79/181. Repeat 1 hr
after bipap trial was 7.42.60/174 while on 2LNC. She was given 2
doses of albuterol nebulizer without clear improvement in her
symptoms, but it did lead to thick yellow sputum clearance. Her
pressures remained in the 90s/40s while on bipap. After bipap
her pressures improved and she was given lasix 40mg IV ONCE for
presumed pulmonary edema. She made approximately 300cc of urine
after this bolus. She had a foley and 1 20 gauge IV placed. Her
last set of vitals were 98.6 95 100/50 26 96%2LNC.
.
In the MICU, she continued to have a heavy [**Date range (2) **] with heavy
secretions and remained mildly dyspneic and mildly tachypneic.
She also became hypotensive to the high 70s/40s, which responded
to a 250cc bolus. She was started on vancomcyin, meropenem for
HAP treatment, hydrocortisone for mild COPD flare and relative
adrenal insufficiency, and kayaxalate for hyperkalemia. Bipap
was started overnight for her known OSA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies Denies chest pain, chest pressure, palpitations, or focal
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes
Past Medical History:
Asthma: (since childhood)/COPD s/p multiple intubations: 2L NC
(since [**2172**]) at baseline for spO2 91-95%, last PFT ~1 yr ago
at OSH, trach previously suggested but pt refused
- OSA: sleep study in [**2187**], recommended CPAP but has not
tolerated it well, unclear how compliant since last discharge
(made some progress on the fit of the mask). Of note, overnight
oximetry "better than expected" when measured at rehab --> now
100% adherance to CPAP at home
- Bronchiectasis: Grows panresistant pseudamonas last admission
[**Date range (2) 111100**] thought to be colonizer
- GERD
- Anemia (history of GI bleeding many years ago)
- Leukopenia, long standing, unclear etiology
- Hyperglycemia when previously on prednisone
- Diastolic heart failure, LVEF > 55%, [**8-/2197**]
- Aortic stenosis (valve area 1.0-1.2 cm^2) -->ballooned in
[**4-/2198**] and again in [**8-/2198**] while intubated for respiratory
failure
- Moderate to severe pulmonary HTN, PCWP > 18
- Atrial fibrillation (on dilt + beta blocker), no
anticoagulation due to questionable history of GI bleeding
- Acute on chronic respiratory failure with intubation in [**8-/2198**]
during which she had balloon valvuloplasty for severe AS and
started workup for TAVI vs surgical AVR, was treated for
resistant Pseudomonas PNA
Social History:
-Smoking/Tobacco: quit smoking in [**2172**] (20 pack years)
-EtOH: None
-Illicits: None
-Lives at/with: sister (a nurse) in [**Name (NI) 4628**], was in rehab until
[**12-4**]; has 3 children, 1 died @ 27 in [**4-/2197**] from asthma
complication, has a daughter who's a CNA.
-Retired manager of a medical answering services
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
-Mother died of CVA
-Father died of lung CA
Physical Exam:
On admission:
General: Alert, oriented, morbidly obese woman in mild-mod resp
distress, frequent coughing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to discern, no LAD
Lungs: Diffuse and heavy ronchi, no rales, wheezes
CV: Regular rate and rhythm, normal S1 + S2, [**4-8**] musical SM at
RLSB, no rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis,
significant bilateral LE edema, tenderness to palpation diffuse,
venous changes bilaterally
On discharge:
99.2 p95 100-108/50-50's 26 93-100% on 2L NC
Able to get out of bed to bedside chair
Extubated, awake, alert, pleasant
Otherwise unchanged
Pertinent Results:
MICRO:
Blood cultures negative x1
Blood cultures myco/lytic negative x1
B-glucan and Aspergillus antigen negative
Legionella Urinary Antigen (Final [**2198-8-15**]): NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2198-8-15**] 4:05 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2198-8-15**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2198-8-19**]):
HEAVY GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- =>64 R
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ =>16 R
LEGIONELLA CULTURE (Final [**2198-8-22**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
[**2198-8-19**] 1:05 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE..
GRAM STAIN (Final [**2198-8-19**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2198-8-25**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.
10,000-100,000 ORGANISMS/ML..
sensitivity testing performed by Microscan.
AMIKACIN & CEFTRIAXONE >32MCG/ML.
GENTAMICIN ,TOBRAMYCIN & MEROPENEM >8MCG/ML.
CEFTAZIDIME & CEFEPIME >16MCG/ML.
PIPERACILLIN >64MCG/ML.
CIPROFLOXACIN >2MCG/ML.
LEVOFLOXACIN >4MCG/ML.
BACTRIM (=SEPTRA=SULFA X TRIMETH) <=2/38MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| NON-FERMENTER, NOT
PSEUDOMONAS AERUGIN
| |
AMIKACIN-------------- =>64 R R
CEFEPIME-------------- =>64 R R
CEFTAZIDIME----------- =>64 R R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R R
GENTAMICIN------------ =>16 R R
IMIPENEM-------------- 2 S
LEVOFLOXACIN---------- R
MEROPENEM------------- 8 I R
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- =>128 R <=8 S
TOBRAMYCIN------------ =>16 R R
TRIMETHOPRIM/SULFA---- S
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
[**2198-8-19**] 1:05 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE..
**FINAL REPORT [**2198-8-22**]**
Respiratory Viral Culture (Final [**2198-8-22**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2198-8-20**]):
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by [**Doctor First Name **]-[**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **] [**2198-8-20**]
1334.
STUDIES:
CXR [**2198-8-14**]:
IMPRESSION: Little change from prior with continued pulmonary
vascular
congestion, bibasilar airspace opacities suggestive of
atelectasis and
probable small left pleural effusion. Please note that infection
within the lung bases cannot be excluded on this exam.
Enlargement of the hila
bilaterally is suggestive of underlying pulmonary arterial
hypertension.
CXR [**2198-8-18**]:
CHEST: There has been no significant change since the prior
chest x-ray of
[**8-17**]. Bibasilar consolidations are again noted with bilateral
effusions. Appearances are consistent with failure and possibly
additional pneumonia.
IMPRESSION: No change. Failure and possible pneumonia.
[**8-19**] CT CHEST WITHOUT CONTRAST
FINDINGS: there is a large nodule in the left lobe of the
thyroid gland measuring 3.2 x 2.4 cm. This contains coarse
calficiations but is unchanged in appearance compared to the
prior study. No supraclavicular lymphadenopathy is seen.
Moderate atherosclerotic calcification of the aortic arch and
coronary arteries is seen. Calcification of the mitral valve
annulus is also noted. A left-sided subclavian line is in situ
with its tip at the distal SVC. The heart is moderately enlarged
but unchanged compared to the prior study. No axillary or
mediastinal lymph nodes which meet the CT size criteria for
pathologic enlargement. There is a cluster of small mediastinal
lymph nodes in a pretracheal and precarinal position (2:17, 10).
These are similar in appearance compared to the prior study.
There are bilateral small simple pleural effusions with
associated compressive atelectasis. There is near-complete
atelectasis of the left lower lobe. Assessment for associated
infection is limited by the lack of intravenous contrast. The
main pulmonary artery measures 4.6 cm, increased in size
compared to the prior study when it measured 4.2 cm. In addition
the right main pulmonary artery measures 3.4 cm, increased from
2.9 cm and the left main pulmonary artery measures 3.1 cm,
increased from 2.7 cm. There is prominence of th intrapulmonary
vasculature also consistent with the patient's known pulmonary
hypertension. There is persistent bronchiectasis in the right
upper lobe (2:21). This has not progressed compared to the prior
study. No other focal abnormalities are seen. An endotracheal
tube is in situ with its tip approximately 2cm proximal to the
carina. The airways are patent to subsegmental level. This study
s
not tailored for evaluation of the subdiaphragmatic organs, only
to note there is a small amount of perihepatic simple free
fluid. An NG tube lies with its tip in the stomach. The right
adrenal gland is unremarkable. The left adrenal gland is not
clearly seen.
BONY STRUCTURES: no destructive lytic or sclerotic bony lesions
are seen.
IMPRESSION:
1. Left lower lobe atelectasis, superimposed infection cannot be
excluded.
2. Persistent pulmonary hypertension with disease progression.
3. Small bilateral pleural effusions not sufficient to account
for the left lower lobe atelectasis.
4. Trace ascites.
5. Cardiomegaly.
6. Atherosclerotic calcification of the aortic arch, coronary
arteries and
mitral valve annulus.
[**8-20**] Cardiac cath
COMMENTS:
1. Resting hemodynamics revealed severely-elevated left-sided
filling
pressures with a mean wedge pressure of 40mmHg,
moderately-elevated
right-sided filling pressures with a mean RA pressure of 18, and
moderate pulmonary hypertension with a mean PA pressure of 44.
The patient's cardiac index was perserved.
FINAL DIAGNOSIS:
1. Severely-elevated biventricular filling pressures.
2. Moderate pulmonary hypertension.
3. Preserved cardiac output.
[**2198-8-22**] TEE
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Significant AS is
present (not quantified) Trace AR. [Due to acoustic shadowing,
AR may be significantly UNDERestimated.]
MITRAL VALVE: Moderate thickening of mitral valve chordae. Mild
(1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. No TEE related complications. The
patient appears to be in sinus rhythm. Resting tachycardia
(HR>100bpm). Left pleural effusion.
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. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is dilated with borderline normal free
wall function. There are simple atheroma in the descending
thoracic aorta 35 cm from the incisors. The number of aortic
valve leaflets cannot be determined. The aortic valve leaflets
are severely thickened/deformed. Significant aortic stenosis is
present (could not be quantified). Trace aortic regurgitation is
seen. [Due to acoustic shadowing, the severity of aortic
regurgitation may be significantly UNDERestimated.] There is
moderate thickening of the mitral valve chordae. Mild (1+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen.
IMPRESSION: Significant calcific aortic stenosis (not
quantified). Preserved left ventricular function. Dilated right
ventricle with borderline normal systolic function.
[**2198-8-22**] TTE
LEFT ATRIUM: Mild LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
Normal IVC diameter (<=2.1cm) with <50% decrease with sniff
(estimated RA pressure (5-10 mmHg).
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal
RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Moderate
to severe [3+] TR. Severe PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. The left atrium is elongated.
The estimated right atrial pressure is 5-10 mmHg. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with borderline normal free wall
function. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Critical calcific aortic stenosis with mild aortic
regurgitation. Moderate left ventricular symmetric hypertrophy
with preserved systolic function. Moderately dilated RV with
borderline systolic function. Moderate to severe moderate
tricuspid regurgitation with severe pulmonary hypertension.
Compared with the prior report dated [**2198-7-27**] (images
reviewed), the degree of aortic stenosis is now quantified and
appears to be critical.
[**2198-8-28**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Unchanged course and position of the left-sided PICC
line. Unchanged cardiomegaly with signs of moderate pulmonary
edema. Unchanged bilateral basal opacities, left more than
right, that are probably atelectatic in origin. The presence of
small pleural effusions cannot be excluded. No newly appeared
focal parenchymal abnormalities.
[**8-26**] CXR
Left PICC line tip is at the level of superior SVC. Cardiomegaly
is present, including severe pulmonary hypertension. The patient
continues to be in pulmonary edema. Right lower lobe opacity is
persistent and might reflect gradual progression of infectious
process. Bilateral pleural effusions are redemonstrated.
ADMISSION LABS:
[**2198-8-14**] 07:45PM BLOOD WBC-4.7 RBC-3.35* Hgb-9.6* Hct-31.4*
MCV-94 MCH-28.6 MCHC-30.5* RDW-17.5* Plt Ct-170
[**2198-8-15**] 05:25AM BLOOD WBC-4.0 RBC-3.15* Hgb-9.1* Hct-28.8*
MCV-91 MCH-28.9 MCHC-31.6 RDW-16.8* Plt Ct-138*
[**2198-8-16**] 03:35AM BLOOD WBC-3.8* RBC-3.11* Hgb-9.2* Hct-28.4*
MCV-91 MCH-29.7 MCHC-32.6 RDW-16.5* Plt Ct-139*
[**2198-8-17**] 06:07AM BLOOD WBC-4.5 RBC-3.42* Hgb-9.6* Hct-31.5*
MCV-92 MCH-28.2 MCHC-30.6* RDW-16.3* Plt Ct-171
[**2198-8-14**] 07:45PM BLOOD Neuts-76.7* Lymphs-16.7* Monos-3.8
Eos-1.7 Baso-1.1
[**2198-8-19**] 03:53AM BLOOD Neuts-68.7 Lymphs-23.6 Monos-6.5 Eos-0.8
Baso-0.3
[**2198-8-19**] 02:45PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2198-8-14**] 07:45PM BLOOD PT-12.9 PTT-23.5 INR(PT)-1.1
[**2198-8-15**] 05:25AM BLOOD QG6PD-17.1*
[**2198-8-19**] 03:53AM BLOOD Ret Aut-3.4*
[**2198-8-15**] 05:25AM BLOOD Ret Aut-3.9*
[**2198-8-14**] 07:45PM BLOOD Glucose-106* UreaN-55* Creat-1.8* Na-141
K-6.2* Cl-94* HCO3-33* AnGap-20
[**2198-8-15**] 05:25AM BLOOD Glucose-117* UreaN-54* Creat-1.5* Na-142
K-4.3 Cl-96 HCO3-38* AnGap-12
[**2198-8-15**] 05:03PM BLOOD Glucose-101* UreaN-54* Creat-1.6* Na-140
K-4.7 Cl-94* HCO3-38* AnGap-13
[**2198-8-16**] 03:35AM BLOOD Glucose-89 UreaN-52* Creat-1.3* Na-141
K-4.5 Cl-95* HCO3-39* AnGap-12
[**2198-8-15**] 05:03PM BLOOD CK-MB-2 cTropnT-0.06*
[**2198-8-15**] 05:25AM BLOOD CK-MB-2 cTropnT-0.08*
[**2198-8-14**] 07:45PM BLOOD proBNP-3366*
[**2198-8-15**] 05:25AM BLOOD CK(CPK)-17*
[**2198-8-15**] 05:03PM BLOOD CK(CPK)-21*
[**2198-8-17**] 06:07AM BLOOD ALT-7 AST-10 LD(LDH)-146 AlkPhos-68
TotBili-0.3
[**2198-8-19**] 03:53AM BLOOD LD(LDH)-122 TotBili-0.4
[**2198-8-14**] 07:45PM BLOOD Phos-5.2* Mg-2.4
[**2198-8-15**] 05:25AM BLOOD Calcium-8.2* Phos-5.0* Mg-2.4
[**2198-8-15**] 05:03PM BLOOD Calcium-8.1* Phos-5.4* Mg-2.5
[**2198-8-19**] 03:53AM BLOOD calTIBC-342 Hapto-130 Ferritn-32 TRF-263
[**2198-8-27**] 03:08AM BLOOD %HbA1c-4.6* eAG-85*
[**2198-8-14**] 07:45PM BLOOD Cortsol-12.6
[**2198-8-15**] 05:25AM BLOOD Cortsol-27.8*
[**2198-8-14**] 08:21PM BLOOD pO2-181* pCO2-79* pH-7.33* calTCO2-44*
Base XS-12
[**2198-8-14**] 11:35PM BLOOD pO2-174* pCO2-60* pH-7.42 calTCO2-40*
Base XS-12 Comment-GREEN TOP
[**2198-8-17**] 04:18PM BLOOD Type-ART pO2-78* pCO2-126* pH-7.15*
calTCO2-46* Base XS-9
[**2198-8-14**] 07:50PM BLOOD Glucose-100 Na-139 K-5.8* Cl-88*
calHCO3-40*
[**2198-8-14**] 08:21PM BLOOD Lactate-0.8 K-5.5*
[**2198-8-17**] 04:18PM BLOOD Lactate-1.0
[**2198-8-20**] 12:59AM BLOOD O2 Sat-96
[**2198-8-14**] 07:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2198-8-14**] 07:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
DISCHARGE LABS:
[**2198-8-28**] 04:25AM BLOOD WBC-2.6* RBC-3.24* Hgb-8.7* Hct-26.9*
MCV-83 MCH-26.7* MCHC-32.2 RDW-15.7* Plt Ct-135*
[**2198-8-27**] 03:08AM BLOOD WBC-2.9* RBC-3.26* Hgb-8.7* Hct-27.1*
MCV-83 MCH-26.6* MCHC-31.9 RDW-15.3 Plt Ct-121*
[**2198-8-26**] 04:09AM BLOOD WBC-2.3* RBC-2.94* Hgb-8.1* Hct-25.1*
MCV-85 MCH-27.5 MCHC-32.3 RDW-15.2 Plt Ct-107*
[**2198-8-21**] 04:39AM BLOOD Neuts-55.7 Lymphs-36.3 Monos-6.8 Eos-1.0
Baso-0.2
[**2198-8-27**] 03:08AM BLOOD PT-13.4 PTT-29.6 INR(PT)-1.1
[**2198-8-28**] 04:25AM BLOOD Glucose-91 UreaN-24* Creat-0.7 Na-140
K-3.3 Cl-95* HCO3-39* AnGap-9
[**2198-8-27**] 03:08AM BLOOD Glucose-101* UreaN-28* Creat-0.7 Na-143
K-3.6 Cl-100 HCO3-38* AnGap-9
[**2198-8-26**] 05:05PM BLOOD Glucose-176* UreaN-31* Creat-0.8 Na-142
K-4.6 Cl-99 HCO3-37* AnGap-11
[**2198-8-26**] 04:09AM BLOOD Glucose-87 UreaN-31* Creat-0.7 Na-146*
K-3.8 Cl-103 HCO3-38* AnGap-9
[**2198-8-25**] 03:12PM BLOOD Glucose-121* UreaN-34* Creat-0.8 Na-146*
K-4.8 Cl-101 HCO3-39* AnGap-11
[**2198-8-27**] 03:08AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.1 Mg-2.0
[**2198-8-26**] 05:05PM BLOOD Calcium-8.5 Phos-3.3 Mg-2.0
[**2198-8-25**] 04:08AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
[**2198-8-25**] 02:25PM BLOOD Type-ART Temp-37.8 O2 Flow-3 pO2-82*
pCO2-67* pH-7.37 calTCO2-40* Base XS-9 Comment-NASAL [**Last Name (un) 154**]
[**2198-8-24**] 03:52PM BLOOD Type-ART PEEP-5 pO2-118* pCO2-69* pH-7.35
calTCO2-40* Base XS-9 Intubat-INTUBATED
[**2198-8-23**] 05:14AM BLOOD Type-ART pO2-84* pCO2-73* pH-7.36
calTCO2-43* Base XS-11
[**2198-8-22**] 11:09PM BLOOD Type-ART pO2-141* pCO2-75* pH-7.35
calTCO2-43* Base XS-12
Brief Hospital Course:
Ms. [**Known lastname **] is a 66 year old woman with a history of COPD on
home O2 2-4LNC, bronchiechtasis with multiple recurrent
pneumonias, diastolic heart failure, atrial fib not on coumadin,
aortic stenosis s/p balloon valvuloplasty [**4-/2198**] who presents
with acute shortness of breath and productive [**Year (4 digits) **].
1. Respiratory failure: Patient presented initially to the ICU
with clinical and ABG evidence of hypercarbic respiratory
failure that improved with bipap however ultimately she
necessitated intubation. Etiology was ? multifactorial including
HCAP (has history of mutliple recurrent PNA's, and both sputum
and BAL grew out a resistant Pseudomonas, see below), pulmonary
edema from severe AS (see below) and uncontrolled atrial
fibrillation), and COPD exacerbation.
She was treated with IV diuresis and was about 13L negative
through LOS; this was occasionally limited by low blood
pressures. She was treated with bronchodilators and steroids,
which are currently being weaned off (currently at 20 mg daily,
switch to 10 mg daily on [**8-30**] for 3 days, and should go down to
5mg indefinitely thereafter until Pulmonology f/u. Of note, pt
is on Dapsone for PCP prophylaxis which could be stopped once pt
is weaned down to 5mg daily Prednisone.
Most importantly, while intubated pt had TEE (55%, significant
calcific AS, dilated RV with borderline systolic fxn, 1+ MR, 2+
TR) and TTE (65-70%, critical AS, mild AR, RV as above, 3+ TR,
severe pulmHTN -> AS now critical) and pt then underwent cardiac
cathterization which confirmed severe AS. Swan Ganz catheter was
placed which showed PCWP's in the 40's, and PAP 60/40, at which
point pt was started on IV Lasix gtt guided by Swan. She then
underwent aortic valvuloplasty which did improve her transaortic
gradient from mid 50's to low 30's. She was diuresed with IV
Lasix gtt and was 13L negative by discharge and last measured
PCWP was 14. She was also given 3d of Acetazolamide for elevated
HCO3.
Pt was evaluated by Cardiology and CSurg for evaluated of aortic
valve replacement vs research protocol transarterial aortic
valve replacement. This workup was ongoing and pt has follow up
scheduled for [**9-5**] with CSurg, Dr. [**Last Name (STitle) 914**].
Pt was eventually weaned from ventilator and extubated without
difficulty. She was weaned down to 2L NC by discharge, and
should receive BiPAP at night. Her Lasix gtt was off by
discharge however she was discharged just before transitioning
her to PO diuresis which she was taking before admission (60 mg
in the am and 20 mg in the pm, and 50 mg daily Spironolactone).
She was placed back on torsemide prior to discharge. Patient
will need daily evaluation of fluid status with goal for further
diuresis of 1L if BP/HR tolerate and patient not symptomatic.
2. Pseudomonas aeruginosa PNA: ID consulted, unclear if this was
colonization vs active PNA, however given pt with acute on
chronic respiratory failure, ID was consulted and recommended
treatment with a 14d course of Merrem (was intermediate to
Merrem and resistant to basically everything else). Her last
dose of Merrem should be around 8pm of [**8-28**] which will be given
at LTAC. She was also empirically treated with a course of
Vancomycin until her WBC count and Plts began to drop; at which
point this was stopped and only continued on Meropenem without
any change in clincal status. A 14 day course of meropenem was
completed at the recommendation of ID.
3. Hypotension: Initially during presentation; this responded
with IVF's. This was early in her course and not further
clinically relevant, she was never on pressors.
4. Acute on chronic renal failure: Cr 1.8 on admission, up from
baseline of 1.2-1.3. Unclear etiology, possibly due to poor
forward flow from severe AS. This improved slowly with diuresis
and pt's Cr was 0.7-0.8 by discharge.
5. Atrial fibrillation: Rate well controlled not on
anticoagulation [**3-7**] bleed history. She was noted to have rapid
ventricular rate, and was initially on Diltiazem gtt that was
transition to oral Diltiazem which provided good rate control
and should be continued. Continued on ASA 325mg daily. However,
she continued to have fast rates, requiring dilt gtt.
6. OSA: Reports 100% adherence. She was given nocturnal BiPAP
after extubation.
7. Leukopenia: This has been previously noted, with Heme Onc
consultation note in [**2193**]. Her WBC 4.7 on admission decreased to
trough of 1.5 which was thought possibly due to Vancomycin, and
so this was stopped without any clinical deterioration and
Vancomycin was added to her allergy list for ? leukopenia and
thrombocytopenia.
8. Anemia: Hct 31.4 on admission trended down through admission
to 26.9 on discharge. She was not transfused. Iron studies
consistent with iron deficiency anemia however supplementation
was deferred to outpatient providers. Of note patient had
heme-positive stool throughout admission.
9. Thrombocytopenia: Plts 170 on admission, trended down to 135
through admission, possibly also thought due to Vancomycin. On
discharge, plts remained 135.
10. Follow up issues: She will need to follow up with Cardiology
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]), CSurg (Dr. [**Last Name (STitle) 914**], Pulmonology (has not
seen in 1.5 yrs due to cancelling appts), Sleep medicine (Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**])
Medications on Admission:
1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
2. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
[**Hospital1 **]:*7 Tablet(s)* Refills:*0*
9. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
until you follow-up with your new lung doctor.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
10. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
11. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO BID (2 times a day).
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. torsemide 20 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
14. torsemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
15. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
16. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain: Please do not exceed 4gm in 24 hours.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): This is for ppx while
in bed and in the hospital.
4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for Until [**2198-9-2**] doses: This is for PCP prophylaxis until
prednisone is at 5 mg per day then okay to stop.
10. insulin lispro 100 unit/mL Solution Sig: One (1) injection
as per SS Subcutaneous ASDIR (AS DIRECTED): Until stop high
doses of prednisone.
11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Please hold for HR<60.
12. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 doses: Last day on [**8-29**] (on prednisone [**Doctor Last Name 2949**]).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Please hold for sedation and
RR<12.
16. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
17. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) Neb Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
18. sodium chloride 0.9 % Solution Sig: Three (3) ML Topical Q8H
(every 8 hours) as needed for line flush.
19. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 1 days: Last day of
Meropenem is [**8-28**] in the evening .
20. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: START ON [**8-30**]- for a total of 3 days. Then decrease
to 5mg Qday.
21. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day:
START ON [**2198-9-2**].
22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
23. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day: START on [**2198-8-29**]- Hold for SBP<95.
24. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day:
QAM and hold for SBP<95.
25. torsemide 20 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please hold for SBP<95.
26. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
27. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary:
- Pseudomonas pna
- dCHF
- AS, s/p balloon valvuloplasty
- COPD exacerbation
- Pulmonary HTN
Secondary:
- Acute renal failure
- A-fib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with max assistance (pt has been in
bed in the ICU for several days. Was not able to walk this AM.)
Discharge Instructions:
Dear Mrs. [**Known lastname **].
It was a pleasure taking care of you. You came in to [**Hospital1 18**] for
increase in SOB and respiratory distress. You had to be
intubated (have a tube placed to help you breath). Your
respiratory failure was thought to be due to numerous causes:
COPD, heart failure, valve stenosis and pseudomonas pneumonia.
You were treated for all of these with antibiotics for the
pneumonia, IV lasix (diuretics) for your heart failure and you
also had a balloon valvuloplasty for your aortic valve stenosis.
You are also in the process of being evaluated by
cardio-thoracic surgery for possible valve replacement surgery.
You have done well and you were able to be extubated with no
complications. You are now breathing more comfortable on [**3-8**]
Liters of oxygen via nasal canula. You will need to have
follow-up appointments with the cardio-thoracic surgeon and
pulmonologist as listed below.
The following changes were made to your medications:
- Meropenem 1000 mg IV every 8 hours (last dose tonight on
[**8-28**])
- Restart Torsimide home dose 60mg every AM and 20mg every PM,
start tomorrow and adjust as needed
- Spirolactone 50mg orally daily
- Dapsone until prednisone is [**Doctor Last Name 2949**] down to 5mg daily then stop
- Diltiazem changed from 240mg Extended release daily to 60 mg
PO/NG TID (it may be increase as tolerated)
- Start on insulin, Humolog Sliding scale while on prednisone
- Prednisone 20mg orally until [**8-29**], then decrease to 10mg for
3 days (from [**Date range (1) 111101**]) and 5mg daily (from [**9-2**])
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SURGERY
When: TUESDAY [**2198-9-4**] at 3:00 PM
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ADULT SPECIALTIES, Pulmonologist
When: WEDNESDAY [**2198-10-17**] at 4:20 PM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: ADULT SPECIALTIES
When: THURSDAY [**2198-12-20**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2198-8-28**]
|
[
"578.1",
"278.01",
"457.1",
"424.1",
"428.0",
"416.8",
"403.90",
"276.7",
"284.1",
"428.33",
"276.3",
"494.0",
"424.2",
"327.23",
"E930.8",
"493.22",
"518.84",
"585.9",
"584.9",
"276.0",
"482.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"37.23",
"33.24",
"37.21",
"88.72",
"35.96",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
34091, 34227
|
24069, 29496
|
295, 445
|
34415, 34415
|
5941, 7359
|
36344, 37487
|
4959, 5118
|
31076, 34068
|
34248, 34394
|
29522, 31053
|
14084, 19654
|
34651, 36321
|
22439, 24046
|
5133, 5133
|
7395, 14067
|
5775, 5922
|
2877, 3280
|
248, 257
|
473, 2858
|
19670, 22423
|
5147, 5761
|
34430, 34627
|
3303, 4598
|
4614, 4943
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,694
| 100,622
|
28173
|
Discharge summary
|
report
|
Admission Date: [**2189-2-26**] Discharge Date: [**2189-3-16**]
Date of Birth: [**2110-11-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Monopril / Lipitor / Amiodarone / adhesive tape
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2189-2-27**] - Redo sternotomy x2 with resection of ascending aortic
aneurysm and ascending aortic replacement with a 32-mm Gelweave
tube graft under deep hypothermic circulatory arrest and redo
coronary artery bypass grafting x4.
[**2189-3-2**] - Mediastinal washout and chest closure
History of Present Illness:
This 78 year old man with prior CABGx4 in [**2175**], a redo CABGx1
and mitral valve repair in [**2178**] now has an ascending aortic
aneurysm which he has known about since [**2184**]. This has been
followed by serial CT scans and has shown nearly a 1cm growth
over the past 3 years. It now measures 6cm. Of note he two
previous cardiac surgeries were complicated by bleeding with
re-exploration. Given the size of his aneurysm he has been
referred for surgical evaluation. He denies any symptoms other
then fatigue.
Past Medical History:
-Hypertension
-Hyperlipidemia
-[**2175**] CAD s/p Inferior wall MI
-[**2-/2177**] TIA
-s/p CVA '[**79**]-no residual
-Cardiomyopathy/CHF admissions
chronic diastolic heart failure
s/p mitral valve repair/coronary artery bypass grafts
s/p redo sternotomy, coronary artery bypass
Paroxysmal atrial fibrillation
s/p resection of colon cancer
gastroesophageal reflux
Arthritis
Anemia
Loss of hearing left ear
Sleep apnea (does not use CPAP)
Mild memory loss
Social History:
Lives with:wife
Contact:[**Name (NI) **] cell# [**Telephone/Fax (1) 68465**]
Occupation:runs a machine shop. Enjoys sailing.
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-27**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
noncontributory
Physical Exam:
Pulse: 62 Resp:18 O2 sat:98/RA
B/P 140/80
Height:5'7" Weight:170 lbs
General: NAD WDWN
Skin: Dry [x] intact [x]
HEENT: NCAT, PERRLA, EOMI, Anciteric sclera. OP benign. Teeth in
fair repair.
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]; well healed sternotomy scar
Heart: Irregular rate and rhythm, soft [**12-26**] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds; healed laparotomy scar
Extremities: Warm [x], well-perfused [x] 1+ Edema; no
Varicosities but skin is thickened and with BLE chronic venous
insufficiency changes; The vein has been endoscopically
harvested
from likely the entire right and the left thigh. Well healed
incisions noted at bilateral knees. Likely suitable vein below
knee on left.
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left: 2+
DP Right:2+ Left: 2+
PT [**Name (NI) 167**]:2+ Left: 2+
Radial Right:2+ Left: 2+
Carotid Bruit Right:no Left:no
Pertinent Results:
[**2189-2-27**] ECHO
PRE-BYPASS: 1. No spontaneous echo contrast is seen in the body
of the left atrium or left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s).
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
to distal inferior and septal walls. Overall left ventricular
systolic function is mildly depressed (LVEF= 45-50 %).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is severely dilated. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta.
6. There are three aortic valve leaflets. There is no aortic
valve stenosis. Mild to moderate ([**12-22**]+) aortic regurgitation is
seen.
7. A mitral valve annuloplasty ring is present. An eccentric,
anteriorly directed jet of moderate (2+) mitral regurgitation is
seen.
8. There is no pericardial effusion.
POST-BYPASS:
1. The patient is V paced. The patient is on epinephrine,
milrinone, and norepinephrine infusions.
2. Left ventricular function appears moderately depressed (LVEF
= 35-40%)
3. The right ventricle is severely dilated with severe global
dysfunction.
4. Moderate (2+) tricuspid regurgitation is seen.
5. Mitral regurgitation is unchanged.
6. Aortic regurgitation is unchanged.
6. The aorta is intact post-decannulation.
[**2189-2-28**] ECHO
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The right ventricular function is probably preserved. The aortic
root is mildly dilated at the sinus level. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The anterior
mitral valve leaflet is mildly thickened. A mitral valve
annuloplasty ring is present. An eccentric, anteriorly directed
jet of Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Probably preserved LV function and RV function.
There is mild eccentric MR.
[**2189-3-16**] 04:15AM BLOOD WBC-13.5* RBC-2.95* Hgb-9.1* Hct-31.4*
MCV-107* MCH-30.8 MCHC-28.9* RDW-23.2* Plt Ct-517*
[**2189-2-26**] 07:15PM BLOOD WBC-8.6 RBC-4.31* Hgb-13.0* Hct-38.4*
MCV-89 MCH-30.2 MCHC-33.9 RDW-15.7* Plt Ct-184
[**2189-3-16**] 04:15AM BLOOD PT-31.9* INR(PT)-3.1*
[**2189-3-15**] 04:20AM BLOOD PT-32.0* INR(PT)-3.1*
[**2189-3-14**] 05:40AM BLOOD PT-27.9* INR(PT)-2.7*
[**2189-3-13**] 05:34AM BLOOD PT-20.8* INR(PT)-2.0*
[**2189-3-12**] 10:49AM BLOOD PT-19.5* INR(PT)-1.8*
[**2189-3-16**] 04:15AM BLOOD UreaN-29* Creat-1.3* Na-142 K-4.4 Cl-110*
Brief Hospital Course:
Mr. [**Known lastname 284**] was admitted to the [**Hospital1 18**] on [**2189-2-26**] for surgical
management of his aneurysm. He underwent preoperative testing
and was placed on Heparin as he had been off his Coumadin for
five days. On [**2189-2-27**], he was taken to the Operating Room where
he underwent replacement of his ascending aorta and hemiarch
with reimplantation of his saphenous vein grafts. Please see
operative note for details. Due to a coagulopathy, he was left
with an open chest and taken to the intensive care unit.
He received multiple blood products for his coagulopathy. The
renal service was consulted for acute renal failure and possible
need for dialysis. He was aggressively diuresed and his renal
function stabilized. On [**2189-3-2**], he was returned to the
Operating rRoom where he underwent mediastinal washout and
sternal closure. Postoperatively he was taken to the intensive
care unit for monitoring. On [**2189-3-4**] he awoke and was extubated.
He had some confusion but was without any focal deficits. His
renal function continued to improve. He was placed on Amiodarone
for ventricular tachycardia in the OR. EP followed the patient.
He developed first degree AV block and beta blocker was held
until it resolved. He then vascilated between sinus rhythm and
AFib. Coumadin was resumed for paroxysmal atrial fibrillation
.
Vascular surgery was consulted and ruled out compartment
syndrome in the right lower extremity.
Leukocytosis developed to a peak of [**Numeric Identifier 14157**] and he was
pan-cultured. Infectious Disease was consulted. Cultures were
unrevealing, CDiff toxin was negative on 4 occassions and torso
and leg CT were negative for source. The patient was started
empirically on Flagyl with a fall in the white count. Other
antibiotics were stopped and the Flagyl changed to oral
Vancomycin per Infectious Disease. He will be treated with a 14
day course of PO vancomycin in the setting of persistent
leukocytosis and loose stool. Ultrasound of the edematous right
leg revealed only edema, no focal collections.
despite being below his preoperative weight he continued to have
edema and diuretics were continued. Spironolactone was given due
to his underlying heart failure.
On [**3-16**] his WBC had fallen to 13,500, he was afebrile and felt
well. He was trasnsferred to Genesis [**Hospital 11252**] rehab . Follow up
appointments were made and medications are as listed.
Medications on Admission:
AMLODIPINE 10 mg daily
DIGOXIN 125 mcg every other day
DONEPEZIL 5 mg daily
FUROSEMIDE 40 mg daily
HYDROCHLOROTHIAZIDE 12.5 mg daily
POTASSIUM CHLORIDE 20 mEq TID
TELMISARTAN-HYDROCHLOROTHIAZID [MICARDIS HCT] 80 mg-12.5 mg - 1
Tablet daily
Telmisartan 40 mg daily
Allopurinol 300 mg daily
***WARFARIN 4 mg daily***- last dose [**2189-2-22**]
ASPIRIN 81 mg daily
Discharge Medications:
1. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO
DAILY (Daily).
13. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): INR [**1-23**].
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
15. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): through [**2189-3-27**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center
Discharge Diagnosis:
s/p redo sternotomy (3rd),graft repair ascending aortic aneurysm
w/ open chest
s/p chest closure
hypertension
Hyperlipidemia
[**2175**] CAD s/p Inferior wall MI
s/p CVA '[**79**]-no residual
Cardiomyopathy-chronic diastolic heart failure
Mitral regurgitation
s/p mitral valve repair
Paroxysmal atrial fibrillation
s/p colon resection for cancer
gastroesophageal reflux
Arthritis
Loss of hearing left ear
obstructive Sleep apnea (does not use CPAP)
ascending aorta aneurysm
mild memory loss
Discharge Condition:
Alert and oriented x3,,nonfocal
Deconditioned
Incisional pain managed with Acetaminophen
Incisions:
Sternal - healing well, no erythema or drainage
Edema: 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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: [**Doctor Last Name **] [**Telephone/Fax (1) 170**] Date/Time:[**2189-4-15**] 1:30 in the
[**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 59323**] [**2189-4-2**] at 3:15p
**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 AFib
Goal INR [**1-23**]
First draw [**3-17**]
MD to dose daily.
**Please arrange for coumadin follow-up prior to discharge from
rehab**
Completed by:[**2189-3-16**]
|
[
"272.4",
"426.11",
"288.60",
"E878.2",
"584.9",
"441.2",
"286.7",
"412",
"401.9",
"425.4",
"427.1",
"530.81",
"716.90",
"428.0",
"780.57",
"E934.2",
"285.9",
"V10.05",
"428.33",
"V45.82",
"997.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"34.79",
"34.03",
"36.15",
"36.13",
"39.59",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10032, 10086
|
5880, 8326
|
324, 614
|
10620, 10780
|
2993, 5857
|
11668, 12430
|
1954, 1972
|
8739, 10009
|
10107, 10599
|
8352, 8716
|
10804, 11645
|
1987, 2974
|
276, 286
|
642, 1162
|
1184, 1641
|
1657, 1938
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,271
| 172,732
|
32815
|
Discharge summary
|
report
|
Admission Date: [**2111-7-22**] Discharge Date: [**2111-7-25**]
Date of Birth: [**2057-4-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Intracranial Mass
Major Surgical or Invasive Procedure:
[**7-22**]: Left Craniotomy for resection of intracranial mass
Social History:
He is divorced with 2 children. He works as a landscaper. He
does not
currently drink or smoke.
Family History:
He has 3 sisters, 2 of whom have a history of melanoma. One of
his sisters died from melanoma. His mother was diagnosed with an
ocular melanoma.
Pertinent Results:
Pre-Operative MRI([**2111-7-22**]):
TECHNIQUE: Limited MR imaging of the brain was performed with
axial MP-RAGE
and multiplanar T1 post-contrast images, for surgical planning.
Heterogeneously hyperintense mass, 2.9 x 4.5 cm with surrounding
vasogenic
edema, in the left frontal lobe, with effacement and mass effect
on the left lateral ventricle is redemonstrated for surgical
planning. Mild shift of the midline structures to the right side
by few millimeters is noted. Overall appearance is not
significantly changed compared to [**2111-7-15**], with evolution of the
products within this mass compared to the prior study. No other
abnormal areas of enhancement are noted in the visualized brain
parenchyma.
Post-operative Head CT([**2111-7-22**]):
Findings: The patient is status post resection of left frontal
tumor. There
is pneumocephalus and marked persistent vasogenic edema. The
patient has had a craniectomy. There are tiny areas of focal
high density at the periphery of the surgical bed, which likely
represent tiny foci of hemorrhage. There is 4-mm midline shift,
not significantly changed from preoperative study.
Post-operative MRI ([**2111-7-24**]):
The patient is status post left frontoparietal craniotomy. There
is an
extraaxial fluid collection underlying the craniotomy site.
There are T1
hyperintense blood products in the operative bed, which limit
evaluation for residual neoplasm.
There does appear to be a small focus of enhancement along the
inferior aspect of the resected mass. This could represent a
small amount of residual neoplasm and recommend attention on
short-term followup imaging after resolution of blood products.
No new foci of hemorrhage are seen. There is mild amount of
subfalcine herniation to the right which is unchanged compared
to the preoperative imaging. The ventricles and sulci are
unchanged in size and configuration. There is slightly increased
edema in the left parasagittal frontal lobe, which may be
postoperative in nature. Flow voids are identified in the
superior sagittal sinus. On the diffusion-weighted images, there
is a small focus of slow diffusion along the medial aspect of
the operative bed, which is likely secondary to hemorrhage.
Labs on Admission:
[**2111-7-22**] 07:13PM BLOOD WBC-9.4 RBC-4.18* Hgb-13.0* Hct-36.3*
MCV-87 MCH-31.2 MCHC-35.8* RDW-14.0 Plt Ct-255
[**2111-7-22**] 07:13PM BLOOD PT-13.7* PTT-23.7 INR(PT)-1.2*
[**2111-7-22**] 07:13PM BLOOD Glucose-230* UreaN-22* Creat-1.0 Na-132*
K-4.1 Cl-96 HCO3-24 AnGap-16
[**2111-7-22**] 07:13PM BLOOD Calcium-9.2 Phos-4.8*# Mg-2.2
Labs on Discharge::
XXXXXXXXXXXXXXXXXXXXXX
Brief Hospital Course:
Mr. [**Known lastname 25788**] is a 54 y/o male who was diagnosed with metastatic
melanoma. He was admitted to [**Hospital1 18**] on [**2111-7-23**] for left frontal
craniotomy and resection of metastatic melanoma. Following
surgery he was observed in PACU and subsequently transferred to
[**Hospital Ward Name 121**] 11 for neurosurgical observation. By [**2111-7-25**] he was
ambulating independently, voiding, and tolerating a regular
diet. He was cleared for d/c by PT, and discharged to home is
stable condition.
Medications on Admission:
unknown
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
5. 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*
6. decadron Sig: One (1) mg every eight (8) hours for 2 days:
start on [**2111-7-28**].
Disp:*6 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Intracranial mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? 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.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-2**] days for removal of your
staples and/or sutures.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
??????You wil not need an MRI of the brain, as this was done during
your hospital stay.
- call radiation oncology at [**Telephone/Fax (1) 9710**] on Monday [**7-27**] to
schedule outpatient appointment for radiation therapy
Completed by:[**2111-7-25**]
|
[
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"785.2",
"V10.82",
"780.39",
"997.1",
"342.91",
"783.21",
"348.5",
"402.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
4618, 4624
|
3330, 3853
|
337, 402
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4686, 4710
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700, 2912
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4645, 4665
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280, 299
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3282, 3307
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2926, 3263
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418, 518
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,125
| 142,054
|
30208
|
Discharge summary
|
report
|
Admission Date: [**2119-3-23**] Discharge Date: [**2119-4-1**]
Date of Birth: [**2075-5-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
43yo female with known metastatic brain cancer now presents with
seizure.
Major Surgical or Invasive Procedure:
Suboccipital Craniotomy
History of Present Illness:
Patient is a 43 yo female with ho of metastatic lung
adenocarcinoma with mets to small bowel s/p resection and mets
to
brain tx with total brain radiation who presented yesterday with
second seizure. In the morning [**2119-3-23**], she had sudden,
irrepressible right hand contraction, followed by right arm
contraction x 15 minutes. She had difficulty expressing
herself,
and spoke with paraphasia. She had post-ictal fatigue and was
taken to OSH where her Dilantin level was <2.5 and she was
loaded
with 1 gram of Fosphenytoin. She also complained of HA. Patient
was then transferred to [**Hospital1 18**] for "local radiation," though the
patient is followed by a Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], oncologist in
[**Hospital1 1474**] ( [**Telephone/Fax (1) 37687**]).
Review of Systems:
+ 2 weeks of frontal and occipital HA, no N/V. Episode yesterday
of "prism" like vision over the right temporal visual field in
her right eye x 10 min.
Past Medical History:
1. Adenocarcinoma of the lung:
Initially presented with small bowel obstruction which turned
out
to be metastasis from right lower lobe lung primary ([**12-23**]). CTH
done at time reported nml. Had small bowel resection and
chemoradiotherapy. Had bronchoscopy and cervical mediastinoscopy
at [**Hospital1 18**] with Dr.
[**First Name (STitle) 4667**] [**Doctor Last Name **] on [**2118-3-29**]- showed multiple nodes
positive for tumor and no further resection of primary tumor
made. She has received cisplatin and etopaside in addition to
local radiation therapy. On [**2118-7-17**], patient presented
with
a seizure to an OSH where she reportedly had right hand
clenching
and ? shaking movements x 5 min. She lost consciousness with
this
episodes and was "sleeping" for 45 min thereafter. She was taken
to [**Hospital3 417**] and head MRI showed multiple metastatic
lesions. She was treated with total brain radiation from
[**Date range (1) 71978**]. She reports that no follow-up neuroimaging was
done. A MRI brain was ordered 2 weeks ago at [**Hospital3 71979**] which showed
multiple enhancing parenchymal lesions consistent with
metastatic
CA with notably inc size of right cerebellar lesions and
frontoparietal lesions. In addition, there is note of right
cerebellar lesion compressing inf aspect of 4th ventricle
resulting in moderate obstructive ventricular dilation. The
patient was unaware of these findings. Oncologist reportedly
wanted her to start Tarceva.
2. h/o sinusitis
Social History:
Lives with husband and daughter. Unemployed. Smoked [**1-18**] ppd x 15
years, then 1 cigarette daily for several years; drinks a few
beers on weekends. Denies history of illicits.
Family History:
Mother with [**Name (NI) 2481**] disease
Physical Exam:
Vitals: T 97.7 F BP107/79 P 95 RR 16 SaO2 100 RA
General: NAD, pleasant woman, appears thin
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: no LAD appreciated, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present,
well-healed midline surgical scars
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes seen
Neurologic Examination:
Mental Status:
Awake and alert, attentive, able to relay history, cooperative
with exam, normal affect
Oriented to person, place, time
Language: fluent, non-dysarthric speech, no paraphasic errors,
naming, comprehension, repetition intact; [**Location (un) 1131**] intact
Calculation: can determine 7 quarters in $1.75
Fund of knowledge: normal
Memory: registration: [**3-20**] items, recall [**3-20**] items at 3 minutes
No apraxia, no neglect
Cranial Nerves:
Optic disc margins appear sharp; Visual fields are full to
confrontation. Pupils equally round and reactive to light, 3 to
2
mm bilaterally.
Extraocular movements intact, no nystagmus. Facial sensation
intact bilaterally. Facial movement normal and symmetric.
Hearing intact to finger rub bilaterally. Palate elevates
midline. Tongue protrudes midline, no fasciculations. Trapezii
full strength bilaterally.
Motor:
Normal bulk and tone throughout. Evidence of subtle right-sided
pronator drift. No tremor.
D T B WE FiF [**Last Name (un) **] IP Q H TA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] EDB
Right 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: No deficits to light touch, pin prick, temperature
(cold), vibration, and proprioception throughout. No extinction
to DSS.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes were downgoing bilaterally.
Coordination: No intention tremor seen, but dysdiadochokinesia
is
noted in right hand. No dysmetria on FNF or HKS bilaterally.
Difficulty with FFM in right hand.
Gait: Narrow-based, normal stride and arm swing while walking
in
hallway with husband.
Pertinent Results:
[**2119-3-23**] 11:01PM GLUCOSE-107* UREA N-8 CREAT-0.6 SODIUM-140
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
[**2119-3-23**] 11:01PM ALT(SGPT)-19 AST(SGOT)-20 ALK PHOS-96 TOT
BILI-0.3
[**2119-3-23**] 11:01PM LIPASE-38
[**2119-3-23**] 11:01PM ALBUMIN-4.5
[**2119-3-23**] 11:01PM PHENYTOIN-15.9
[**2119-3-23**] 11:01PM WBC-4.9 RBC-3.96* HGB-12.2# HCT-34.4* MCV-87
MCH-30.8# MCHC-35.5* RDW-12.9
[**2119-3-23**] 11:01PM NEUTS-88.9* LYMPHS-7.7* MONOS-2.9 EOS-0.4
BASOS-0.1
[**2119-3-23**] 11:01PM PLT COUNT-294
[**2119-3-23**] 11:01PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2119-3-23**] 11:01PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2119-3-25**] 04:06AM BLOOD PT-11.7 PTT-28.0 INR(PT)-1.0
MRI +/- head [**2119-3-24**]
There are multiple supra- and infratentorial tentorial
metastatic lesions, the
largest supratentorially is in the left frontal lobe measuring
1.6 x 1.2 cm.
There is extensive edema in the left frontal lobe relating to
the metastatic
disease.
There is a tiny lesion possibly in a leptomeningeal location in
the right
frontal lobe in a parasagittal location.
Smaller lesions are seen in the left temporal lobe and the right
thalamus.
There is a large lesion in the right cerebellum measuring 1.9 x
2.2 cm, with
mass effect on the fourth ventricle and mild inferior tonsillar
herniation.
There is extensive edema extending to the middle cerebellar
peduncle and mild
ascending supratentorial herniation.
There is prominence of ventricles and sulci suggesting mild
volume loss for
age.
There is a small focus of hyperintensity in the right frontal
subcortical
white matter, without definite enhancing focus in this locale.
This finding
is of uncertain etiology and attention on followup imaging may
be helpful.
No acute diffusion abnormality is seen.
Intracranial flow voids are maintained.
IMPRESSION:
Diffuse intracranial metastatic disease with the cerebellar mass
causing
significant mass effect on the fourth ventricle.
MRI +/- head [**2119-3-29**] (pre-op)
Multiple enhancing lesions, specifically in the left frontal and
the right
cerebellar hemispheres are demonstrated for the surgical
planning. No
significant change in size and appearance is noted since [**2119-3-24**].
IMPRESSION:
Multiple enhancing lesions consistent with metastatic disease
are
redemonstrated for surgical planning, with no significant
change, compared to
[**2119-3-24**], on the post-contrast images.
CT head [**2119-3-29**] (post-op)
The patient is status post right suboccipital craniotomy, with
bony defect in
the right occipital bone, with post-surgical changes in the soft
tissues along
with small amount of air in the soft tissues as well as in the
extra-axial
location in the right side of the posterior fossa.
Small amount of air is also noted in the basal cisterns and in
the extra-axial
location in the frontal regions on both sides. Hypodense area
is noted in the
right cerebellar hemisphere, partly extending across the
midline, likely
related to edema following the surgical resection of the lesion.
Hypodensity
noted in the left frontal white matter, series 2, image 17, is
unchanged,
comparing to the FLAIR sequence on [**2119-3-24**].
There is no evidence of large intracranial hemorrhage, new mass
effect, or
large area of acute infarction or significant change in the size
of the
ventricles.
IMPRESSION:
Status post right suboccipital craniotomy with post-surgical
changes and small
amount of air in the soft tissues in the occipital region as
well as in the
basal cisterns and bifrontal extra-axial location.
No large intracranial hemorrhage, mass effect, large acute
infarct or
significant change in the size of the ventricles, compared to
the prior MRI
studies.
Close followup is to be considered based on clinical status.
MRI +/- head [**2119-4-1**]
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility
and diffusion
axial images of the brain were acquired before gadolinium. T1
axial and
sagittal as well as coronal images were obtained following
gadolinium. MP-RAGE
axial images were also acquired. Comparison was made with the
previous MRI
examination of [**2119-3-29**] and [**2119-3-24**].
Since the previous MRI examination the patient has undergone
resection of
right-sided cerebellar lesion. Post-craniotomy changes are
visualized with
blood products in the cerebellum. Comparison of pre- and
post-gadolinium
images demonstrate no definite signs of residual enhancement.
Again identified are several enhancing brain lesions including
one in the left
posterior frontal lobe, smaller lesion in the right posterior
frontal lobe and
the lesions in right and left medial temporal lobes. Edema is
seen
surrounding the left posterior frontal lesion. There is no
midline shift or
hydrocephalus. No evidence of slow diffusion seen.
IMPRESSION: Status post resection of right cerebellar
metastatic lesion with
no definite evidence of residual enhancement. Expected
post-surgical changes
are visualized. Previously noted several other enhancing
lesions including
the largest in the left posterior frontal lobe with surrounding
edema are
again noted.
CXR [**2119-3-23**]: There is thickening of the right paratracheal
stripe and hilum,
which is indicative of underlying lymphadenopathy. Overall,
this is
relatively unchanged when compared to the previous examinations.
An ill-
defined opacity projects over the right lower lobe, which could
represent
focal atelectasis. The right lung overall appears better aerated
compared to
the previous examinations. Increased density is again noted
along the medial
aspect of the right middle lobe, but is overall improved
compared to previous
examination as well. The left lung is clear. There is no pleural
effusion.
IMPRESSION: No acute cardiopulmonary process. Chronic right
lung findings
slightly improved when compared to previous examination.
Brief Hospital Course:
The patient was initially admitted to the inpatient Neurology
service for concern of seizures and was started on keppra to
control her seizures. An MRI of the head on [**3-24**] showed
cerebellar mass causing significant mass effect on the fourth
ventricle. A neurosurgical consult recommended the initiation
of decadron and close follow-up of her neurologic examination
(for which she was briefly transferred to the ICU overnight).
Both neuro-onc and radiation oncology services were contact[**Name (NI) **] to
offer recommendations regarding her care. After discussion of
her case in the brain tumor conference, it was decided to pursue
a suboccipital craniotomy for resection of the cerebellar mass
to decompress the 4th ventricle. Official pathology on the
specimen was pending at the time of discharge, although initial
pathology was presumed to represent metastatic disease. The
patient tolerated the procedure well and returned to the floors
under the care of the Neurosurgery service. She was discharged
in stable condition on [**2119-4-1**] after having a post-operative MRI
in anticipation of future treatment.
Medications on Admission:
- Dilantin 100 mg po qday (level was appropriate on this low
dose
per patient)
- Vitamins inc MVI and Vit E
- Claritin 10 mg po qday
- Amoxicillin 500 mg po tid
- Sudafed prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain .
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebellar mass
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after staples have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO THE OFFICE AT [**Hospital Ward Name **] 3B [**4-10**] 11AM FOR
STAPLE REMOVAL AND WOUND CHECK
PLEASE CALL [**Telephone/Fax (1) **] IF YOU NEED TO CANCEL YOUR APPOINTMENT
AT THE TIME OF YOUR WOUND CHECK YOU WILL NEED TO SCHEDULE A
FOLLOW UP APPOINTMENT FOR A HEAD CT AND ALSO TO BEE SEEN BY
DR.[**Last Name (STitle) **]
You have an MRI on [**2119-5-1**] at 1:55 pm. It is on the [**Hospital Ward Name 5074**] - [**Hospital Ward Name 23**] [**Location (un) **].
You have a Brain [**Hospital 341**] Clinic appointment the same day with
[**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2119-5-1**] 4:00 pm.
It is on [**Hospital Ward Name 23**] [**Location (un) **]. Radiation oncology is also
following your care with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**]. Please call his
office on Monday [**2119-4-3**] to schedule appointment for this week.
Completed by:[**2119-4-3**]
|
[
"348.4",
"780.39",
"198.3",
"197.4",
"196.1",
"162.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.04"
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icd9pcs
|
[
[
[]
]
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13415, 13421
|
11389, 12517
|
392, 418
|
13481, 13490
|
5383, 11366
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14860, 15867
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3163, 3206
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12743, 13392
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13442, 13460
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12543, 12720
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13514, 14837
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3221, 3659
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1275, 1429
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279, 354
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446, 1256
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4145, 5364
|
3698, 4129
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3683, 3683
|
1451, 2947
|
2963, 3147
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,091
| 104,052
|
34944+57954
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-10-10**] Discharge Date: [**2120-10-20**]
Date of Birth: [**2040-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ferrous Sulfate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x4 (Left internal mammary artery >
left anterior descending, saphenous vein graft > diagonal,
saphenous vein graft > obtuse marginal, saphenous vein graft >
right coronary artery) [**2120-10-10**]
History of Present Illness:
80F, Russian speaking. Reports chest discomfort over the
previous two months, worse with humidity, and responsive to
nitroglycerin. Describes discomfort in the left shoulder
radiating to the left chest and down left arm. Stress test was
abnormal. Cath reveals severe 3 vessel Coronary Artery Disease.
She is referred for surgical revascularization.
Past Medical History:
Coronary Artery Disease
Bilateral Patellofemoral Osteoarthritis
Hypertension
Hemolytic Anemia
Hyperlipidemia
Anxiety
Social History:
She is married and lives with her husband,
She emigrated to US 3.5 years ago.
Cigarettes: Smoked no [x]
ETOH: denies
Family History:
non contributory
Physical Exam:
Pulse: 61SR Resp: 12 O2 sat: 100%RA
B/P Right: Left: 140/68
Height: Weight: 133lb
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] none_
Varicosities: minor
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: cath Left:2+
Carotid Bruit no bruits
Pertinent Results:
CXR [**10-14**]
PA AND LATERAL CHEST:
Chest tubes and mediastinal drains have been removed. A right IJ
line again extends to the cavoatrial junction. There is
decreased pulmonary vascular congestion and edema. There is a
persistent small right subpulmonic effusion and likely trace
left pleural effusion. There is no pneumothorax. Right
hemidiaphragm remains elevated, with atelectasis at the right
lung base. Additional atelectasis is seen in the left base,
though the aeration here is improved from prior study.
Cardiomediastinal contour is unchanged. Sternotomy wires remain
aligned.
IMPRESSION:
1. Interval removal of mediastinal drains and chest tubes.
Persistent right and likely trace left pleural effusions. No
pneumothorax.
2. Decreased atelectasis, with improved aeration of the left
base compared to prior study.
3. Resolution of pulmonary edema.
Echocardiogram [**10-10**]
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]S.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. Tricuspid regurgitation is
unchanged. The aorta is intact post-decannulation.
[**2120-10-15**] 04:32AM BLOOD WBC-5.0 RBC-3.72* Hgb-11.0* Hct-33.1*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.8 Plt Ct-179
[**2120-10-11**] 02:09AM BLOOD PT-13.3 PTT-30.3 INR(PT)-1.1
[**2120-10-18**] 06:13AM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-143
K-4.8 Cl-107 HCO3-26 AnGap-15
Brief Hospital Course:
Ms [**Known lastname 79959**] was admitted for same day surgery and underwent
coronary artery bypass graft surgery. Of note she had issues
with bleeding in her endovein harvest site from her left leg in
the operating room and postoperatively. See operative report
for further details. She received cefazolin for perioperative
antibiotics and was transferred to the intensive care unit for
post operative management. She remained intubated overnight and
on neosynephrine for blood pressure management. The leg
continued to ooze and it was monitored overnight with a hemovac
for drainage. Blood transfusions were required for a decreased
hematocrit. On post operative day one she had no further
bleeding from the leg, she was weaned from sedation, awoke, and
was extubated without complications. She was started on
betablockers and then on post operative day two started on
lisinopril for blood pressure management. Additionally she was
started on lasix for diuresis. She was transferred to the floor
on post operative day two for the remainder of her care.
Physical therapy was consulted for strength and mobility. She
continued to progress slowly and was ambulating with a walker.
Wound care was consulted for skin impairment of left leg with no
evidence of infection.Twice daily softsorb dressing changes were
recommended. Keflex was re-started prophylactically. She will
be seen early next week for a wound check. The wound service
stated that they would be happy to be paged for consultation
during that out-patient wound check if there continue to be
concerns. By post-operative day eight she was ready to be
discharged to home. All appropriate follow-up appointments were
advised.
Medications on Admission:
Norvasc 5 mg po daily
Atenolol 25 mg po daily
Folic acid 1 mg daily
Propranolol 80 mg daily
Simvastatin 20 mg daily
Aspirin 81 mg daily
Santura XR 60 mg daily
Nitrostat 0.4 prn
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sanctura XR 60 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks.
Disp:*56 Capsule(s)* Refills:*2*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*2*
11. wound care
Softsorb dressing to left leg wounds two times each day for two
weeks. Wash wounds gently with soap and pat dry daily with a
towel.
Discharge Disposition:
Home
Facility:
tbd
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Hyperlipidemia
Anxiety
Hemolytic anemia
Osteoarthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with walker
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - with multiple abrasions along medial calf
Edema - 1 to 2+ bilat
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check cardiac surgery office - [**Telephone/Fax (1) 170**]
Date/Time:[**2120-10-22**] 11:00
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2120-11-13**] 1:30
PCP/Cardiologist: Dr [**Last Name (STitle) 3357**] [**Telephone/Fax (1) 4606**] on [**2120-11-14**] 2:45pm
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2120-10-18**] Name: [**Known lastname 12830**],[**Known firstname 1731**] Unit No: [**Numeric Identifier 12831**]
Admission Date: [**2120-10-10**] Discharge Date: [**2120-10-20**]
Date of Birth: [**2040-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ferrous Sulfate
Attending:[**First Name3 (LF) 741**]
Addendum:
Pt stayed in hopital, trying to find [**Hospital6 **]. Pt without
insurance. Pt family agrees to do wound care. Russian
interperter present. Family agrees.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2120-10-20**]
|
[
"272.4",
"276.3",
"413.9",
"285.9",
"458.29",
"401.9",
"283.9",
"715.36",
"E878.2",
"998.11",
"414.01",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"86.04",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10811, 10941
|
5234, 6937
|
328, 556
|
8585, 8813
|
1914, 5211
|
9703, 10788
|
1230, 1248
|
7164, 8396
|
8461, 8564
|
6963, 7141
|
8837, 9680
|
1263, 1895
|
278, 290
|
584, 939
|
961, 1080
|
1096, 1214
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,625
| 186,749
|
26399
|
Discharge summary
|
report
|
Admission Date: [**2122-12-3**] Discharge Date: [**2122-12-16**]
Date of Birth: [**2081-6-18**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
left thumb traumatic amputation
Major Surgical or Invasive Procedure:
Left thumb replant [**1-3**]
Left thumb revascularization [**1-5**]
History of Present Illness:
Mr. [**Known lastname 65285**] is a 41-year-old man who was brought to the emergency
room today after he had sustained a traumatic amputation of his
left thumb on a table saw. He works as a truck driver and was at
his home doing some woodworking. He amputated a portion that had
be fished out of the saw and brought with him. There is a
multilevel injury on the amputated part.
Past Medical History:
none
Social History:
nonsmoker, occ EtOH
Family History:
NC
Physical Exam:
As previously noted, prior to the patient arriving in the
operating room, dissection of the amputated part had been
done. The amputation was an oblique one at the metaphysis to
the proximal phalanx with the most tissue on the radial side.
The radial neurovascular bundle had been amputated much more
proximal than the ulnar. An avulsion of the ulnar digital
nerve however was obvious. Reattachment of the radial digital
nerve to the thumb proximally was joined to the ulnar digital
nerve distally. This should give him good protective
sensibility in the very important ulnar pulp surface. In
addition to the proximal amputation, there was a midline deep
laceration through the flexor mechanism through the pulp to
the bone. This was explored, as well, and at this level the
digital vessels had not been injured. After dissecting out
flexors, extensors, nerves, arteries and veins, it was
decided to go ahead with a reattachment effort.
Pertinent Results:
[**2122-12-3**] 11:50AM WBC-8.0 RBC-5.28 HGB-15.8 HCT-41.7 MCV-79*
MCH-29.9 MCHC-37.9* RDW-12.4
[**2122-12-12**] 02:38AM BLOOD Hct-18.0*
[**2122-12-15**] 02:52AM BLOOD Hct-21.8*
Brief Hospital Course:
Pt was taken to OR for replant of L thumb on [**12-3**]. He was
extubated in the OR, recovered for the usual amount of time in
the PACU, and transferred to the surgical floor. He improved
over POD#1, but on POD#2 the thumb was noted to be dusky. He was
urgently taken back to the OR on [**12-5**], where the replanted
artery was found to be thrombosed. The thumb was revascularized
(see operative report for details) and he was transferred to the
PACU in stable condition. Due to the thrombosis, an aggressive
program of anticoagulation was started to protect the venous
outflow. He was started on a heparin drip as well as leeches and
heparin-soaked sponges. He was transferred to the SICU for close
monitoring of his thumb and blood levels. He syncopized twice
due to blood loss and required several units of RBC transfusion.
After 6 days in the SICU the anticoagulation was gradually
reversed and he was transferred to the surgical floor. He
continued to improve and was discharged home in stable condition
on POD#[**10-18**]. He will follow-up in plastic surgery hand clinic
as instructed.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
5. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
left thumb traumatic amputation
Discharge Condition:
stable
Discharge Instructions:
Take all medications as prescribed. Keep all follow-up
appointments. Keep the thumb clean and dry. The visiting nurse
will change the dressings daily. Wear the splint at all times.
You may use your fingers but do not put pressure or weight
through the thumb.
Call your doctor or go to the ER if you experience:
-chest pain or shortness of breath
-fevers or chills
-change in color or temperature of the thumb
-drainage, redness, increased pain at the incision sites
Followup Instructions:
Follow-up in the hand clinic on Tuesday ([**12-22**]). Call
[**Telephone/Fax (1) 4652**] to schedule your appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
|
[
"E920.1",
"885.0",
"E849.3",
"996.74",
"E878.2",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.21",
"99.99",
"39.99",
"79.64",
"86.22",
"39.56",
"99.04",
"79.34",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
3927, 3986
|
2087, 3182
|
347, 417
|
4062, 4071
|
1882, 2064
|
4586, 4830
|
906, 910
|
3237, 3904
|
4007, 4041
|
3208, 3214
|
4095, 4563
|
925, 1863
|
276, 309
|
445, 825
|
847, 853
|
869, 890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,711
| 110,587
|
7377
|
Discharge summary
|
report
|
Admission Date: [**2131-8-22**] Discharge Date: [**2131-8-28**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
hypotension in cardiology clinic
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]-year-old female admitted for hypotension,
fevers, leukocytosis, and decreased PO intake x1 week. Pt is
mildly disoriented and a poor historian at time of admission.
The pt has a PMHx of CAD s/p CABG x3, severe aortic stenosis s/p
valvuloplasty [**4-4**] with improved ischemic & valvular
cardiomyopathy (EF 50% in [**6-4**]), who was sent in from
cardiology clinic after a routine scheduled visit showed that
the pt had a leukocytosis, hypotensive reportedly to SBP 80s (BP
80/40, T 100.7, WBC 16 in nursing home today), and fever to 101.
For that she was sent to the ED. The pt reports that if she
weren't referred to the ED that she wouldn't have wanted to go
by herself. The pt at the time of clinic visit had no chief
complaint except decreased PO intake x1 week, and increased b/l
leg edema, but reports that she is normally edematous. Pt
denies SOB and CP, no abdominal pain, no change to bowel or
bladder habbit, no headache, no neck pain, no change in vision,
no new confusion. Patient reportly endorsed minimal dry cough
reported by cardiologist but denies to us.
.
In the more recent past, the patient was recently admitted with
pancolitis in [**7-30**] through [**2131-8-2**]. During that stay she was
treated non-operatively, had two negative C.diff toxins, and
that the pt improved with medical management, and was
subsequently discharged from the hospital on [**8-2**]. On the day of
discharge she suffered a fall at home that resulted in a
subdural hematoma and the pt was re-admitted here for neuro
checks, during which time the pt's coumadin and asprin were
stopped. She was discharged to a rehab facility and over the
past week she has felt progressively weaker with less energy.
Notes from the rehab facility indicate that about a week ago her
blood pressures started to drop. On [**8-8**] her lisinopril and
lasix were both held for hypotension and her BP has not
recovered. Of note, during past admission and clinic visits her
BP has been in the 80's to the low 110's.
.
Even more distantly, the pt is s/p a balloon aortic
valvuloplasty in [**2131-3-25**], which was complicated by a CVA
without lingering defiecits. Intervally after that the pt had a
repeat echo which showed that her LVEF improved from 25% to 50%.
.
In the ED, initial VS were 97.6, 74, 89/42, 20, 93%RA. Labs were
notable for WBC 16.3 w/85% polys & no bands and BNP [**Numeric Identifier 27150**] (was
[**Numeric Identifier 18214**] on [**2131-7-30**]). Troponin <0.01 & lactate 1.8. Hematocrit
stable at 32; creatinine 1.5 (recent baseline 1.2-1.6). UA
negative; 10 hyaline casts. Patient received ~300cc fluid.
Bedside U/S showed collapsing IVC, was negative for pericardial
effusion. CXR with no acute process. Blood cultures were sent
and she was started empirically on vancomycin 1g IV,
levofloxacin 750mg IV, flagyl 500mg IV. Given ongoing
hypotension, a left IJ central venous line was placed and she
was started on levophed (currently SBP 110s on levophed @
0.09mcg/min). An hour prior to transfer in the ED, had a rectal
temp 100.8. VS on transfer were 99.6 PO, HR 94, 105/48, 21,
100%RA.
Past Medical History:
1. CAD, Severe aortic stenosis with [**Location (un) 109**] of 0.8 cm2, CABG: 3V
CABG
recent catheterization with widening of her aortic valvuloplasty
[**4-4**]
complicated by CVA.
2. Diabetes mellitus type 2.
3. Hypertension
4. Hyperlipidemia.
5. Ischemic and valvular cardiomyopathy with an EF 20-25%
6. History of left breast cancer, grade 3.
7. Right rotator cuff tendinopathy.
8. Right biceps tendinitis.
9. Polymyalgia rheumatica.
10. Osteoporosis.
11. Moderate mitral regurgitation
12. History of squamous cell carcinoma.
13. Moderate MR
14. Severe AS: symptoms started in [**2127**]
15. Atrial fibrillation: coumadin, amiodarone
.
PAST SURGICAL HISTORY:
1. Right mastectomy.
2. Coronary artery bypass graft 22 years ago.
3. Hysterectomy.
4. Excision of left dorsal hand squamous cell carcinoma.
5. Right fourth trigger finger release.
Social History:
Housing: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital3 400**] Facility. Has a daughter
nearby who is her emergency contact.
Occupation: Was a homemaker.
Functional Status: Very active, exercises 3x week, does
treadmill, aerobics and yoga.
Tobacco/EtOH/Illicit Drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
VS: T: 100.4 BP: 117/37 P: 66 R: 14 O2: 95% RA
General: Alert but not completley oriented. Oriented to person,
place, generally to events, to date and month and year and
president. Pt seems confused why she's here, is slow to speak,
but does so with complete and fluent sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear. No step offs,
depressions, or tenderness to palaption. LIJ in place and
covered with occlusive dressing.
Neck: supple, JVP to 2cm above clavicles when 45* recumbant, no
LAD
CV: Regular rate and rhythm, diminished S1 and S2 with
pan-systolic systolic murmurs in RUSB, LUSB, and at left apex.
Lungs: Diffuse mid-inspiratory crackles in bases, left more than
right, about [**11-27**] way up chest wall.
Abdomen: no body wall ecchymoses, no percussion tenderness,
soft, non-tender, non-distended, bowel sounds present, no
organomegaly
GU: foley to gravity with dark colored urine.
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis.
Noted for 2+/3+ symmetric edema to the legs b/l coming up to
mid-calf.
Skin: intact without any defects. Reported birth mark to
anterior left thigh.
.
DISCHARGE PHYSICAL EXAM
Vitals - Tm/Tc 100.7/97.9 BP 103-47 (102-116/40-50) HR 66
(66-80)
RR 18 SaO2 95%RA (94-98%RA)
In/Out: 2180/920
Weight: 53 kg
GENERAL: Frail, elderly lady, NAD. Alert and oriented x3. Very
pleasant.
HEENT: NCAT. EOMI, MMM.
NECK: Supple with JVP of 3cm above sternal notch.
CARDIAC: RRR, diminished S1 and S2 with pan-systolic murmur in
RUSB, LUSB, and at left apex, which radiates to the carotids.
LUNGS: Diffuse mid-inspiratory crackles in bases, about [**11-26**] the
way up chest wall.
ABDOMEN: Soft, NTND. Normoactive bowel sounds.
EXTREMITIES: 1+ symmetric edema to the legs b/l coming up to
mid-calf.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs
[**2131-8-22**] 05:50PM BLOOD WBC-16.3*# RBC-3.79* Hgb-11.0* Hct-32.9*
MCV-87 MCH-29.1 MCHC-33.6 RDW-16.5* Plt Ct-221
[**2131-8-22**] 05:50PM BLOOD Neuts-85* Bands-0 Lymphs-9* Monos-5 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2131-8-22**] 05:50PM BLOOD PT-13.7* PTT-26.8 INR(PT)-1.2*
[**2131-8-22**] 05:50PM BLOOD Glucose-98 UreaN-35* Creat-1.5* Na-135
K-4.7 Cl-95* HCO3-30 AnGap-15
[**2131-8-22**] 05:50PM BLOOD ALT-10 AST-24 AlkPhos-71 TotBili-0.4
[**2131-8-22**] 05:50PM BLOOD proBNP-[**Numeric Identifier 27150**]*
[**2131-8-22**] 05:50PM BLOOD cTropnT-<0.01
[**2131-8-22**] 05:50PM BLOOD Albumin-2.6*
.
Discharge labs:
[**2131-8-28**] 06:10AM BLOOD WBC 7.2, RBC 3.69, HGB 10.3, HCT 33.4,
MCV 91, MCH 27.8, MCHC 30.7, RDW 15.6, PLT 275
[**2131-8-28**] 06:10AM BLOOD PT 14.8, PTT 28.6, INR 1.3
[**2131-8-29**] 06:10AM BLOOD GLUC 101, BUN 24, CR 1.2, NA 134, K 4.9,
CL 103, HCO3 27
[**2131-8-29**] 06:10AM BLOOD CA 6.9, PHOS 2.4, MG 2.4
.
IMAGING
[**2131-8-23**] TTE: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
hypokinesis of the basal and mid septal, inferior, and
inferolateral segments. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The ascending
aorta is mildly dilated. The aortic valve leaflets are
moderately thickened. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild to moderate ([**11-26**]+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal left ventricular cavity size. Mild to moderately
depressed left ventricular hypokinesis of the basal and mid
septal, inferior, and inferolateral segments. Mild global right
ventricular free wall hypokinesis. Critical aortic stenosis with
mild to moderate aortic regurgitation. Mild to moderate mitral
regurgitation. Normal pulmonary artery systolic pressure. Left
pleural effusion.
Compared with the prior study (images reviewed) of [**2131-6-15**],
the mildly to moderately depressed left ventricular systolic
function and regional wall motion abnormalities are new. The
severity of aortic stenosis has increased and is now critically
stenosed (the LVOT gradient has decreased), although visually
and by transvalvular aortic gradient it is more consistent with
moderate to severe aortic stenosis and appears unchanged. The
pulmonary artery systolic pressure has normalized.
.
[**2131-8-23**] CHEST (PORTABLE AP): Persistent cardiomegaly without
evidence of congestive heart failure. Slightly improved left
retrocardiac opacity is likely due to a combination of
atelectasis and effusion. Remainder of the lungs are grossly
clear, but lung apices are partially obscured and cannot be
fully assessed.
.
[**2131-8-24**] UNILAT UP EXT VEINS US: Grayscale, color and Doppler
images were obtained of the right IJ, subclavian, axillary,
brachial, basilic, and cephalic veins. Normal flow, compression,
and augmentation are seen in all of the vessels. No evidence of
deep vein thrombosis in the right arm.
.
[**2131-8-25**] Head CT w/o contrast: Previously seen right parietal
subdural hematoma has significantly decreased in size and
density with a small residual subdural hemorrhage (series 2,
image 19).
There is no new acute intracranial hemorrhage, edema, masses,
mass effect, or acute territorial infarction. Unchanged
encephalomalacia in the left superior parietal lobe (series 2,
image 20) from prior injury. Small lacunar infarcts are seen in
the basal ganglia and in the left subinsular region.
Moderate-to-severe atherosclerotic calcification of the
cavernous segments of the carotid artery. Paranasal sinuses and
mastoids are clear. No fracture.
Brief Hospital Course:
[**Age over 90 **]F with hx of severe AS, moderate AR/TR, A-fib, sent from
cardiology clinic for hypotension and found to have c diff.
.
ACUTE
# C. Difficile Infection - Pt presented with hypotension, low
grade fever and leukocytosis to 12.5 without bandemia. She
developed diarrhea and was found to be positive for C. Diff
toxin. She was started on PO flagyl on [**8-24**] and will continue
treatment for a total of 14 days.
.
#. Hypotension: The pt's blood pressure seems to be baseline
about SBP 80-110. Etiology of her hypotension is most likely
contributed to by [**12-27**] worsening AS and hypovolemia secondary to
gastrointestinal losses due to C. difficile infection. A repeat
ECHO showed critical AS, worsened after the valvuloplasty in [**Month (only) 116**]
[**2130**]. Pt's BP is 70s/40s with good mentation when not on
pressor. Her Troponin is neg X2 with no EKG changes. She was
first started on lisinopril 2.5mg daily and her carvedilol was
held due to persistently low blood pressures. She was given
small fluid boluses to maintain intravascular volume.
.
#. [**Last Name (un) **]: Was 1.5 on admission, but back to baseline of 1.2 by
[**8-26**]. Could have been pre-renal or [**12-27**] end organ dysfunction
from poor perfusion. Pt was given small fluid boluses to
maintain UOP and Cr back to baseline. Creatinine was 1.2 upon
discharge.
.
CHRONIC
#. Afib: Longstanding problem with no acute issues this
admission. She was continued on amiodarone at her home dose.
.
#. DM2: Home metformin was held and put her on ISS while
in-house.
.
#. CAD: ASA was initially held due to recent SAH but Head CT on
[**8-25**] showed a significant interval decrease in size and density
of the right parietal
subdural hematoma. ASA was re-started on [**8-27**] per her PCP.
.
#. HTN: Due to hypotension this admission, her home carvedilol
was held.
.
#. HL: Pt was continued on her home simvastatin.
.
#. Hypothyroidism: Pt was continued on her home levothyroxine.
.
#. Osteoporosis: On alendronate at home. Held while in house.
Medications on Admission:
- ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet
PO twice a day: Do not take with thyroid hormone
- carvedilol 3.125 mg Tablet Sig: One (1) Tab PO BID (2 times a
day)
- simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
- alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
- metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
- levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day
- amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
- multivitamin Tablet Sig: One (1) Tablet PO DAILY
- cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY
- ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
- Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
once a day as needed for pain
- ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
- docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day)
- recently discontinued from Lasix and lisinopril
Discharge Medications:
1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day): after lunch and dinner.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: please hold for
diarrhea.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
give on Monday.
5. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day:
give after lunch.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): give before breakfast.
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO at bedtime:
give at hs.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO at bedtime.
10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 9 days.
11. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
give after lunch, hold SBP < 100.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
Please start once diarrhea is resolved.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
C difficile Colitis
Acute on Chronic Kidney Injury
Atrial fibrillation
Severe Aortic Stenosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had fevers and an elevated white blood cell count that we
believe was due to the infection in your colon. You were started
on flagyl, an antibiotic to treat this infection for a 2 week
course. Your kidney function also worsened because of
dehydration, your kidney function is almost normal now. Weigh
yourself every morning, call Dr. [**Last Name (STitle) 911**] if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1.Discontinue carvedilol as your blood pressure has been low
2. START Metronidazole pills to treat your bowel infection
3. Restart Lasix when the diarrhea goes away
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2131-9-27**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], 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: RADIOLOGY
When: THURSDAY [**2131-9-6**] at 1:15 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 [**2131-9-6**] at 2:15 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2131-11-21**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"425.4",
"427.31",
"424.1",
"276.52",
"428.42",
"585.9",
"733.90",
"584.9",
"250.00",
"V45.81",
"458.9",
"432.1",
"272.4",
"424.0",
"725",
"428.0",
"008.45",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.94"
] |
icd9pcs
|
[
[
[]
]
] |
15451, 15528
|
11115, 13152
|
284, 290
|
15666, 15666
|
6712, 7335
|
16524, 17681
|
4677, 4793
|
14199, 15428
|
15549, 15645
|
13178, 14176
|
15851, 16501
|
7351, 11092
|
4153, 4336
|
4808, 6693
|
212, 246
|
318, 3469
|
15681, 15827
|
3491, 4130
|
4352, 4661
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,818
| 152,519
|
18097+56922
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-10-17**] Discharge Date: [**2195-10-21**]
Service: [**Doctor Last Name **] Medicine Firm
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
man with a history of coronary artery disease status post
CABG and multiple lower GI bleeds likely from diverticulosis
and known diverticulosis, who presented with bright red blood
per rectum at about 1:30 p.m. after eating pizza on the day
prior to admission.
The patient felt a rumbling in his stomach and then passed
bright red blood per rectum, and does note that he has been
more constipated than usual over the past week. At the time
of the bleed, he then presented to [**Hospital3 3583**] and his
blood pressure dropped from 142/90 to after passing a large
amount of stool of 90/60 with lightheadedness and signs of
presyncope. The patient subsequently received 2 units of
packed cells after the hematocrit dropped from 42 to 31. He
was transferred to the [**Hospital1 **] for further
evaluation. His hematocrit was stable, but then passed a
maroon stool and received another unit and more IV fluids.
He denies abdominal pain, nausea, vomiting, and diarrhea. He
had a nasogastric lavage that was negative at 500 cc.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post three vessel CABG in
[**12-15**].
2. Multiple lower GI bleeds, approximately 10, most recently
in [**Month (only) 547**]. Known diverticulosis spread throughout the colon.
3. Gastritis and duodenitis.
4. Hemorrhoids.
5. Benign prostatic hypertrophy.
6. Cataracts.
MEDICATIONS ON ADMISSION:
1. Atenolol 12.5 q.d.
2. Accupril 5 q.d.
3. Donnatal.
4. Ativan prn.
5. Caltrate.
ALLERGIES: Dimetapp.
SOCIAL HISTORY: The patient is married to his new wife
approximately five years ago. He works part-time. He is a
former alcohol drinker, who quit 30 years ago and former
tobacco user, quit 30 years ago.
FAMILY HISTORY: Notable for a father who died of a MI.
Mother died of cirrhosis.
PHYSICAL EXAMINATION: The patient was afebrile with a blood
pressure of 194/88 with a pulse of 86, respiratory rate 19,
and O2 saturation is 96% on room air. Generally, he was
alert and oriented x3. He was pleasant and appropriate. His
head and neck examination is notable for having extraocular
movements intact. Pupils are equal, round, and reactive to
light and accommodation with dry lips and he was anicteric
sclerae. His neck had no bruits and no lymphadenopathy. His
chest was clear to auscultation bilaterally. Cardiac
examination: Regular, rate, and rhythm, no murmurs, rubs, or
gallops. On abdominal exam, he had hyperactive bowel sounds.
He was distended, but nontender, and no organomegaly, with no
clubbing, cyanosis, or edema in his extremities. His cranial
nerves were intact and his upper and lower extremity strength
was [**5-18**].
LABORATORY DATA: He had a white count of 11.4 and a
hematocrit of 35.6, platelets of 156. His electrolytes were
notable for a bicarbonate of 20. He had an INR of 1.4 and a
negative urinalysis.
EKG that was in normal sinus rhythm with a Q in III and
T-wave inversions in lateral leads that were unchanged from
previous.
LFTs were normal. Calcium was 8.8.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Medical Intensive Care Unit where he was watched for
approximately 24 hours and received q.4h. hematocrit checks.
The patient received a total of 1 unit while in the Emergency
Department, but did not receive any further blood products.
After one day in the ICU, the patient was transferred to the
floor. He had q.8h. hematocrit checks while they were lower
than his baseline low 40s. He did not drop below 30. The
patient was maintained on his IV proton-pump inhibitors.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 7693**]
MEDQUIST36
D: [**2195-10-21**] 19:07
T: [**2195-10-23**] 09:51
JOB#: [**Job Number 50084**]
Name: [**Known lastname 8945**], [**Known firstname 126**] Unit No: [**Numeric Identifier 9297**]
Admission Date: [**2195-10-17**] Discharge Date: [**2195-10-21**]
Date of Birth: [**2110-11-5**] Sex: M
Service:
ADDENDUM:
The patient had a stable hematocrit over the course of
admission. On the day prior to discharge, the patient had an
elective colonoscopy that revealed multiple diverticulosis
throughout his colon, as well as several polyps. Three
polyps were removed. The patient had a stable hematocrit
over the next twenty-four hours, and he was discharged home
with close outpatient follow-up. He had no further evidence
of bleeding while he was on the floor, and it was impossible
to localize the bleeding. Of note, the patient did have a
bleeding scan performed while having red stool per rectum and
the bleeding scan was negative.
DISCHARGE STATUS: To home.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Atenolol 12.5 mg p.o. once daily.
2. Accupril 5 mg p.o. once daily.
3. Donnatal one tablet four times a day.
4. Ativan p.r.n.
5. Caltrate one tablet once daily.
FOLLOW-UP PLANS: The patient will follow-up with his primary
care physician in approximately seven to ten days and his
outpatient gastroenterologist within the next month.
[**Doctor Last Name **] [**Name6 (MD) 909**] [**Name8 (MD) **], M.D. [**MD Number(1) 348**]
Dictated By:[**Last Name (NamePattern1) 4993**]
MEDQUIST36
D: [**2195-10-21**] 19:11
T: [**2195-10-21**] 20:53
JOB#: [**Job Number 9298**]
|
[
"285.1",
"211.3",
"401.9",
"V45.81",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
1896, 1962
|
4966, 5136
|
1566, 1672
|
3214, 4906
|
1985, 3185
|
5154, 5579
|
152, 1213
|
1235, 1540
|
1689, 1879
|
4931, 4940
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,654
| 162,228
|
43178+43179+58598
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2173-1-4**] Discharge Date: [**2173-1-16**]
Service: C-Medicine
CHIEF COMPLAINT:
Left toe ulcers times five months.
HISTORY OF PRESENT ILLNESS: The patient is an 87 year old
man with a past medical history shown below, complaining of
five months of pains in the left toes accompanied by ulcers.
The patient's partner noted that the left foot problems began
when he was fitted with ill-fitting shoes approximately five
months ago. The patient had a prior history of right foot
ulcers that have now since healed.
The patient had been followed by the [**Hospital **] Clinic, where
he a number of in-clinic debridements, namely on [**2172-10-29**], [**2172-10-7**], [**2172-8-20**], during which the
OMR notes indicate there was presence of no pus or probing of
bone. The patient was also started on Keflex in
mid-[**Month (only) **]. The patient was admitted to the C-Medicine
service for pre-catheterization hydration, renal protection,
because of his diabetic nephropathy.
PAST MEDICAL HISTORY:
1. Congestive heart failure with a recent admission on
[**2172-12-7**] as well as [**2172-11-21**].
2. Coronary artery disease with an inferior wall myocardial
infarction in [**2155**] and coronary artery bypass grafting
approximately ten years ago; no detailed records currently
available.
3. Type 2 diabetes mellitus, on insulin, diagnosed 25 years
ago.
4. Hypercholesterolemia.
5. Bilateral internal carotid disease.
6. Chronic renal insufficiency with a baseline creatinine of
2 to 2.5.
7. Cholecystectomy in [**2171-2-4**].
8. Benign prostatic hypertrophy, status post transurethral
resection of prostate in [**2171-3-7**].
9. Right eye surgery.
10. Left foot ischemic ulcers.
REVIEW OF SYSTEMS: The patient has two pillow orthopnea and
decreased appetite times several months.
ALLERGIES: The patient has been warned to avoid epinephrine
because of his poor peripheral circulation.
MEDICATIONS ON ADMISSION: Vasotec 10 mg p.o.q.a.m. and 5 mg
p.o.q.p.m., insulin 16 units q.a.m. and q.p.m., Lasix 20 mg
alternating with 40 mg p.o.q.o.d., Isordil 10 mg p.o.t.i.d.,
carvedilol 12.5 mg p.o.b.i.d., Zaroxolyn 2.5 mg p.o.q.
Monday, Wednesday and Friday.
SOCIAL HISTORY: The patient quit tobacco 20 years ago. He
lives with a female partner.
PHYSICAL EXAMINATION: On physical examination upon
presentation, the patient had a prominent jugular venous
pressure of approximately 10 cm but no bruits auscultated.
Lungs: Bilateral rales, right greater than left.
Cardiovascular: II/VI systolic ejection murmur heard best at
the apex. Extremities: On the right foot, there were well
healing ulcer scars, left notable for prominent ulcers on the
third and fourth toes with the fourth toe discolored and
blackened especially in comparison with the third toe.
LABORATORY DATA: The patient underwent his last cardiac
catheterization in [**2160-6-3**], which showed a left ventricular
ejection fraction of only 30%, 90% stenosis in the proximal
right coronary artery, 100% stenosis in the mid-right
coronary artery, 90% stenosis in the mid-left anterior
descending artery. He had undergone an exercise tolerance
test in [**2172-4-3**], notable for no electrocardiographic
changes and fixed perfusion defects only. An echocardiogram
in [**2172-11-3**] showed a left ventricular ejection fraction
of only 10% to 20%, severe left ventricular hypokinesis with
2+ mitral regurgitation, 1+ tricuspid regurgitation.
[**2172-12-7**] electrocardiogram was notable for right
bundle branch block, left anterior hemiblock, old inferior
myocardial infarction and old anterior myocardial infarction.
[**2172-12-7**] chest x-ray was notable for bilateral
pleural effusions, right greater than left.
HOSPITAL COURSE: The patient went for an MRA of his left leg
to establish the vascular anatomy. Multiple vessel diseases
were noted including plaques, no seclusions. Radiology
report indicated no significant vessels supplying circulation
to the distal foot. Catheterization performed on [**2173-1-5**] found no identifiable perfusion of the left foot through
any major vessels. There was occlusion of the left popliteal
artery, occlusion of the left superficial femoral artery,
there was moderate systolic and diastolic ventricular
dysfunction, moderate pulmonary hypertension.
The patient therefore had been started on milrinone because
of low cardiac index of 1.8. His cardiac index improved.
The patient was transferred to the Unit while the milrinone
infusion was begun, and soon began to feel less short of
breath. As described in the catheterization report, the
patient had been found to have elevated pulmonary pressures
and low cardiac index, which improved significantly on
milrinone infusion.
After the milrinone, the patient was able to sleep
comfortably lying flat, which he had been unable to do
before, with a history of chronic two pillow orthopnea.
However, it was noted that the patient's creatinine began to
rise, which was believed secondary to the cardiac
catheterization dye creatinine acute renal failure on top of
his chronic renal insufficiency. Renal medicine was
consulted as well as heart failure consult, who recommended
suspension of his daily doses of Lasix as well as his
Zaroxolyn. Further, the patient's ACE inhibitor was held for
several days, allowing the patient's creatinine, which had
bumped up to as high as 4.2, to slowly recover.
When the patient's creatinine fell to 2.6, an ACE inhibitor,
Captopril, was restarted at 6.25 mg three times a day with
the plan to load on the Captopril slowly, monitoring the
creatinine and then weaning off the milrinone if possible.
After consulting physical therapy, the plan is to discharge
the patient to a rehabilitation facility with final
disposition regarding whether or not to continue milrinone
pending fluid status as his medications are adjusted. The
plan is to discharge the patient to rehabilitation on
approximately [**2173-1-16**]. Additional notes will be
appended as an addendum to this discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Last Name (NamePattern1) 8442**]
MEDQUIST36
D: [**2173-1-14**] 15:44
T: [**2173-1-14**] 14:06
JOB#: [**Job Number **]
Admission Date: [**2173-1-4**] Discharge Date: [**2173-1-24**]
Service:
ADDENDUM: For the patient's coronary artery disease he was
continued on Carvedilol 12.5 mg po b.i.d., statin, aspirin,
and an ace inhibitor, which was being titrated up. His
nitrate was switched over to Imdur 30 mg po q.d. As far as
his congestive heart failure the patient was weaned off of
the Milrinone drip from 6 cc an to 0 cc an hour. After his
Milrinone was discontinued, his Captopril was titrated up.
With withdraw of the Milrinone and increase in the ace
inhibitor, his creatinine did fluctuate, but remained quite
steady around 2.5, which is his baseline. As far as his
anemia and diabetes mellitus his hematocrit held steady
around 32 during the whole hospital course and sugars
remained below 200.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Coronary artery disease.
3. Chronic renal insufficiency.
4. Hypertension.
5. Diabetic foot ulcer.
6. Anemia secondary to chronic renal insufficiency.
7. Constipation.
8. Diabetes mellitus type 2 insulin dependent.
DISCHARGE MEDICATIONS: Carvedilol 12.5 mg po b.i.d.,
Atorvastatin 10 mg po q day, aspirin 325 mg po q day, Digoxin
0.125 mg q.o.d., Lasix po 20 mg q.a.m. and 40 mg q.p.m., NPH
11 units in the morning and 3 units p.m. subQ. Regular
insulin sliding scale, Propoxyphene N-100 tablets one tab po
q 4 to 6 hours prn pain. Colace 100 mg po b.i.d. Senna two
tabs po q day, Milk of Magnesia and Lactulose 30 cc prn
constipation. Imdur 30 mg po q day. Zantac 150 mg po
q.h.s., heparin 5000 units subQ b.i.d., Atrovent one to two
puffs q 6 hours prn shortness of breath. Captopril unknown
dose at this time.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehab.
DISCHARGE DIET: Cardiac - 1800 [**Doctor First Name **] diet.
FOLLOW UP: The patient is to follow up with the laboratory
for his potassium, magnesium, creatinine times one and then
creatinine every third day if ace inhibitor is being
increased. The patient should follow up with a cardiologist
or a primary care physician within one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Last Name (NamePattern1) 3796**]
MEDQUIST36
D: [**2173-1-22**] 11:09
T: [**2173-1-22**] 12:48
JOB#: [**Job Number 93046**]
Name: [**Known lastname 14662**], [**Known firstname **] Unit No: [**Numeric Identifier 14663**]
Admission Date: [**2173-1-14**] Discharge Date: [**2173-1-16**]
Date of Birth: [**2085-3-12**] Sex: M
Service:
Just additional notes to the original discharge summary for
this admission. The patient will be going to [**Hospital3 7766**], and will be continued on his milrinone at 23
mcg/kg rate through peripheral IV. Instructions for changing
the peripheral line q4 days had been written on the page one
to be included with his discharge papers.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Chronic renal failure.
3. Type 2 diabetes.
4. Left foot ulcer with peripheral vascular disease.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Carvedilol 18.75 mg po bid.
2. Aspirin 325 mg daily.
3. Atrovent prn.
4. SubQ Heparin 5,000 units subQ [**Hospital1 **] to be discharged when
the patient is ambulatory.
5. Ambien 5 mg po q hs prn.
6. Protonix 40 mg po q day.
7. Atorvastatin 10 mg po q day.
8. Isordil 10 mg po tid.
9. Docusate 100 mg po bid.
10. Dextromethrophan, guaifenesin diabetic syrup [**2-5**]
teaspoons q hs and q6h prn.
11. Regular insulin-sliding scale 2 units starting at 200
mg/dl with standing coverage of NPH 11 units in the morning
and 3 units in the evening at bedtime.
12. Captopril 12.5 mg tid.
13. Milk of magnesia prn.
14. Senna prn.
15. Bisacodyl prn.
16. Lasix 20 mg and 40 mg po, 20 and 40 on alternating days.
17. Digoxin 0.125 q other day.
18. Darvocet one tablet q6h prn.
19. Percloperazine 5 mg q6h prn nausea.
The patient will contact Dr.[**Name (NI) 14678**] office for followup in
one week and also to evaluate for a possible discontinuation
of the milrinone.
Discharge plan has been reviewed by the attending covering
for Dr. [**Last Name (STitle) 1129**] today.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14679**], M.D. [**MD Number(1) 14680**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2173-1-16**] 10:51
T: [**2173-1-19**] 13:24
JOB#: [**Job Number 14681**]
|
[
"585",
"V45.81",
"250.40",
"496",
"428.0",
"414.01",
"412",
"584.9",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"37.21",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
8023, 8126
|
9293, 9450
|
9473, 10816
|
1960, 2201
|
3750, 7119
|
8138, 9272
|
2314, 3732
|
1744, 1933
|
112, 148
|
177, 1010
|
1032, 1724
|
2218, 2291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,304
| 174,277
|
43736
|
Discharge summary
|
report
|
Admission Date: [**2103-1-15**] Discharge Date: [**2103-2-19**]
Date of Birth: [**2032-4-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
70 year old male with one month of increasing jaundice,
pseudocyst of the pancreas on CT scan, in the background of
alcoholism.
Major Surgical or Invasive Procedure:
Puestow procedure, cholecystectomy, feeding jejunostomy tube
placement, central venous line placement.
History of Present Illness:
This 70-year-old gentleman firstpresented one year ago with new
onset diabetes. He is an alcoholic who drinks constantly at home
and lives a sedentary
lifestyle. He has been noncompliant with his treatment of
diabetes for this year. He presented with new onset jaundice
in late [**Month (only) **] to an outside hospital and was transferred
to our facility for endoscopic retrograde
cholangiopancreatography. This was attempted on two
occasions and he was found by CT to have a grossly dilated
pancreatic duct with jaundice. However, he was unable to be
cannulated by ERCP and therefore he was referred to Dr. [**Name (NI) 60612**] care
for a surgical evaluation. I found him to be weak,
malnourished and not suitable for an operation at the point
that he was evaluated. Furthermore, he suffered a GI bleed from
his
attempted sphincterotomy one week afterwards and was
transfused many units of blood to resuscitate him. In the
interim, we provided TPN for nourishment and made him nil per os
through this period of time. His history showed that he had
an elevated alkaline phosphatase as well as significant
elevations of amylase and lipase whenever he ate food.
Past Medical History:
diabetes mellitus type 1, pancreatitis, depression, anxiety,
alcoholism
Social History:
alcoholism, depression
Family History:
noncontributory
Physical Exam:
96.9F, 72, 110/62, 18 98%RA
Alert, cachectic, withdrawn, mildly jaundiced
RRR, no M/R/G
CTAB, no W/R/R
ND, NABS, soft, slight epigastric tenderness, no
hepatosplenomegaly
DP 2+, no peripheral edema
Pertinent Results:
Pertinent admission laboratories
[**2103-1-15**] 08:11PM GLUCOSE-219* UREA N-10 CREAT-0.5 SODIUM-137
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-33* ANION GAP-12
[**2103-1-15**] 08:11PM ALT(SGPT)-162* AST(SGOT)-123* ALK PHOS-937*
AMYLASE-284* TOT BILI-5.5*
[**2103-1-15**] 08:11PM LIPASE-253*
[**2103-1-15**] 08:11PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2103-1-15**] 10:00AM ALT(SGPT)-170* AST(SGOT)-144* ALK PHOS-886*
AMYLASE-285* TOT BILI-5.1*
[**2103-1-15**] 10:00AM LIPASE-490*
[**2103-1-15**] 10:00AM WBC-4.4 RBC-3.22* HGB-10.1* HCT-30.7* MCV-95
MCH-31.3 MCHC-32.9 RDW-15.4
[**2103-1-15**] 10:00AM PLT COUNT-250
[**2103-1-15**] 10:00AM PT-12.5 PTT-24.7 INR(PT)-1.0
Brief Hospital Course:
The patient was admitted to the [**Hospital1 1170**] on [**2103-1-15**] for further evaluation of his abdominal pain
and likely pancreatic pseudocyst. The patient was made nil per
os and was started on TPN as at the time of admission the
patient was not physically prepared to withstand the rigors of a
major abdominal procedure. A CTA of the abdomen was also
performed that showed the following:
1) Multiple cystic appearing structures within the pancreatic
head and body, with the dominant one at the pancreatic head,
possibly causing compressive obstruction of the common bile
duct. In addition pancreatic calcifications are seen. The
dindings are more consistent with chronic pancreatitis with
mature pseudocysts rather than cystic pancreatic tumor.
After preparing him with TPN for multiple weeks, the patient was
ready
for an operative intervention for relief of the bile duct.
Furthermore, the hope was to address his pancreatic
pseudocyst through internal drainage and possibly even deal
with the dilated distal pancreatic duct with calcific disease
inside of it. Long and thorough discussions with both
the patient and primarily his daughter regarding his problem
and the need to intervene surgically took place. They understood
the
risks and benefits of this operation and both wished to
proceed and provided informed consent to that effect. It was
made very clear that he was at a heightened risk for
perioperative complications primarily from anesthetic
induction, but also from the operation itself, given his
frail constitution. However, this was socially a situation
where there would be no advantage to continuing with weight
gain over a longer period of time.
The patient was brought to the operating room on the morning of
[**2-6**]
with the intent of performing a biliary bypass through a
choledochojejunostomy as well as a drainage of the pancreatic
pseudocyst. Furthermore, a jejunostomy feeding tube was
placed for postoperative nutritional support. Also, in the
operating room a right sided [**Doctor Last Name 406**] drain was placed that was
later removed in the postoperative period.
In the postoperative period the patient was initially maintained
on TPN until tube feeds were started. The patient also was
noted to have slightly labile blood glucose levels that were
being recorded four times a day. The [**Last Name (un) **] diabetes service
was consulted at this time and adjusted the doses of his insulin
to better control his blood glucose. In the days leading up to
his discharge the patient was also started on a regular diabetic
diet and was tolerating oral intake fairly well.
During his stay patient was also found to have superior rotation
of the acetabular component of his left hip prosthesis, with a
slight superior dislocation of the left femoral head prosthesis.
This limited his mobility though patient was able to work with
physical therapy and was out of bed to chair consistently in the
postoperative period.
In the postoperative period the patient was continued on all of
his home medications and progressed well overall and on [**2103-2-19**]
the patient was deemed fit for discharge to a rehabilitation
facility with instructions to follow up with Dr. [**Last Name (STitle) **] in two
weeks.
Medications on Admission:
colace, multivitamin, ECASA, glipizide, thiamine, folic acid,
vitamin D
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed for after each loose stool.
5. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q2H
(every 2 hours) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Papain Miscell. for flushing J-tube
9. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing
Discharge Diagnosis:
pancreatic pseudocyst, diabetes type 1, post Puestow procedure
Discharge Condition:
stable
Discharge Instructions:
Patient to be discharged to rehabilitation facility and to
aware if patient having worsening pain, fevers, chills, nausea,
vomiting, or if there are any questions or concerns.
Followup Instructions:
Patient to follow up with Dr. [**Last Name (STitle) **] in two weeks, appointment
to be scheduled, call [**Telephone/Fax (1) 1231**] to confirm.
|
[
"998.11",
"578.9",
"577.8",
"263.9",
"577.2",
"211.3",
"577.1",
"996.4",
"250.00",
"303.90",
"V58.67",
"286.7",
"576.2",
"575.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.42",
"51.22",
"45.13",
"99.15",
"99.04",
"38.93",
"45.24",
"52.96",
"44.43",
"96.6",
"51.36",
"88.74",
"45.16",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
6985, 7042
|
2850, 6106
|
441, 546
|
7149, 7157
|
2139, 2827
|
7381, 7529
|
1889, 1906
|
6228, 6962
|
7063, 7128
|
6132, 6205
|
7181, 7358
|
1921, 2120
|
274, 403
|
574, 1738
|
1760, 1833
|
1849, 1873
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,061
| 193,150
|
33741
|
Discharge summary
|
report
|
Admission Date: [**2181-4-6**] Discharge Date: [**2181-4-10**]
Date of Birth: [**2123-11-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2181-4-6**] 1)Off Pump Single Vessel Coronary Artery Bypass Grafting
utilizing the left internal mammary artery to left anterior
descending artery. 2) Thoracoscopic takedown of the internal
mammary artery.
History of Present Illness:
57 year old male with intermittent exertional chest pain for 2
weeks with elective stress test with ST changes and left arm
pain. Transferred to [**Hospital1 18**] for further cardiac evaluation.
Cardiac catheterization revealed severe 80% lesion in the left
anterior descending artery, along with severe disease in the
right coronary artery. The circumflex had minimal disease. He
subsequently underwent successful PCI/stenting with two Endeavor
drug eluding stents in the right coronary artery. Given the LAD
lesion, he was concomitantly referred for hybrid
revascularization.
Past Medical History:
-Coronary Artery Disease
-Recent PCI/Stenting to RCA
-History of Myocardial infarction approximately 10 years ago
-Hypertension
-Cervical disc herniation
-Arthritis
Social History:
Works as pharmacist
Lives with spouse
Denies [**Name2 (NI) 1139**] and ETOH
Family History:
Denies
Physical Exam:
General NAD
Skin unremarkable
HEENT unremarkable
Neck full ROM
Chest CTA bilat
Heart RRR
Abd soft, NT, ND, +BS
Ext warm well perfused
Neuro grossly intact
Pertinent Results:
[**2181-4-9**] 05:45AM BLOOD WBC-7.0 RBC-2.83* Hgb-8.8* Hct-25.1*
MCV-89 MCH-31.0 MCHC-35.0 RDW-14.7 Plt Ct-138*
[**2181-4-9**] 05:45AM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
[**2181-4-10**] Discharge Chest x-ray: In comparison with study of
[**2181-4-9**], there is little overall change. Moderate left pleural
effusion persists, as does mild blunting of the right
costophrenic angle. Some atelectatic changes are again seen in
the lower left lung. No evidence of acute focal pneumonia.
Brief Hospital Course:
Went to operating room and underwent off pump coronary artery
bypass grafting. See operative report for further details. He
was transferred to the intensive care unit for hemodynamic
monitoring. In the first 24 hours he was weaned from sedation,
awoke neurologically intact, and was extubated. He required a
chest tube insertion for hemothorax on the left side. He
continued to be monitored in the ICU and was ready for transfer
to the floor on POD 2. Physical therapy worked with him for
strength and mobility. He was gently diuresed towards his
preoperative weight and started on beta blockers. He continued
to progress and was ready for discharge home with services on
POD 4.
Medications on Admission:
Plavix 75 daily
metoprolol 50 [**Hospital1 **]
lipitor 20 daily
Zetia 10 daily
ASA 81 daily
darvocet 100 [**Hospital1 **]
Valium 5 [**Hospital1 **]
Tramadol 50 [**Hospital1 **]
Xanaflex 4 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:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
4. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease s/p Off Pump CABG
Postop Pleural Effusion
Elevated Cholesterol
Hypertension
Cervical disc herniation
Arthritis
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 two weeks for while taking pain
medication
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 1637**] in [**12-27**] week ([**Telephone/Fax (1) 14655**]) please call for
appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2181-4-10**]
|
[
"998.11",
"511.8",
"401.9",
"722.0",
"414.01",
"E878.2",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.09",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4374, 4425
|
2206, 2894
|
342, 552
|
4604, 4611
|
1657, 2183
|
5111, 5445
|
1459, 1467
|
3136, 4351
|
4446, 4583
|
2920, 3113
|
4635, 5088
|
1482, 1638
|
281, 304
|
580, 1161
|
1183, 1350
|
1366, 1443
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,716
| 171,434
|
11611
|
Discharge summary
|
report
|
Admission Date: [**2113-6-13**] Discharge Date: [**2113-6-20**]
Date of Birth: [**2033-1-2**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Atenolol / Nifedipine / Hydrochlorothiazide
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Weakness and jaundice
Major Surgical or Invasive Procedure:
ERCP [**2113-6-16**]
History of Present Illness:
80 year old [**Month/Day/Year **] speaking man without significant past
medical history who was admitted on [**6-13**] with one month of
anorexia, malaise,
intermittent abdominal pain (not associated with eating), gas,
dark urine, and jaundice. On admission, he had a CT which
demonstrated a large lesion in the right lobe of the liver;
however, an MRCP performed the following day demonstrated
cirrhosis but no mass. He was found to be in liver failure. He
was evaluated by both the hepatology team and ERCP team; he
underwent an ERCP on [**6-16**] which showed no obstruction. He then
developed a post-ERCP pancreatitis with abdominal pain and
distension. His abdominal pain improved slightly with bowel
rest; however overnight, he developed worsening abdominal
distension and tachypnea to the 30s. The patien is feeling short
of breath. He reports abdominal bilat lower quadrant abdominal
pain [**6-12**] and vomiting x2 (food-stuff) this am and nausea. He
denies passing flatus or having BM in 3 days. He reports poor
appetite and bloating. NGT was placed for decompression and
drains
.
On the floor, the patient reports feeling tired from having to
breathe so fast. He is tachypneic to the mid-40s with kussmal
respirations.
.
Review of sytems:
(+) Per HPI and for dark urine
(-) Denies fever, chills, night sweats,
lightheadedness/dizziness. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied diarrhea or
BRBPR. No dysuria/hematuria. Denied arthralgias or myalgias or
rash.
.
Past Medical History:
Hypertension
Choledochelithiasis, ERCP [**2105**]
Acute liver failure/cirrhosis - possibly secondary to herbal
medications / simvastatin and the fact that patient is a
Hepatitis B carrier. Hemochromatosis also suspected
Social History:
Retired, lives with wife, former [**Name2 (NI) 1818**] x 30 years
Family History:
Non-contributory
Physical Exam:
Temp: Afebrile, 101/70 70 18
GEN: NAD
HEENT: PERRL, EOMI, scleral icterus
Oropharynx within normal limits, + fetor hepaticus
Chest: Clear to auscultation
Cardiovascular: Regular, S1 and S2, no murmurs.
Abdominal: Soft, nontender, mild distension, unable to feel
liver edge
Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, warm and dry, jaundiced
Neuro: Speech fluent, lucid, normal gross motor function
Pertinent Results:
[**2113-6-13**]:
LACTATE-1.7
GLUCOSE-141* UREA N-11 CREAT-1.2 SODIUM-134 POTASSIUM-3.8
CHLORIDE-102 CO2-22 ANION GAP-14
ALT(SGPT)-716* AST(SGOT)-1339* ALK PHOS-157* TOT BILI-23.1* DIR
BILI-17.8* INDIR BIL-5.3
LIPASE-26
CALCIUM-8.3* PHOSPHATE-1.7* MAGNESIUM-2.3
WBC-7.8 RBC-4.32* HGB-13.8* HCT-41.9 MCV-97 MCH-32.0 MCHC-32.9
RDW-15.2 PLT COUNT-249
NEUTS-68.5 LYMPHS-21.7 MONOS-8.2 EOS-0.8 BASOS-0.7
HEPATITIS WORKUP:
calTIBC-163* Ferritn->[**2103**] TRF-125*
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE HAV Ab-POSITIVE HCV
Ab-NEGATIVE
AMA-NEGATIVE Smooth-NEGATIVE
[**Doctor First Name **]-NEGATIVE
AFP-613.0*
IgG-2227* IgA-545* IgM-172
IgM HBc-NEGATIVE IgM HAV-NEGATIVE
Acetmnp-NEG
[**2113-6-17**]:
WBC-14.0*# RBC-4.13* Hgb-13.0* Hct-39.5* MCV-96 Plt Ct-341
PT-18.5* PTT-37.6* INR(PT)-1.7*
Glucose-148* UreaN-13 Creat-1.0 Na-138 K-3.6 Cl-106 HCO3-21*
AnGap-15
ALT-522* AST-783* AlkPhos-126 Amylase-876* TotBili-22.1*
Lipase-1669*
[**2113-6-18**]:
Glucose-128* UreaN-38* Creat-2.4*# Na-134 K-4.7 Cl-107 HCO3-11*
AnGap-21*
Lactate-10.2*
WBC-12.5* RBC-4.44* Hgb-14.1 Hct-43.1 MCV-97 Plt Ct-400
[**2113-6-13**] RUQ Ultrasound: 1. No evidence of cholecysto-, or
choledocholithiasis. No evidence of acute gallbladder pathology
or biliary dilatation. 2. Heterogenous liver echotexture. 3.
Multiple right renal cysts.
[**2113-6-13**] CT Abd/Pelvis: 1. Large hypodense heterogeneously
enhancing infiltrative lesion occupying the entire right lobe of
the liver is concerning for primary neoplastic process such as
HCC. A biopsy is warranted for further evaluation. Enlarged
enhancing portacaval and porta hepatic nodes are concerning for
local spread. 2. Normal-appearing gallbladder, CBD, pancreas,
and pancreatic duct. 3. No CT evidence of tumor thrombosis. 4.
Right pleural effusion, trace intrapelvic free fluid. 5.
Multiple bilateral renal cysts.
[**2113-6-14**] MRCP: 1. Findings compatible with liver cirrhosis and
acute hepatic inflammation. 2. No mass in the liver. 3.
Gallstones and gallbladder wall thickening which is most likely
secondary to underlying liver disease. 4. Renal cysts.
[**2113-6-16**] CT Triple Phase Liver: 1. Nodular contour of the liver
likely represents cirrhosis. Perfusion abnormality, No definite
hepatic masses are identified. Enlarged lymph nodes in the porta
hepatis and along the celiac axis could be secondary to
cirrhosis and inflammation. 2. Multiple renal cortical cysts.
[**2113-6-16**] ERCP: Papilla major diverticulum. Normal biliary tree -
no evidence of obstruction was noted. Normal pancreatic duct
[**2113-6-18**] KUB (midnight): Air-filled loops of large and small
bowel are demonstrated but not abnormally dilated. There is no
evidence of free air or pneumatosis. Contrast media fills the
gallbladder, consistent with the recent administration of
contrast on the CT of [**2113-6-16**].
[**2113-6-18**] KUB (9:00AM): Nonspecific non-obstructive bowel gas
pattern is observed with no evidence of progressive distention
of bowel loops compared to prior. An NG tube tip is seen
overlying the expected location of the gastric antrum. Contrast
media seen in the gallbladder and the urinary bladder. There is
no evidence of pneumatosis or free air although a single supine
view limits assessment for the latter.
[**2113-6-18**] pCXR: Shallow inspiration but still suspect volume
overload.
[**2113-6-18**]: CXR - NGT in place, no obvious edema or inflitrates. no
free air.
[**2113-6-18**]: KUB - diffuse small bowel dilation
.
EKG: ST 106, no ST changes or T wave inversions
.
Brief Hospital Course:
80 year-old [**Month/Day/Year 8230**] speaking gentleman with history of hep B
infection, presented with abdominal pain and jaundice consistent
with an acute hepatitis, complicated by sepsis requiring
pressors and mechanical ventilation.
1. ABDOMINAL PAIN/JAUNDICE- likely from acute hepatitis
superimposed upon background of underlying cirrhosis. Imaging
was consistent with chronic cirrhosis (etiology unclear) which
could be [**3-7**] known hep B carrier state and/or hemochromatosis
(from Fe/TIBC ratio) or acute exacerbation of underlying liver
disease from potential ingestion of herbal medicines while in
[**Country 651**] or other toxic exposures. There was a question of a liver
mass (w/ AFP 613) on CT scan which was not noted on ultrasound
or MRCP. AFP being over 500 raises strong suspicion for
hepatocellular carcinoma. ERCP was performed on hospital day #4
([**6-16**]) to evaluate TBILI>20 which revealed no biliary disease.
He then developed post-ERCP pancreatitis with some bloating
after the procedure. On hospital day #6, his condition acutely
worsened. He became tachypneic with increased abdominal
distention and loss of bowel sounds. Laboratory studies
revealed lactic acidosis. He quickly worsened and became
hypotensive. He was transferred to the ICU where he was
intubated for respiratory fatigue and placed on pressors.
2. [**Name (NI) 36862**] pt developed distributive (hypovolemic) shock as
above, which could have been exacerbated by some component of
septic shock. He required intubation and blood pressure support
while in the ICU. Most likely this was caused by worsening
hepatic failure and post-ERCP pancreatitis. Etiology of acute
liver injury was unclear and could be related to toxic
ingestion/exposure, exacerbation of underlying chronic liver
disease or hepatocellular carcinoma, given elevated AFP.
However, mass was not clearly visualized on imaging. Diffuse HCC
could be a possibility. Patients clinical status continued to
deteriorate throughout the night of [**6-19**]. He developed anuric
renal failure likely in the setting of ATN from severe
hypotension with some contribution from contrast-induced
nephropathy. CVVH was initiated in an attempt to alleviate renal
failure and pt received CVVH on [**6-19**]. However, on that day
serial ABGs became more and more acidotic and lactate continued
to rise. Multiple meetings with pt's family members and
[**Name (NI) 8230**] interpreter were held throughout the day to clarify
patient's goals of care. Due to the pt's poor prognosis in the
setting of severe pancreatitis compounded by renal and hepatic
failure, decision was reached to make pt DNR. After continued
discussion through the night, decision was made to withdraw
CVVH. Patient was kept comfortable on maximum sedation and pain
control. Patient's electrolytes continued to worsen, lactate
rose to 14, potassium increased to 7.6 and pt displayed EKG
evidence of hyperkalemia on telemetry, from peaked T waves to
sine-waves to ultimately PEA arrest. Patient expired in the
presence of family at 0632 on [**2113-6-20**].
Medications on Admission:
Amlodipine 5mg daily
Simvastatin 20mg daily
Discharge Medications:
none, expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2113-6-28**]
|
[
"E878.8",
"518.81",
"276.2",
"571.5",
"997.4",
"995.92",
"584.5",
"401.9",
"038.9",
"V02.61",
"577.0",
"276.7",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"39.95",
"38.95",
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9587, 9596
|
6373, 9455
|
342, 364
|
9647, 9656
|
2823, 6350
|
9712, 9886
|
2317, 2335
|
9549, 9564
|
9617, 9626
|
9481, 9526
|
9680, 9689
|
2350, 2804
|
281, 304
|
1642, 1974
|
392, 1624
|
1996, 2218
|
2234, 2301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,127
| 188,583
|
35519
|
Discharge summary
|
report
|
Admission Date: [**2153-3-14**] Discharge Date: [**2153-4-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Post-Operative MI
Major Surgical or Invasive Procedure:
Cardiac catheterization
Dobhoff
Nasogastric tube
PEG placement
Thoracentesis
History of Present Illness:
Mr. [**Known lastname **] is an 86 y/o Male with hypertension, hyperlipidemia,
and h/o ruptured AAA in [**2146**] who was admitted to NEBH on [**2153-3-12**]
for elective right total hip replacement for osteoarthritis. His
post-operative course was complicated by rapid afib with RVR to
140s on post-op day on [**2153-3-13**] accompanied by hemodynamic changes
and SBPs in the 70s. He reportedly did not have any chest pain
throughout. ECG from this time showed deep ST depressions in
precordial leads, and by notes posterior leads did not show STE.
CK returned at peak of 1516 / MB 127.90 / Trop I 23.34. He was
loaded with amiodarone and started on amio gtt, with improvement
in heart rate control and conversion into sinus rhythm.
However, he developed hypoxia and ongoing hypotension, and was
started on dopamine 2mcg/min with improvement in SBPs. STD
remained on ECG. He had an associated HCT drop and was
transfused. Platelets dropped to 96. He was transferred to [**Hospital1 18**]
this morning for urgent catheterization and continued care.
He was taken to the cath lab where angiography showed 30% LM
disease, Left Circ with 50% ostial lesion and an eccentric 70%
proximal/long lesion with subtotal occlusion that was felt to be
the culprit lesion. He also had 50% stenosis in the LAD at D1
and D1 had an ostial 50%. The RCA had a 50% mid lesion and
posterolateral branch had subtotal proximal occlusion. Cypher
stents x2 were deployed in the LCx. Following this intervention,
the patient desaturated to 70s% and was intubated. Bedside
echocardiogram showed severe mitral regurgitation. A right heart
cath was performed that showed PA pressures of 60/35 and PCWP of
37. IABP was inserted, and he was brought to the CCU on
phenylephrine infusion for further care.
Past Medical History:
Obtained from Records
Hypertension
Lyperlipidemia
AAA rupture in [**2146**], managed by [**Hospital1 2025**]
BPH
Osteoarthritis
CARDIAC RISK FACTORS:
[ ] Diabetes [x] Dyslipidemia [x] Hypertension
CARDIAC HISTORY:
- CABG: No history
- Percutaneous coronary intervention: NO history
Pacemaker/ICD: No History
Social History:
Patient widowed, closest contact is friend [**Name (NI) **] [**Name (NI) 1356**]
[**Telephone/Fax (1) 80881**]
Tobacco Use: No Current Tobacco Use
Alcohol Abuse: History of 4 drinks per week obtained during
pre-op eval.
Family History:
There is no known family history of premature coronary artery
disease or sudden death. Parents died in 70s.
Physical Exam:
Gen: WDWN elderly aged male in NAD. Intubated and sedated, but
with spontaneous eye opening and movements
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of *** cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs
[**2153-3-14**] 03:44PM BLOOD Glucose-269* UreaN-35* Creat-1.1 Na-133
K-4.2 Cl-106 HCO3-17* AnGap-14
[**2153-3-14**] 03:44PM BLOOD PT-110.4* PTT-150* INR(PT)-15.0*
[**2153-3-14**] 03:44PM BLOOD WBC-14.4* RBC-3.12* Hgb-10.1* Hct-29.0*
MCV-93 MCH-32.3* MCHC-34.9 RDW-16.1* Plt Ct-109*
[**2153-3-14**] 07:42PM BLOOD Fibrino-422* D-Dimer-As of [**12-12**]
[**2153-3-14**] 07:42PM BLOOD ALT-51* AST-418* LD(LDH)-931*
CK(CPK)-2964* AlkPhos-37* TotBili-0.9
[**2153-3-14**] 03:44PM BLOOD CK-MB-163* cTropnT-7.61*
[**2153-3-14**] 07:42PM BLOOD CK-MB-220* MB Indx-7.4*
[**2153-3-14**] Glucose-165* Lactate-3.5* Na-128* K-4.3
Other Labs
[**2153-3-17**] Lactate-1.2
[**2153-3-16**] WBC-16.9* RBC-2.68* Hgb-8.8* Hct-25.0* MCV-93 MCH-32.7*
MCHC-35.1* RDW-17.1* Plt Ct-112*
[**2153-3-25**] WBC-19.9* RBC-2.55* Hgb-8.2* Hct-25.3* MCV-99*
MCH-32.3* MCHC-32.5 RDW-19.3* Plt Ct-391
[**2153-3-26**] WBC-18.1* RBC-2.43* Hgb-7.7* Hct-24.1* MCV-99* MCH-31.7
MCHC-31.9 RDW-19.6* Plt Ct-397
[**2153-3-27**] WBC-17.3* RBC-2.27* Hgb-7.3* Hct-22.9* MCV-101*
MCH-32.0 MCHC-31.6 RDW-20.0* Plt Ct-377
[**2153-3-28**] WBC-17.3* RBC-2.11* Hgb-6.8* Hct-21.6* MCV-102*
MCH-32.2* MCHC-31.4 RDW-21.3* Plt Ct-361
[**2153-3-28**] Hct-25.4*
[**2153-3-31**] WBC-14.4* RBC-2.47* Hgb-8.1* Hct-25.3* MCV-103*
MCH-32.7* MCHC-31.9 RDW-23.4* Plt Ct-265
[**2153-3-27**] Ret Man-10.8*
[**2153-3-29**] Ret Man-5.6*
[**2153-3-31**] Ret Man-10.8*
[**2153-3-15**] ALT-55* AST-374* LD(LDH)-1138* CK(CPK)-2282* AlkPh-35*
TBili-0.8
[**2153-3-28**] ALT-18 AST-20 LD(LDH)-437* AlkPhos-44 TotBili-3.3*
DirBili-0.8* IndBili-2.5
[**2153-3-30**] LD(LDH)-428* TotBili-2.2* DirBili-0.9* IndBili-1.3
[**2153-3-27**] VitB12-305 Folate-3.4 Hapto-<20*
[**2153-3-28**] calTIBC-166* VitB12-290 Folate-5.2 Ferritn-479*
TRF-128*
[**2153-3-31**] Hapto-<20*
[**2153-3-19**] Na-150* K-3.7
[**2153-3-20**] Glucose-113* UreaN-50* Creat-0.9 Na-149* K-3.7 Cl-113*
HCO3-29 AnGap-11
[**2153-3-22**] Na-146*
[**2153-3-31**] Glucose-133* UreaN-29* Creat-0.9 Na-143 K-3.9 Cl-108
HCO3-33* AnGap-6*
[**2153-3-15**] CK-MB-144* MB Indx-6.3*
[**2153-3-30**] Cortsol-27.2*
[**2153-3-27**] Vanco-10.6
[**2153-3-30**] Vanco-37.3*
[**2153-4-5**] 02:01PM PLEURAL WBC-450* RBC-3950* Polys-6* Lymphs-5*
Monos-0 Plasma-4* Meso-6* Macro-74* Other-5*
[**2153-4-5**] 02:01PM PLEURAL TotProt-1.3 LD(LDH)-142 Albumin-LESS
THAN 1
Micro:
Blood cx: negative x8, NGTD x4
PA catheter cx: negative
Urine legionella: negative
Urine cx: negative x2, yeast x3
Sputum cx: SPARSE GROWTH OROPHARYNGEAL FLORA. YEAST, MODERATE
GROWTH.
C diff: negative x2
Pleural fluid: no growth to date
IMAGING/REPORTS:
Cardiac cath [**2153-3-14**]:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel obstructive coronary artery disease. The LMCA had a 30%
distal
stenosis. The LAD had a 50% stenosis at D1. D1 had an ostial 50%
stenosis. The LCX was diffusely diseased and had a 50% ostial
stenosis,
an eccentric 70% proximal stenosis and a long subtotal mid
stenotic
segment. The RCA had a 50% stenosis in the mid portion, and
subtotal
proximal occlusion of the posterolateral branch.
2. Resting hemodynamics after PCI demonstrated elevated PA
pressures at
59/32, and elevated wedge pressure of 38mm Hg. The cardiac
output and
index were 4.92 L/min and 2.24 L/min/m2 respectively, using an
estimated
oxygen consumption of 125 ml/min/m2 (on dopamine).
3. Successful PTCA and stenting of the LCX with a 3.0x33 and a
3.0x8mm Cypher stent that was complicated by poor flow distally
that
improved with IC nicardipine.
4. Successful placement of IABP through LFA.
TTE [**2153-3-14**]:
Moderately depressed left ventricular systolic function (EF
30-35%) consistent with coronary artery disease with moderate to
severe (3+) ischemic mitral regurgitation. Significant aortic
stenosis, not adequately quantified.
TTE [**2153-3-19**]: Left ventricular cavity enlargement with regional
dysfunction c/w CAD. Moderate to severe (3+) mitral
regurgitation. Severe pulmlnary artery systolic hypertension.
Minimal aortic valve stenosis.
Head CT [**2153-3-18**]: No acute intracranial hemorrhage, edema, or mass
effect.
[**2153-3-20**] RLE US: Right popliteal veins not visualized due to
patient's inability for repositioning because of pain.
Otherwise, no evidence of DVT seen in the visualized deep veins
in either right or left lower extremities.
[**2153-3-23**] Chest CT:
1. Bilateral airspace consolidations with air bronchograms
concerning for
pneumonia.
2. Pulmonary edema, improved in comparison to chest x-ray [**3-16**], [**2153**].
3. Small layering bilateral pleural effusions.
4. Punctate high density within the right lower lobe concerning
for
aspiration of barium. Differential considerations include
granuloma within
the atelectatic lung.
5. Left lower lobe collapse.
6. Aortic valvular calcifications.
7. Evidence of prior granulomatous infection.
[**2153-3-26**] R hip films
Status post right THR, in overall anatomic alignment. No
dislocation or
fracture. Nonspecific soft tissue prominence adjacent to the
right thigh --
please note that assessment for hematoma on radiograph is
limited.
[**2153-3-28**] CT A/P:
1. Bilateral pleural effusions, left lower lobe collapse with
multifocal
pneumonia versus aspiration at the lung bases.
2. Extensive vascular calcifications.
3. Cholelithiasis without evidence of cholecystitis.
4. Renal cysts. Right renal non-obstructing calculus without
evidence of
hydronephrosis.
5. Diverticulosis without evidence of diverticulitis.
6. Hematoma within the right gluteus, lateral compartment of the
right thigh and posterior subcutaneous soft tissues. Moderate
fat stranding and soft tissue edema in the right lower extremity
is noted.
CXR [**2153-4-6**]: Since [**2153-4-4**], interstitial markings
increased, suggesting increased interstitial edema. Multifocal
areas of consolidation increased, mostly in the right
paratracheal and left lower lobe region, could be due to
worsening multifocal pneumonia. There is no other change. The
nasogastric tube ends at least in the stomach. Right PICC ends
at least in the upper SVC.
Reports of multiple interval CXRs not included.
Brief Hospital Course:
1. CAD/NSTEMI: Pt was transferred with anterolateral ECG changes
and elevated biomarkers with peak troponin on transfer of 7.61,
peak CK 2900 and peak CKMB 220. He had PCI with Cypher (DES)
stents x 2 to LCx. He was plavix loaded and on bivalirudin
periprocedure. Periprocedurally, he required pressors and IABP
as discussed below. He was continued on ASA 325, plavix 75 and
lipitor 80mg with no further complaints of chest pain. Acute HF
and MR managed as below. Attempted to start lisinopril, and
later captopril, but these were held as they induced
hypotension.
2. ACUTE SYSTOLIC HF: Likely related to ischemic MR plus
inferior/inferolateral wall motion abnormalities. Pt was
intubated for respiratory failure as well as hemodynamic
instability while on pressors and with IABP in place. He was
extubated [**2153-3-17**]. IABP was inserted to help with afterload
reduction to improve MR and also to increase coronary perfusion
pressure through new stents. He was continued on heparin drip
while IABP in place. He was initially on phenylephrine, which
was then changed to dopamine for afterload reduction. Dopamine
and IABP were both weaned by [**2153-3-16**]. Repeat echo showed
persistent MR. [**Name13 (STitle) **] was given IV lasix for diuresis, with typical
dosing of 40mg IV BID-TID. He's was noted to have bordeline low
K. He was noted to be euvolemic prior to discharge and his lasix
was held. If he exhibts signs of volume overload, such as edema,
crackles, dyspnea, lasix may be given. As above, ACE-I was
started then held for hypotension.
3. ATRIAL FIBRILLATION: Patient developed afib post op and was
given amio prior to transfer. This was discontinued on arrival.
He was mostly in sinus, but had several episodes of
afib/flutter. He was initially anticoagulaetd with heparin gtt
which was then changed to therapeutic lovenox SC BID given his
recent postoperative hip status. Anticoagulation was held
[**2153-3-28**] given major bleed (hip hematoma), as discussed below.
After he stabilized, he was restarted on enoxaparin 30mg SC BID.
He should continue this until he has a therapeutic INR from
warfarin (INR>2). He was discharged on warfarin 5 mg qd. Please
note that his nutritional support contains vitamin K, which
could not be removed from the solution. With this in mind we are
discharging him on warfarin 10 mg. He should have his INR
checked on [**2153-4-13**] and adjust the warfarin dose as needed.
He was rate controlled in sinus rhythm with metoprolol, which
was uptitrated to 25 mg PO TID.
4. Fever/MULTIFOCAL PNA: Pt had low grade fevers and
leukocytosis peaking in low 20s. He was intially on levofloxacin
for treatment of presumed UTI given dirty UA although cx data
not positive. Given persistently uptrending WBC, Chest CT was
obtained which was consistent with multifocal PNA. Since he was
recently intubated x approximately 72 hours, he was treated as
VAP with 8 day course of vancomycin/pip-tazo. C diff and blood
cultures were negative. Urine cx only grew yeast. WBC trended
down and he became afebrile. However, on [**4-2**], he spike to 101.8
rectal with persistent tachypnea and sputum production, so
vancomycin/pip-tazo was restarted. The following day, he spiked
to 101, so levofloxacin was added. CXR showed multifocal
infiltrates. ID and pulm were consulted, and felt he most likely
had recurrent aspiration, rather than a new infection. He was
made NPO as discussed below. He also had a thoracentesis, with
removal of 1L transudative fluid, although without clinical
improvement. His vancomycin and levquin was stopped, and zosyn
was continued for total of 10day course. Last day of zosyn is
[**2153-4-11**]
5. Status post total hip replacement/right hip hematoma: Pt
transferred s/p right total hip replacement. We contact[**Name (NI) **] his
OSH orthopedist who recommended weight bearing as tolerated with
posterior precautions. He was seen by physical tharapy with
initially no complications. Ortho was later consulted given
concern for hematoma with declining HCT and hematoma on exam.
They did not recommend any further procedures unless he
developed sciatic nerve compression (foot drop). They agreed
with holding anticoagulation and DVT ppx while pt had evolving
hematoma. Anticoagulation was held and then restarted at
prophylactic doses. He was transfused 2 units [**3-28**] then required
no further transfusions. Hematoma slowly resolved and HCT
stabilized at 25 with holding anticoag briefly.
6. Anemia: Pt had anemia on admission which was consistent with
inflammation or anemia of chronic disease. HCT remained low and
trended down so repeat studies were done which showed hemolysis
and likely bleed from hematoma. B12 WNL. Folate borderline low
so he was started on folic acid 5mg daily as recommended by
hematology. He was transfused initially after PCI then
transfused 2 units again [**3-28**] for bleed from hip hematoma. HCT
subsequently remained stable and he required no further
transfusions.
7. FEN: Pt developed hypernatremia with sodium peak of 150 which
resolved with free water replacement. He was seen by speech and
swallow with diet advanced slowly, but it was felt he was not
taking in adequate nutrition, so a Dobhoff tube was placed and
he was started on suppplemental tube feeds. Given the continued
aspiration concern, he was made strict NPO except tube feeds.
His Dobhoff occluded, and given the continued need for tube
feeds, a PEG tube was placed without complication.
Medications on Admission:
EcASA 81mg PO daily
Lopressor 25mg PO daily
Lipitor 20mg PO daily
Flomax 0,4mg PO daily
Ditropan 5mg PO daily
MVI 1 tab PO daily
Zantac 150mg PO daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Clopidogrel 75 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) Inhalation
Q6H (every 6 hours).
8. Guaifenesin 100 mg/5 mL Syrup [**Month/Year (2) **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
9. Folic Acid 1 mg Tablet [**Month/Year (2) **]: Five (5) Tablet PO DAILY (Daily).
10. Enoxaparin 30 mg/0.3 mL Syringe [**Month/Year (2) **]: Thirty (30) mg
Subcutaneous Q12H (every 12 hours): until he has a therapeutic
inr on warfarin.
11. Olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Year (2) **]: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
14. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for hip pain.
15. Warfarin 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4
PM: [**2153-4-13**]- check INR and adjust PRN .
16. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Month/Day/Year **]: One (1) Intravenous Q8H (every 8 hours) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
CHF
Hip fracture complicated by hematoma
NSTEMI
Afib with RVR
VAP
Anemia of chronic disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after you had hip surgery and suffered a heart
attack for which you were treated with medications and a
procedure that inserted a stent in your heart. Your course was
complicated by intubation for several days and then pneumonia.
You were treated with antibiotics including vancomycin and
zosyn. Also you had a tube inserted in your stomach through your
belly. This was done in order to provide you nutritional
support.
You are being discharged to a rehab facility. Please follow up
with your regular doctor within the next 7-10 days. Also follow
up with our cardiologist, Dr [**Last Name (STitle) 80882**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please return to the ED if you have fever, chills, chest pain,
weakness, confusion, diarrhea, palpitations or any symptom that
concern you
Followup Instructions:
Please follow-up with your regular doctor, [**Last Name (un) 32791**],[**Doctor First Name 275**] B.
[**Telephone/Fax (1) 9386**].
Please follow up with your cardiologist: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2153-5-30**] 11:20
Completed by:[**2153-4-16**]
|
[
"599.0",
"785.51",
"599.70",
"292.81",
"285.29",
"285.1",
"396.2",
"E937.8",
"507.0",
"707.03",
"600.01",
"V43.64",
"E878.1",
"707.22",
"518.81",
"788.20",
"287.4",
"486",
"428.0",
"401.9",
"414.01",
"998.12",
"428.41",
"E879.8",
"715.90",
"997.31",
"272.4",
"276.0",
"867.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"38.93",
"36.07",
"96.72",
"34.91",
"37.23",
"37.61",
"43.11",
"96.6",
"00.66",
"00.46",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
17425, 17499
|
9901, 15360
|
279, 357
|
17635, 17643
|
3722, 9878
|
18559, 18908
|
2744, 2853
|
15561, 17402
|
17520, 17614
|
15386, 15538
|
17667, 18536
|
2868, 3703
|
222, 241
|
385, 2159
|
2181, 2491
|
2507, 2728
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,729
| 192,105
|
42362
|
Discharge summary
|
report
|
Admission Date: [**2125-1-28**] Discharge Date: [**2125-2-22**]
Date of Birth: [**2041-4-3**] Sex: F
Service: NEUROLOGY
Allergies:
Levofloxacin / ciprofloxacin / Codeine / Erythromycin Base /
Penicillins / sulfa drugs / Tetracycline / Theophylline
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
shortness of breath, myasthenic crisis
Major Surgical or Invasive Procedure:
R internal jugular line placement
Chest tube placement
Plasmapheresis
History of Present Illness:
The patient is an 87 year old woman with a recent diagnosis
of myasthenia [**Last Name (un) 2902**], CAD s/p MI and stenting, HTN, HL, and
pulmonary embolism on warfarin presenting with two days of
progressive weakness, bulbar symptoms, and respiratory distress.
This limited history was provided by the patient just prior to
intubation. She was diagnosed with myasthenia [**Last Name (un) 2902**] in
[**2124-9-28**] and was started on Prednisone and Pyridostigmine, although
she does not recall the doses. She reportedly had a dose change
recently (possibly an increase). One day prior to admission, the
patient felt it was very difficult to get out of bed. She does
recall also finding it difficult to swallow and difficult to
clear her throat of the mucus that was accumulating there. She
noticed her voice was becoming more muffled. Her breathing
became
progressively more difficult and was especially bad today,
prompting her hospitalization at [**Hospital3 **] Hospital. There, her
NIF was noted to be -18, and a transfer to [**Hospital1 18**] was requested.
Her NIF was -20 at arrival to [**Hospital1 18**]. Besides these
aforementioned
symptoms, she has also had some diplopia but it has not been as
apparent in the past two days. She denies any recent fevers,
chills, rigors, cold symptoms, nausea, diarrhea, chest pain,
headache, or other infectious symptoms. She reports adherence to
her medication regimen but does not recall all of the doses. She
lives alone.
The review of systems is pertinent for the findings above but
was
otherwise limited at this time.
Past Medical History:
[] Neurologic - Myasthenia [**Last Name (un) **] (dx [**2124-9-28**], likely followed
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90507**], [**Telephone/Fax (1) 91749**] vs [**Telephone/Fax (1) 83499**])
[] Cardiovascular - CAD/MI s/p stent, HTN, HJL
[] Pulmonary - Pulmonary embolism (on warfarin, unknown date)
Social History:
Lives alone. Has at least one daughter [**Name (NI) **], one son who is a
project manager at [**Hospital1 18**].
Family History:
non-contributory
Physical Exam:
Physical Examination on Admission:
VS T: not recorded HR: 90 BP: 150/108 RR: 17 SaO2: 96% 2LNC
General: Seated in bed, mild respiratory distress. / Head:
NC/AT,
no conjunctival icterus, no oropharyngeal lesions / Neck:
Supple,
no nuchal rigidity / Cardiovascular: RRR, no M/R/G / Pulmonary:
Equal air entry bilaterally, shallow breaths, no crackles or
wheezes, weak cough / Abdomen: Soft, NT, ND, +BS, no guarding /
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses / Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Recalls a coherent
history. Follows commands, midline and appendicular. Language
fluent with intact repetition and verbal comprehension. Normal
prosody. No paraphasic errors. Mild dysarthria. No neglect.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to
confrontation. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3
without deficits to light touch bilaterally. [VII] No facial
asymmetry, but mild weakness with forced eye closure. [IX, X]
Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5
bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 4- 5 4- 5 x 4- 4+ 4+ 5 5
x
R 4- 5 4- 5 x 4- 4+ 4+ 5 5
x
- Sensory - No deficits to light touch bilaterally.
- Reflexes - Deferred
- Coordination - Unable to assess at the time of examination.
- Gait - Unable to assess at the time of examination.
Physical Exam on Discharge:
************
Awake, alert, oriented, speech fluent, no dysarthria, EOMI
without diplopia, no facial weakness/asymmetry, palate elevation
and tongue protrusion midline, neck flexion 5-/5, neck extension
[**6-2**], deltoids 5-/5, biceps [**6-2**], triceps 5-/5, iliopsoas 5-/5.
Pertinent Results:
Admission labs:
pH 7.5, PCO2 31, PO2 96, HCO3 26, SaO2 100% (intubated)
WBC 98, Hgb 14.8, Plt 263, MCV 86, INR 1.9, PTT 48.3
Na 141, K 3.8, Cl 102, HCO3 26, BUN 16, Cr 0.8, Glu 115, Ca 9.9,
Mg 1.9, Phos 2.7, BNP 692, Trop 0.02
UA - prot 30, otherwise negative
UA [**2-6**]: WBC >182, RBC 5, few bacteria, pos nitrite, lg leuk
esterase
Urine culture: E. coli
CXR [**2125-1-28**]:
IMPRESSION:
1. Endotracheal tube tip projecting over the low trachea.
2. Small left pleural effusion.
3. Bibasilar atelectasis or scarring. Attention to right
cardiophrenic angle opacity is recommended to exclude early
infiltrate.
CXR [**2125-1-29**]:
1. Interval placement of right IJ catheter, with tips over
distal SVC.
2. New moderate-to-moderately large right lung pneumothorax with
some degree of collapse. Mediastinum remains midline.
CXR [**2125-1-31**]:
1. Interval development of bilateral pleural effusions, greater
on the right than the left.
2. Endotracheal tube approximately 2.2 cm from the carina.
3. Chest tube in position within the right chest.
CT torso [**2125-2-1**]:
1. No evidence for retroperitoneal hematoma.
2. Right chest wall hematoma along the chest tube.
3. High-density right pleural effusion concerning for
hemothorax. Please
note that the chest tube does not appear to reach that aspect of
the pleural effusion.
4. ET tube with its tip at the carina. The tube should be
retracted about 2 cm.
5. A 4-mm nonobstructing left renal stone.
6. Extensive colonic diverticulosis without evidence for
diverticulitis
CXR [**2125-2-2**]:
The pigtail catheter is in place as well as the right chest
tube. There is no appreciable pneumothorax demonstrated on the
right and minimal pleural
effusions seen, substantially improved since the prior
radiograph obtained
earlier in the morning. The NG tube tip is in the stomach. The
ET tube tip
is 2 cm above the carina. Left retrocardiac consolidation is
demonstrated,
unchanged since the prior study. There is interval improvement
of vascular
engorgement.
CXR [**2125-2-5**]:
1. Stable moderate right and small left pleural effusions.
2. Improvement in bibasilar atelectasis.
CXR [**2125-2-8**]:
INDICATION: Pigtail clamped for pneumothorax.
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. No right-sided pneumothorax is visible. The position of
the right
pigtail catheter is constant. Unchanged extent of bilateral
pleural
effusions. Unchanged bilateral areas of atelectasis and signs of
mild fluid overload.
[**2-16**] CT Torso
IMPRESSION:
1. New large right retroperitoneal hematoma, as detailed and
described above,
with anterior displacement of the right kidney and involvement
of the right
psoas muscle.
2. Interval removal of right sided chest tube, with right
decreasing and
evolving hemorrhagic pleural effusion. Slight increase in size
of right simple
pleural effusion.
3. Bilateral, right greater than left, lower lobe atelectasis,
with possible
right lower lobe aspiration.
4. Anemia.
[**2-6**] Video Swallow
NDICATION: 82-year-old woman with myasthenia [**Last Name (un) 2902**] crisis
status post
plasmapheresis. Evaluate swallowing ability.
COMPARISONS: None.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was
performed in
conjunction with the speech and swallow division. Multiple
consistencies of
barium were administered.
FINDINGS: After mild swallowing delay, barium passes freely
through the
oropharynx and esophagus without evidence of obstruction. Trace
penetration
was seen with thin liquids, but otherwise no gross aspiration or
penetration.
A barium tablet passes freely into the stomach without holdup.
For details,
please refer to speech and swallow division note in OMR.
IMPRESSION: Trace penetration with thin liquids.
CT Torso [**2125-2-18**] - IMPRESSION:
1. Large right retroperitoneal hematoma, stable from the most
recent
examination performed today. No definite source of bleeding is
identified.
2. Small bilateral pleural effusions with adjacent compressive
atelectasis.
The right pleural effusion measures slightly higher than simple
fluid in
Hounsfield units suggesting complexity .
3. Severe stenosis at the origin of the celiac axis.
4. Right chest wall soft tissue lesion measuring 2.2 x 5.4 cm.
Findings are
new from [**2125-2-1**] examination. Soft tissue lesion may be
resolving
hematoma given interval chest tube placement and removal.
Attention on
followup is recommended.
[**2125-2-14**] Hgb 9.8 (after 2 units pRBCs transfused)
[**2125-12-17**] Hgb 9.3
[**2125-2-16**] Hgb 10.4
[**2125-2-21**] Hgb 9.3, Hct 27.4
[**2125-2-21**] Hgb 9.9, Hct 29.6
[**2125-2-22**] Hgb 9.3, Hct 27.7
Brief Hospital Course:
83yoW h/o recent dx myasthenic [**Last Name (un) 2902**], CAD s/p stent, recent PE
on warfarin who presents in myasthenic crisis with respiratory
distress, dysarthria, and dysphagia progressing over at least
two days likely related to a prednisone dose change (?initiation
at 50mg daily). Her NIF was low at -18 to -20 and thus the
patient was intubated in the ED and transferred to the Neuro ICU
for further care. She was started on plasmapheresis on [**2125-1-29**],
and prednisone was increased to 70mg daily.
[] Myasthenia [**Last Name (un) **] - She was initially intubated for
respiratory support. She was treated with five days of
plasmapheresis from [**Date range (1) 91750**]/12. The neuromuscular service was
consulted and made recommendations regarding prednisone and
pyridostigmine uptitration. Her NIF/FVCs gradually improved to
the -30 to -42 range and 1.4-1.7L range, respectively. She
remained stable from a myathenia standpoint after her ICU
course.
[] Hemothorax/Chest wall hematoma - The patient had a
right-sided CVC placed which resulted in a right chest wall
hematoma and right hemothorax with partial lung collapse. The
Thoracic surgery service was consulted and placed a thoracostomy
to drain the hematoma. She was mechanically ventilated from [**1-28**]
to [**2125-2-3**] with successful extubation. The hemothorax/hematoma
issue resolved with stable Hgb/Hct; the chest wound was
frequently reevaluated by Thoracic surgery. She was transfused
multiple units of pRBCs.
[] Retroperitoneal Hemorrhage - The patient on [**2-16**] experience
an acute drop in blood pressure and lightheadedness/dizziness
which occurred with a 2 point drop in Hgb; a right sided RP
hematoma was identified. This occurrd while on enoxaparin for
anticoagulation for her prior DVT/PE. This medication was
stopped. Acute Care Surgery was consulted and followed her for
the RP hematoma, but the bleed tamponaded spontaneously and did
not result in any further drop in Hgb. She was transfused 4
units of pRBCs.
controlled.
[] Occult blood positive stools - While her hemothorax was
addressed, her Hgb/Hct continued to drift and she was found to
have occult blood positive stools. GI was consulted and deferred
inpatient endoscopy and colonoscopy at this time given her prior
results and the unlikely possibility of acute intervention. She
was started on Ferrous sulfate for iron repletion with suspicion
for iron deficiency anemia. Her prior endoscopy/colonoscopy at
[**Hospital3 **] Hospital in [**6-/2124**] showed gastritis, diverticulosis,
and internal hemorrhoids, all of which could be sources of GIB.
This could be reevaluated as an outpatient if indicated.
[] Anticoagulation - She was anticoagulated for about 4 months
for a DVT/PE provoked suspected to be provoked by immobility and
has suffered multiple life-threatening bleeding complications,
the decision was made to stop all anticoagulation but to
continue aspirin for her coronary artery disease/coronary stent.
[] Urinary tract infection - UA on [**2-4**] was grossly positive with
culture growing pan-sensitive E. coli. She was started on
ceftriaxone IV on [**2-6**]. She had one fever to 101.9 on the
evening of [**2-6**] and was subsequently afebrile without
leukocytosis. Blood and sputum cultures were negative. She
completed the course of ceftriaxone.
[] Nutrition - She initially had dysphagia, but on repeat
evaluation she could tolerate regular consistency diet and thin
liquids.
PENDING STUDIES: NONE
TRANSITIONAL CARE ISSUES:
[] Hemoglobin/Hematocrit - Consider checking a CBC every [**4-2**]
days to monitor her blood counts given her recent complication
of hemothorax/chest wall hematoma and retroperitoneal hematoma
and her prior positive fecal occult blood tests.
[] NIF/VC - Have respiratory monitor her NIF and VC as indicated
to measure for improvement in her respiratory status.
[] Anticoagulation - Anticoagulation has been stopped due to her
multiple bleeding complications; she received about 4 months of
anticoagulation for a DVT/PE believed to be provoked by
immobility from her myasthenia. She was evaluated for IVC filter
placement which was deemed not beneficial in her case.
[] Neuromuscular followup - The patient needs to followup with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**] at [**Hospital1 69**] in
[**Location (un) 86**] for close monitoring and management of her myasthenia
[**Last Name (un) 2902**]. The current recommendation from Dr. [**Last Name (STitle) 1206**] is to
continue Prednisone 70mg daily until [**3-2**], then decrease
to 60 mg daily for two weeks, and then decrease to 40 mg daily
for two weeks (and continue at that dose until additional
assessments are made). She should continue Pantoprazole [**Hospital1 **] and
Bactrim. She may continue to require an insulin sliding scale
for glycemic control.
[ ] Ambulation/PT/OT - She has a good chance of functional
recovery and achieving some degree of independence. Please
pursue PT/OT and evaluate her for home services.
Medications on Admission:
Warfarin (alternating 3mg and 4mg, patient unsure
which days)
Pyridostigmine (taking 6x daily, q2h, unknown dose),
Prednisone (3 tabs qAM and 2 tabs qNoon, unknown dose),
Duloxetine (unknown dose)
Atorvatastin 10
Metoprolol succinate 100 daily
Aspirin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): for
ulcer prevention and GERD.
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): for Pneumocystic infection prevention.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. prednisone 20 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
70mg daily, for treatment of myasthenia [**Last Name (un) 2902**].
11. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. insulin regular human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): Q6H, dose according to
sliding scale, glucose 0-70 mg/dL proceed with hypoglycemia
protocol, 71-150 mg/dL give 0 Units,
151-200 mg/dL give 4 Units, 201-250 mg/dL give 6 Units,
251-300 mg/dL give 8 Units, 301-350 mg/dL give 10 Unit, > 350
mg/dL Notify M.D.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day): for suspected iron deficiency.
15. pyridostigmine bromide 60 mg Tablet Sig: 0.75 Tablet PO Q6H
(every 6 hours): for relief of myasthenia symptoms.
16. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
Primary Diagnosis: Myasthenia [**Last Name (un) 2902**] (acute exacerbation)
Secondary Diagnosis: Chest wall hematoma, Hemothorax, Coronary
artery disease, Retroperitoneal hematoma, Hemorrhagic shock,
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: Awake, alert, oriented, speech fluent, no
dysarthria, EOMI without diplopia, no facial weakness/asymmetry,
palate elevation and tongue protrusion midline, neck flexion
5-/5, neck extension [**6-2**], deltoids 5-/5, biceps [**6-2**], triceps
5-/5, iliopsoas 5-/5.
Discharge Instructions:
Dear Ms. [**Known lastname 91751**],
You were admitted to [**Hospital1 69**] on
[**2125-1-28**] with difficulty breathing and swallowing due to an acute
exacerbation of your myasthenia [**Last Name (un) 2902**]. You were intubated and
placed on a breathing machine for the first several days to help
support your breathing. You were treated with prednisone
(corticosteroids) and plasmapheresis and improved on this
treatment.
During your hospitalization, there were multiple complications
including bleeding into the right side of your chest (treated
with a chest tube or "thoracostomy"), a urinary tract infection,
and bleeding into the "retroperitoneal space" on the right side
of your back/hip. Your anticoagulation (warfarin and Lovenox)
were stopped due to these bleeding complications; at this time,
the benefits of this treatment do not exceed the considerable
risks. You will continue to take your aspirin, however.
We made the following changes to your medications:
1. DISCONTINUE Warfarin
2. CHANGE Prednisone to 70 MG DAILY on a tapering schedule.
3. CHANGE Pyridostigmine to 45 MG EVERY 6 HOURS.
4. START Bactrim SS 1 tablet daily for prophylaxis against
Pneumocyistic jirovecii infection (while taking Prednisone, a
recommendation of our Neuromuscular physicians).
5. START Pantoprazole 40 mg twice daily for protection of your
stomach from possible ulceration or reflux disease.
Otherwise, continue your other prescribed medications.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
Please followup with Dr. [**Last Name (STitle) 90507**] and Dr. [**Last Name (STitle) 22149**] as listed below.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
NEUROLOGY/NEUROMUSCULAR Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 44**] Date/Time: [**2125-3-2**] 2:30, [**Hospital Ward Name 23**] Building,
[**Location (un) 858**], [**Location (un) 830**], [**Location (un) 86**], [**Numeric Identifier 718**]
NEUROLOGY: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90507**] ([**Hospital3 **] Health Care, Neurology),
phone [**Telephone/Fax (1) 90508**], Appointment: [**2125-3-6**] at 11:00AM
(You also have a [**Month (only) 958**] appointment still scheduled; if your time
at the Rehabilitation center at [**Hospital1 **] [**Hospital3 **] extends
beyond [**3-6**], you can call the office to reconfirm the
[**Month (only) 958**] appointment time.)
PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22149**], appointment: [**2125-4-9**] at 10:30 AM, phone [**Telephone/Fax (1) 69695**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
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79,452
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Discharge summary
|
report+addendum
|
Admission Date: [**2183-2-11**] Discharge Date: [**2183-2-16**]
Date of Birth: [**2127-11-28**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
s/p cardiac cath with BMS to prox RCA, hypertensive urgency
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
55 yo W with Hx of CAD s/p PCI with BMS to RCA in [**4-13**], also PVD
s/p R SFA stenting, dCHF, IDDM, HTN, HLD and active tobacco use
who presented to OSH on [**2183-2-7**] with acute dyspnea and chest
discomfort, had pulmonary edema on CXR and elevated troponins
(peak at 0.67). Treated with IV Lasix 40 [**Hospital1 **] with resolution of
symptoms, and began on heparin gtt (which was d/c in setting of
g+ stools). Per report, repeat echo revealed preserved EF.
.
At OSH Pt had one episode of agitation and disorientation the
morning of transfer. Head CT was negative for ICH. She was
brought to [**Hospital1 18**] where she underwent cardiac catheterization and
had BMS placed to a 60% proximal RCA lesion with positive
resting gradient by pressure wire. During the procedure her
blood pressure was extremely difficult to control. She was
started on a Nitroglycerin gtt at 180 mcg, then Nipride gtt, as
well as given IV labetalol bolus (dose unspecified) to keep her
sBP<180. She had normal b/l renal arteries. She required 4L of
O2 by facemask to keep her oxygen saturations in the mid 90s.
Her LVEDP was 30. She is being transferred to the CCU for
management of her hypertension and CHF.
.
Currently she reports feeling well. She denies any chest pain,
dyspnea, fever or chills. No abdominal pain or pain at cath
site.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: prior Non-Q wave MI in [**4-13**]
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: Cardiac cath in [**4-13**] with
BMS placed to RCA (severe mid 90% lesion and diffuse 70% mid
disease)
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY: as above, additionally
-peripheral neuropathy
-bilateral carotid stenosis (50-60%)
-osteomyelitis/gangrene of right fourth toe s/p amputation in
[**2182-5-4**]
-s/p right SFA stenting in [**4-13**]
-s/p L iliac angioplasty in [**2167**]
-cataract surgery
Social History:
- Retired nurse
- Exercises daily
- Tobacco history: currently uses [**2-6**] pack/week since age 16
- ETOH: denies
- Illicit drugs: denies
Family History:
- Father had CAD, MI in 60s, died from complications of cancer
Physical Exam:
VS: 98.2, 69, 174/50, 23, 97%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at angle of mandible while supine.
CARDIAC: RR, normal S1, S2. No S3 or S4. +SEM loudest @ LUSB, +
carotid bruits
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB of anterior fields
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e, + right femoral bruit
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pulses: faint DP & PT pulses b/l
Pertinent Results:
Right and Left Heart Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary artery disease. The LMCA was
free of angiographically significant disease. There was mild
paquing of the LAD with a 60% ostial stenosis leading to a small
D2. The LCx had diffuse insignificant plaquing. The RCA had a
40% ostial lesion and a 60% proximal stenosis. Pressures were
damped with a 5-Fr catheter. The gradient across the lesion by
pressure wire was hemodynamically significant at rest (32mmHg).
2. Limited resting hemodynamics revealed elevated right and left
heart filling pressures. There was moderate pulmonary artery
hypertension. The cardiac output and index were normal as was
the SVR. The PVR was slightly elevated. There was severe
systemic arterial hypertension despite aggressive IV vasodilator
therapy (SBP=184mmHg). On careful pullback from the LV there was
no pressure gradient across the aortic valve.
3. Selective angiography of the bilateral renal arteries
revealed no angiographically significant disease.
4. Successful PCI with BMS to RCA.
5. [**Hospital **] medical therapy and BP control.
6. Watch renal function closely.
.
FINAL DIAGNOSIS:
1. NSTEMI with one vessel coronary artery disease.
2. Severe systemic arterial hypertension
3. Moderate diastolic dysfunction
4. No renal artery stenosis
5. Successful FFR guided PCI to proximal RCA.
.
LOWER EXTREMITY ULTRASOUND: Targeted Grayscale and Doppler
son[**Name (NI) **] of the right common femoral artery and vein was
performed. There is normal flow and waveforms within the veins.
There is no evidence of pseudoaneurysm.
Brief Hospital Course:
55 yo W with PMHx of CAD s/p POBA to LAD in 99, BMS to RCA in
[**4-13**], PVD (s/p L iliac angio & R SFA stenting), HTN, HLD, IDDM
presenting to OSH with elevated troponins and acute on chronic
diastolic CHF, transferred for cath where she received BMS to
prox RCA, and had significantly elevated blood pressures
necessitating nitroglycerin and nipride gtts
.
# Hypertensive Urgency: Patient had been receiving her home
antihypertensive medication regimen at the OSH. Per report, the
day prior to transfer her pressures were elevated and
supplemental labetalol was given. During catheterization the
patient was maxed on a nitroglycerin gtt, then started on a
nitroprusside gtt to keep her SBPs <180. Her renal arteries
appeared normal. Based on the patient's description of the
procedure, a component of her elevated BPs was likely secondary
to anxiety. On arrival to the CCU she denied any symptoms of end
organ damage. Given her baseline poor renal function we
discontinued the Nipride gtt and re-started the Nitroglycerin
gtt, as well as re-started her outpatient antihypertensive
regimen (except for Lisinopril during [**Last Name (un) **]). She was easily
weaned off the Nitroglycerine gtt and her blood pressure
remained well controlled. On discharge we asked the patient to
hold her Lisinopril until she follows up with her providers.
.
# Acute on chronic diastolic CHF: Patient presented to OSH with
acute dyspnea, and had CXR findings of pulmonary edema and
elevated troponin (peak 0.6, CKMB flat). She was diuresed with
IV Lasix 40 [**Hospital1 **] with subsequent improvement in her symptoms. An
echocardiogram obtained at the OSH revealed preserved EF of 55%,
mild MR, mild TR, mod elevated PAP, and mild LVH. Unclear
trigger as the patient denied medication non-compliance, dietary
indiscretion, or symptoms to suggest infection. She was
transferred to our hospital and underwent cardiac
catheterization where her LVEDP was noted to be 30. BNP was
elevated at 2891. Clinical exam revealed bibasilar rales. She
was given IV Lasix boluses and diuresed over her hospital
course. She initially required supplemental oxygen to maintain
adequate oxygen saturations, but that improved with diuresis.
She was continued on Metoprolol, but Lisinopril was held given
her acute on chronic kidney injury. She was discharged on a
decreased dose of Lasix 40 mg PO daily.
.
# Acute on Chronic Kidney Injury: Likely secondary to contrast
nephropathy given her baseline poor renal function and history
of diabetes, despite pre and post-cath hydration. She received
160 cc dye load during the catheterization. Her ace-inhibitor
was held. Her creatinine was 1.2 on admission (baseline likely
1.5 based on OSH records), peaked at 4.3, and began to trend
down. Her creatinine was 3.3 at discharge. She was making good
urine output, and will follow up for a lab check as outpatient.
.
# CAD/PVD: The patient has a long history of diffuse vascular
disease. She presented to OSH with elevated troponins (peak
0.62) in setting of CHF and chest discomfort. CKMBs remained
flat. She was transferred for cardiac catheterization which
revealed diffuse, but non-critical plaquing of LAD and LCx, and
60% proximal RCA stenosis, for which a BMS was placed. Her EKG
remained stable from baseline. Post-cath check was notable for a
bruit at entry site not documented on admission physical.
Ultrasound was obtained and negative for pseudoaneurysm. She was
continued on ASA 325, Plavix 75, and Atorvastatin 80 daily. She
was also given a prescription for SL Nitro to take for chest
pain in the future.
.
# Agitated Delirium: The patient had one episode of agitation
and disorientation during her stay at the OSH. Given she had
been on a heparin gtt, a head CT was obtained and negative for
ICH. During her stay in the ICU she had a few episodes of
transient disorientation (often after awakening), and became
quite tearful, agitated, and distrustful of the care she was
receiving. We performed a delirium work up (B12, folate, TSH,
RPR), as well as obtained a urinalysis, which were negative for
gross abnormalities. According to her family members, this was
new behavior; however, they had been noticing mild increased
confusion for some time now. Psychiatry was consulted and
recommended delirium work-up, frequent reorientation, transfer
out of ICU, and Haldol if needed for agitation. Haldol was not
needed. Her symptoms improved.
.
# Rhythm: Monitored on telemetry. Remained in sinus rhythm,
occasionally asymptomatic sinus bradycardia with rate in the
50s.
.
# IDDM: Diagnosed at age 14. Has many microvascular and
macrovascular complications including retinopathy, neuropathy,
nephropathy, CAD and PVD. Hgb A1c of 9.9 indicating need for
tighter control. We monitored her FSBG levels, provided
diabetic, consistent-carbohydrate diet, and continued her on her
outpatient regimen of Glargine and Humalog SSI.
.
# Chronic Normocytic Anemia: History of guaiac + stools, but
prior evaluation of GI tract has been negative. Takes Fe
supplement as outpatient, which was held on admission, and
re-started at discharge. Her hematocrit was closely monitored
and remained relatively stable. Given that her Fe studies
reflected iron deficiency, this should continued to be monitored
and evaluated by her Primary Care Physician after discharge.
.
# HLD: Continued Atorvastatin 80 daily.
.
# Peripheral Neuropathy: Initially continued Lyrica 100 TID,
then discontinued it in the setting of her acute kidney injury.
Her pain was controlled with tramadol and low dose oxycodone.
Upon discharge she was given a two day prescription for Percocet
for pain relief, then told to re-start her Lyrica.
.
# GERD: We initially held her outpatient Omeprazole and started
renally-dosed Famotidine given the patient's history of being on
Plavix. Famotidine was discontinued in the setting of acute
kidney injury. Upon discharge she was restarted on Omeprazole.
This should be discussed with her outpatient Cardiologist.
.
# Risk Factor Modification: The patient was encouraged to stop
smoking tobacco. We provided her with a nicotine patch to reduce
cravings. Social Work was consulted for smoking cessation
counseling.
Medications on Admission:
-Metoprolol 75 [**Hospital1 **]
-Lisinopril 10 [**Hospital1 **]
-Norvasc 30 AM, 60 PM
-Prilosec 40 qd
-Lantus 26 units
-Novolog SSI
-Aspirin 325 daily
-Plavix 75 qd
-Lasix 80 daily
-Lipitor 80 daily
-Percocet 5/325 q6
-Lyrica 100 TID
-Slow Fe daily
Discharge Medications:
1. Outpatient Lab Work
Please have Chemistry 7 drawn (sodium, potassium, chloride,
bicarbonate, BUN, creatinine and glucose). Please fax these
results to Dr. [**Last Name (STitle) 39822**] [**Name (STitle) **] at fax # [**Telephone/Fax (1) 19406**] (phone #
[**Telephone/Fax (1) 8506**])
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Lantus 100 unit/mL Solution Sig: 26 units daily Subcutaneous
once a day.
5. Novolog 100 unit/mL Solution Sig: One (1) Subcutaneous once
a day: Use per home insulin sliding scale.
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: [**Month (only) 116**] repeat two
times. If you need to use this medication more than once, please
call your physician.
[**Name Initial (NameIs) **]:*30 tablets* Refills:*0*
9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-9**]
hours for 2 days: Please continue for two days.
[**Month/Day (3) **]:*10 Tablet(s)* Refills:*0*
10. iron 325 mg (65 mg Iron) Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day: please restart home
dose of iron supplement.
11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
[**Month/Day (3) **]:*30 Tablet(s)* Refills:*0*
13. Lyrica 100 mg Capsule Sig: One (1) Capsule PO three times a
day: please start in two days.
14. nifedipine 30 mg Tablet Extended Release Sig: 1 in the
morning, 2 in the evening Tablet Extended Release PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
acute on chronic diastolic congestive heart failure
hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for management of heart failure. On transfer
to [**Hospital1 69**], a cardiac
catheterization revealed coronary artery disease. A bare metal
stent was placed in one of the arteries supplying your heart.
You were admitted to cardiac intensive care unit for management
of elevated blood pressures after your procedure. You were given
diuretics to help relieve some of the excess fluid that had
collected while in heart failure. While admitted, you developed
acute kidney injury likely from the contrast dye that was
injected into your arteries during the catheterization, a not
uncommon side effect. Your renal function was
improving at the time of discharge. It will be important for
you to follow-up closely with your primary care physician this
week regarding your hospitalization and kidney function.
The following medication changes were made:
1. Please STOP taking Lisinopril until your primary care
physician or cardiologist allows you to restart. This medication
was held due to your acute kidney injury.
2. Please DECREASE your dose of Lasix to 40mg daily and discuss
this change with your physicians.
3. Please take Percocet for pain management for 2 more days
4. Please RESTART Lyrica in 2 days.
5. Please START sublingual nitroglycerin for management of chest
pain. If you need to use this medication more than once in a
row, or with increasing frequency, please contact your physician
[**Name Initial (PRE) 2227**].
4. Please DISCONTINUE Norvasc
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call your cardiologist Dr. [**First Name11 (Name Pattern1) 518**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 8579**] to schedule
an appointment within the next 1-2 weeks for a follow-up
appointment.
Address: [**State **], [**Apartment Address(1) 39823**], [**Location (un) **], [**Numeric Identifier 23881**]
Phone: ([**Telephone/Fax (1) 39824**]
Please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for
follow-up this week. It will be important to have your blood
drawn on Tuesday for monitoring of your kidney function and have
these results faxed to Dr. [**Last Name (STitle) **] if you are unable to see her
before Tuesday.
Name: [**Doctor Last Name **],[**Doctor Last Name **] C.
Location: [**Hospital **] MEDICAL ASSOC-[**Location (un) **]
Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
Fax: [**Telephone/Fax (1) 19406**]
Name: [**Known lastname 7173**],[**Known firstname 7174**] Unit No: [**Numeric Identifier 7175**]
Admission Date: [**2183-2-11**] Discharge Date: [**2183-2-16**]
Date of Birth: [**2127-11-28**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 4871**]
Addendum:
This patient's acute contrast nephropathy is consistent with
acute tubular necrosis.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 1397**] Home Health Care
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 4878**] MD [**MD Number(1) 4879**]
Completed by:[**2183-4-7**]
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10,891
| 134,206
|
8671
|
Discharge summary
|
report
|
Admission Date: [**2191-12-30**] Discharge Date: [**2192-1-7**]
Date of Birth: [**2141-10-30**] Sex: F
Service: CARD [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 51 year old female
with a past medical history significant for coronary artery
disease, hypercholesterolemia, hypertension and tobacco abuse
who status post inferior myocardial infarction in [**2187**] with a
PCI stent of the right coronary artery at that time and a
repeat catheterization in [**2188-7-1**] with a repeat PCI of
the in-stent restenosis and another stent of the distal right
coronary artery lesion. The patient had been treated
medically and had been doing fine until [**2191-10-1**]
where she presented to [**Hospital6 3872**] with chest
pain.
The patient ruled out for a myocardial infarction at that
time, however, she presented again at the end of [**Month (only) 404**] with
unstable angina. She underwent a cardiac catheterization
which showed 99% proximal right coronary artery, 90% PLD,
serial 90% left anterior descending lesion. The patient was
transferred to [**Hospital1 69**] for
operative management.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypercholesterolemia.
3. Hypertension.
4. Fibromyalgia.
5. Diabetes mellitus type 2.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Zocor.
2. Atenolol.
3. Plavix.
4. Aspirin.
5. Enalapril.
6. Insulin.
7. Protonix.
8. Procardia XL.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2191-12-30**] to the
Cardiology Service preoperatively for a coronary artery
bypass graft. The patient underwent an echocardiogram which
was limited due to the patient's size. It was felt that the
ejection fraction was 45 to 55% with mild mitral
regurgitation.
The patient was taken to the Operating Room on [**1-2**]
with Dr. [**Last Name (STitle) 70**] for a coronary artery bypass graft times
three, left internal mammary artery to the left anterior
descending, saphenous vein graft to PDA and saphenous vein
graft to RI. Please see operative note for further details.
The patient was transferred to the Intensive Care Unit in
stable condition.
The patient was weaned and extubated from mechanical
ventilation on postoperative day number one. Postoperatively
the patient had significant hypertension requiring Nipride,
Nitroglycerin and Labetalol. After extubation, the patient
was started on beta blocker and ACE inhibitor and the Nipride
and Nitroglycerin were successfully weaned.
Labetalol was weaned to off by the afternoon of postoperative
day number two. The chest tubes were removed on
postoperative day number two. The patient was transferred
from the Intensive Care Unit to the regular part of the
hospital on postoperative day number two. Pacing wires were
removed on postoperative day number three without incident.
The patient began working with Physical Therapy. By
postoperative day number three, the patient was able to walk
500 feet with Physical Therapy. On postoperative day number
four, the patient was able to ambulate 500 feet and climb one
flight of stairs without difficulty and remaining
hemodynamically stable. The patient's anti-hypertensives had
been increased. The patient had good blood pressure and
heart rate control, good blood sugar control and by the
morning of postoperative day number five, the patient was
cleared for discharge to home.
CONDITION AT DISCHARGE: Temperature maximum 98.1 F.; pulse
86 and sinus rhythm; blood pressure 126/76; respiratory rate
18; oxygen saturation 94% on room air. The patient is alert
and oriented times three. Neurologically nonfocal. Heart is
regular rate and rhythm without rub or murmur. Respiratory:
Breath sounds are clear bilaterally. GI: The abdomen is
obese, soft, nontender, nondistended, positive bowel sounds.
Sternal incision Steri-Strips are intact and open to air.
There is no erythema or drainage. Left leg vein harvest
site, Steri-Strips are intact. There is minimal surrounding
erythema at the medial knee, however, there is no drainage
and no warmth and no tenderness over the area. Bilateral
lower extremities have trace pedal edema; they are warm and
well perfused. The patient's weight on [**1-6**] is 89.4
and preoperatively the patient weighed 85.3 kilograms.
LABORATORY: White blood cell count 12.6, hematocrit 33.4,
platelet count 197. Sodium 141, potassium 3.8, chloride 102,
bicarbonate 29, BUN 12, creatinine 0.7, glucose 123.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Hypertension.
4. Diabetes mellitus.
5. Fibromyalgia.
DISCHARGE MEDICATIONS:
1. Fluvastatin 20 mg p.o. q. h.s.
2. Enalapril 20 mg p.o. q. day.
3. Protonix 40 mg p.o. q. day.
4. Avandia 4 mg p.o. q. day.
5. Lopressor 100 mg p.o. three times a day.
6. Percocet 5/325, one to two p.o. q. four to six hours
p.r.n.
7. Clonazepam 0.25 mg p.o. twice a day.
8. Colace 100 mg p.o. twice a day.
9. Enteric coated aspirin 325 mg p.o. q. day.
10. Plavix 75 mg p.o. q. day.
11. Norvasc 2.5 mg p.o. q. day.
12. Lasix 20 mg p.o. q. day times ten days.
13. Potassium chloride 20 mEq p.o. q. day times ten days.
14. Trazodone 100 mg p.o. q. h.s. p.r.n.
15. NPH insulin, 24 units q. a.m. and 15 units q. p.m.
16. Humalog sliding scale.
DISPOSITION: The patient is to be discharged to home.
CONDITION AT DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with her Cardiologist, Dr.
[**First Name (STitle) **], in one to two weeks.
2. The patient is to follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30380**] in one week.
3. The patient is to follow-up with Dr. [**Last Name (STitle) 70**] in five to
six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2192-1-6**] 16:24
T: [**2192-1-6**] 17:55
JOB#: [**Job Number 30381**]
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|
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[
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icd9pcs
|
[
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4516, 4651
|
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|
1479, 3438
|
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|
1350, 1461
|
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|
195, 1141
|
1163, 1324
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,779
| 131,979
|
40567
|
Discharge summary
|
report
|
Admission Date: [**2156-5-8**] Discharge Date: [**2156-5-27**]
Date of Birth: [**2095-7-29**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
[**2156-5-8**] Left craniectomy, evacuation of left ICH, partial
temporal lobectomy
[**2156-5-11**] Dobhoff placement
[**2156-5-15**] PEG placement, Dr. [**Last Name (STitle) 853**].
History of Present Illness:
Ms. [**Known lastname **] is a 60 year old female with history significant for
hypertension, cocaine and alcohol abuse who presented to [**Hospital1 18**]
after she began to develop altered mental status including
speech disturbance and right sided hemiparesis. Her son reports
she was involved in an altercation earlier in the day where she
most likely struck her head. Upon presentation to [**Hospital1 18**] her left
pupil was dilated and right was small and reactive, she was not
moving her right side to noxious. Her respiratory status was
tenuous and she was emergently intubated. CT scan of the brain
showed a large left IPH with midline shift and mass effect. She
was not on any anticoagulation and her BP upon arrival was 200's
systolic.
Past Medical History:
Past Medical History:
#Hypertension
#Glaucoma NOS
#Alcohol abuse
#Cocaine abuse
#Tobacco dependency
#Peptic ulcer disease
#Hx breast lump
#Hepatitis C
#Myocardial infarction, subendocardial assoc. w/ cocaine
Social History:
The patient is widowed and lives with her son. She has a long
history of cocaine use; last known use was a week prior to
presentation. She has a long history of alcohol use, and
finishes [**12-22**] gallon of hard liquor every 2 days. She was in a
[**Hospital 88809**] rehab for one month in [**Month (only) 404**], but has continued
to drink alcohol since then. She also has a long history of 1
pack per day cigarette smoking.
Family History:
(per son, [**Name (NI) **]: Father with stroke at age 78 and seizures in the
context of alcohol use.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Gen: intubated and sedated
HEENT: Pupils: Left 4mm NR right pinpoint
Neck: Supple.Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: sedated, intubated, no commands
Orientation: unable to obtain
Language: intubated
Cranial Nerves:
I: Not tested
II: LEft pupil 4mm NR, right pupil pinpoint
III-XII: unable to assess given clinical status
Motor: RUE and RLE flaccid, LUE and LLE weak withdrawal
Sensation: unable to assess
Toes mute
Coordination: unable to asses
At discharge: she is awake and alert. She intermittently follows
commands. She was oriented to self.
Pertinent Results:
ADMISSION LABS:
[**2156-5-8**] 01:56AM BLOOD WBC-8.2# RBC-3.92* Hgb-13.2 Hct-40.2
MCV-103* MCH-33.6* MCHC-32.8 RDW-12.1 Plt Ct-298
[**2156-5-8**] 01:56AM BLOOD Neuts-87.7* Lymphs-10.4* Monos-1.3*
Eos-0.2 Baso-0.4
[**2156-5-8**] 01:56AM BLOOD PT-10.1 PTT-25.4 INR(PT)-0.9
[**2156-5-8**] 01:56AM BLOOD Glucose-135* UreaN-10 Creat-0.5 Na-139
K-3.3 Cl-98 HCO3-22 AnGap-22*
[**2156-5-8**] 01:56AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.6
[**2156-5-8**] 02:28AM BLOOD Type-ART Rates-16/0 Tidal V-450 PEEP-5
FiO2-100 pO2-455* pCO2-39 pH-7.38 calTCO2-24 Base XS--1
AADO2-219 REQ O2-45 -ASSIST/CON Intubat-INTUBATED
[**2156-5-8**] 02:28AM BLOOD Lactate-3.6*
[**2156-5-8**] 04:57AM BLOOD Hgb-10.8* calcHCT-32 O2 Sat-98 COHgb-1
MetHgb-0.3
[**2156-5-8**] 04:57AM BLOOD freeCa-0.99*
REPORTS:
NCHCT [**2156-5-8**]: IMPRESSION:
1. Large left temporoparietal intraparenchymal hemorrhage with
extension in the left lateral ventricle and surrounding edema
resulting in sulcal
effacement and 7 mm of rightward shift of midline structures.
Basal and
suprasellar cisterns appear patent with a small amount of
effacement.
2. Underlying lesion is not excluded on this study.
CXR [**2156-5-8**]: IMPRESSION: Mild vascular congestion with
satisfactory position of endotracheal tube.
CTA [**2156-5-8**]: IMPRESSION: 1. Stable large left temporal and
parietal intraparenchymal hemorrhage, causign aterior
displacement of the left middle cerebral artery as described in
detail above, with no frank evidence of aneurysms larger than 2
mm in size. Slightly prominent venous structures surrounding
the left middle cerebral artery, possibly representing crowded
vessels due to mass effect, however, underlying conditions
including vascular malformations cannot be completely ruled out.
Followup is recommended after complete resolution of
the hematoma.
2. The posterior circulation, right middle and anterior
cerebral arteries are grossly unremarkable.
CT C-SPINE [**2156-5-8**]: IMPRESSION:
1. No fracture with mild en bloc retrolisthesis of C5 and C6 on
C7 which is likely degenerative. Multilevel degenerative
disease results in moderate canal narrowing, most pronounced at
C5-C6.
2. A large amount of secretions and fluid are seen in the nasal
and
oropharynx.
POSTOP NCHCT [**2156-5-8**]: IMPRESSION: Marked reduction in the left
temporoparietal intraparenchymal hemorrhage after craniectomy
and evacuation, with expected post-operative appearance and
decreased mass effect as above.
[**5-10**] MRI brain - Findings related to the left temporoparietal
intraparenchymal hemorrhage and left craniectomy are similar in
appearance to the most recent head CT. Subdural blood is likely
a sequela of the craniectomy. No new hemorrhage identified.
2. Given the limitations on the prior CTA, repeat vascular
imaging to rule out AVM as the underlying cause of the
hemorrhage is recommended once there has been sufficient
clearing of intraparenchymal blood.
[**5-11**] CXR - Dobhoff placed in stomach
[**5-11**] Left Upper extremity U/S - Significantly limited study due
to patient's condition. Normal flow is seen in portions of the
brachial and basilic veins, but the entire veins could not be
assessed and a focal thrombus could be missed. The remainder of
the left upper extremity veins could not be evaluated.
[**5-12**] Portable Abdomen- NG tube in the stomach. Nonspecific
bowel gas pattern.
[**5-13**] CT Abdomen- IMPRESSION:
1. No evidence of surgical change within the abdomen; colon is
interposed
between the gastric body and abdominal wall as above.
2. 7-mm right lower lobe pulmonary nodule for which followup in
[**6-1**] months is required if the patient is low risk for primary
lung neoplasm, or 3-6 months if patient is high risk according
to [**Last Name (un) 8773**] Society guidelines.
3. Mild left basal bronchial wall thickening, correlate with
infectious or inflammatory symptoms.
[**2156-5-17**] LENIS:
IMPRESSION:
1. No right lower extremity deep venous thrombosis.
Augmentation could not be performed on the right.
2. Unable to perform the left lower extremity due to patient's
inability to cooperate.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 60 year old woman who presented with AMS with
respiratory decompensation and hypertension found to have a
large left IPH. She was given mannitol and Keppra in the ER and
a CTA was obtained which showed no gross evidence of aneurysm.
The patients exam was consistent with flaccid right side. The
patients left side withdrew minimally to noxious stimulus. The
right pupil was pinpoint and the left pupil was 3mm and non
reactive. The patient had both cough and corneal reflexes.
After discussion with the family she was taken to the OR
emergently
for left hemicraniectomy, left temporal lobectomy, and partial
clot evacuation. After surgery, she did well and was able to be
extubated. After extubation, it became clear that she had both
receptive and expressive aphasia. Post operatively, the patient
was unable to follow commands The patient tracked with her eyes
and smiled. The patient was verbal but non sensical and
difficult to understand. The patient was purposeful/antigravity
with the bilateral upper extremities. The patient exhibited
spontaneous/antigravity movement in the left lower extremity.
The patient a small amount of movement in the right lower
extremity. A Non Contrast Head CT was performed and consistent
with expected post operative changes. A CIWA scale was initiated
for ETOH withdrawal.
On [**5-9**], a urine toxicology screen was positive for cocaine.
Decadron continued. The patient was found to be hypertensive
with a systolic blood pressure of 160 and a Clonidine patch was
initiated. Subcutaneous heparin was initiated for deep vein
thrombosis prophylaxis.
On [**5-10**], a helmet was ordered for the patient to be worn at all
times when the patient is out of bed given her craniectomy. The
Decadron wean was initiated and the blood pressure goal was
libralized to 100-160. A MRI was performed which was consistent
with previous known left temporoparietal intraparenchymal
hemorrhage
and left craniectomy. There was no new hemorrhage identified or
vascular anomaly.
On [**5-11**], she continued to be confused and agitated requiring
Haldol and Zyprexa. She was noted to have a LUE swelling at IV
site. This was removed and a LUE u/s was obtained which showed
no DVT although study was incomplete. A Dobbhoff was placed in
routine fashion and a CXR confirmed placement. ON [**5-12**] TFs were
initiated and nutrition was consulted. ACS was also consulted
for PEG placement.
Physical and occupational therapy consults were placed. A
speech and swallow consult was also consulted but was deferred
due to patient's mental status as of [**5-12**]. ACS was called to
evaluate her for PEG. She had a KUB to evaluate her abdomen as
she has a surgical scar from an unknown procedure. Tube feeds
were started. She was put on Bactrim for a positive U/A. On
[**5-13**], a CT abdomen was ordered for further evaluation for PEG
placement. This confirmed no surgical changes. Exam remains
unchanged. Family meeting was held updating them of the current
plan of care.
On [**5-14**] she was on the add on list for PEG placement. She
remained neurologically stable and was cleared for transfer to
the floor from stepdown.
She underwent PEG placement on [**5-15**] and was restarted on tube
feeds on [**5-16**]. She continued to be agitated and she was
switched from standing Zyprexa with PRN Valium to standing and
PRN Seroquel.
She remained stable through [**5-19**] while awaiting rehab placement.
She pulled out her Foley and was incontinent of urine post-pull.
Bladder scan was done and she was not retaining urine.
She was offered a rehab bed at [**Hospital1 **] however the family
initially declined the bed and subsequently [**Hospital1 **] rescinded
the bed offer.
On [**5-22**], The patient continued to follow commands, her eyes were
open spontaneously, she was verbalizing and moving all four
extremities with equal strength. The patient was asking to eat.
Speech and swallow was re-consulted giving improved exam. She
continued to require restraints as she was impulsive and
attempting to get out of bed.
On [**5-23**], The patients exam was stable. Intervenous fluid was
discontinued.
On [**5-24**], The patient passed her swallow exam and was initiated on
a diet of thin liquids/soft solids. The patient continued to be
screened for rehabilitation. She continued to require
restraints as she was impulsive attempting to get out of bed.
On [**5-25**] she was following commands and doing well with her meals.
TF were stopped. She had a UIT and antibiotics were started on
[**5-26**] for a 7 day course.
She was discharged to [**Hospital1 **] on [**5-27**], tolerating a regular
diet, ambulating with assistance, afebrile with stable vital
signs.
Medications on Admission:
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: max 4g/day.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. levetiracetam 100 mg/mL Solution Sig: One (1) gram PO BID (2
times a day).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
9. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
13. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H PRN ()
as needed for SBP >160.
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for SBP>160mmHg or HR >120: Hold HR <
55
.
15. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
16. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. insulin regular human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): see sliding scale.
18. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO Q12H (every 12 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cocaine use
HTN
Left intracerebral hemorrhage
Cerebral edema with herniation
seizures
acute mental status change
respiratory failure
malnutrition
agitation
confusion
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - always.
Discharge Instructions:
General Instructions
- Helmet at all times when OOB
?????? 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.
?????? Your wound closure are dissolvable sutures, you may now get
this area wet.
?????? 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 were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this when cleared by your Neurosurgeon.
?????? You have been prescribed Keppra (Levetiracetam), you will not
require blood work monitoring.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
If diet advancement goes well, please call Dr.[**Name (NI) 88810**] office for
removal of your PEG. The number is [**Telephone/Fax (1) 600**]
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in __4__weeks.
??????You will need a CT scan of the brain without contrast.
You should follow up with your PCP. [**Name10 (NameIs) **] was noted that you have
pulmonary nodules on your CT scan and its recommended that these
are followed every 6-12 months.
Completed by:[**2156-5-27**]
|
[
"292.0",
"599.0",
"401.9",
"303.91",
"788.39",
"853.01",
"784.3",
"305.1",
"412",
"263.9",
"365.9",
"305.60",
"305.01",
"291.81",
"348.5",
"784.51",
"348.4",
"V12.71",
"070.70",
"345.90",
"342.00",
"V49.87",
"E960.0",
"518.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.39",
"96.6",
"96.71",
"01.59",
"43.11",
"96.04",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
13353, 13423
|
6904, 11654
|
311, 496
|
13633, 13748
|
2765, 2765
|
15563, 16009
|
1971, 2073
|
11704, 13330
|
13444, 13612
|
11681, 11681
|
13808, 15540
|
2113, 2298
|
2658, 2746
|
268, 273
|
524, 1273
|
2412, 2644
|
2782, 6881
|
13763, 13784
|
1317, 1504
|
1520, 1955
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,647
| 174,420
|
8929
|
Discharge summary
|
report
|
Admission Date: [**2184-10-27**] Discharge Date: [**2184-11-2**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
removal of left femur intramedullary rod and left hip
hemiarthroplasty with open reduction internal fixation of
greater trochanter on [**2184-10-27**]
History of Present Illness:
[**Known firstname **] is a [**Age over 90 **]-year-old woman with multiple medical problems
including diabetes, chf, cerebrovascular disease and chronic
renal insufficiency, who about 5 months ago, sustained a
multiple part intertrochanteric femur fracture that extended
down into the subtrochanteric level, calcar. This was treated by
another surgeon with an open reduction and internal fixation
utilizing an intramedullary rod. Unfortunately, the patient has
had cut out of the hardware
with complete failure, nonunion of the 4 part fracture,
shortening of the leg, persistent pain and no evidence of
ongoing healing. In order for the patient to become ambulatory
again and to restore leg length, it is necessary to remove
the hardware and to perform a complex revision operation. The
patient is thus admitted electively following medical clearance
for the above procedure.
Past Medical History:
Hypertension
right ICA stenosis
right-sided stroke
Bell's Palsy on left
diabetes mellitus
diabetic retinopathy
chronic renal insufficiency
peripheral edema
total abdominal hysterectomy
cholecystectomy
congestive heart failure - [**4-/2184**] LVEF 45%
open reduction internal fixation left hip [**2184-5-11**]
Social History:
nursing home resident
Family History:
deferred
Physical Exam:
General: Awake, Alert, Orientedx3, NAD
HEENT: PERRL, MMM, wears glasses
CV: regular s1,s2. no m/r/g
LUNGS: CTA B, occasional fine rales at bases
ABD: +bs, soft, nt/nd
PERIPHERAL: 1+ le edema.
EXT: wwp, 5/5 strength-gastroc/at, sensation intact to light
touch in sural/deep peroneal/superficial perneal/tibial nerve
distributions
Pertinent Results:
chest x-ray: mild vasc redist, small L pleural effusion
EKG: 60 bpm, L axis, TwI avL, unchanged
[**2184-10-27**] 10:27PM GLUCOSE-165* UREA N-30* CREAT-0.9 SODIUM-143
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14
[**2184-10-27**] 10:27PM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-2.1
[**2184-10-27**] 10:27PM WBC-12.1*# RBC-3.44* HGB-10.7* HCT-30.5*
MCV-89# MCH-31.3 MCHC-35.3*# RDW-15.1
[**2184-10-29**] 12:24PM BLOOD CK-MB-2 cTropnT-0.02*
[**2184-10-29**] 08:12PM BLOOD CK-MB-2 cTropnT-0.02*
[**2184-10-30**] 02:50AM BLOOD CK-MB-2 cTropnT-0.03*
[**2184-11-1**] 06:20AM BLOOD Hct-30.4*
[**2184-11-1**] 06:20AM BLOOD Glucose-148* UreaN-26* Creat-1.1 Na-142
K-4.2 Cl-105
[**2184-11-1**] 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
Brief Hospital Course:
[**Age over 90 **] year-old female with past medical history cad, CHF, DM, and
cri underwent removal of left intramedullary nail and
hemiarthroplasty without complication. She had an estimated
blood loss of one liter and received three liters of LR, two
units of PRBCs intraoperatively. She spent the night following
surgery in the intensive care unit intubated. She was extubated
without difficulty on post-operative day number one and her
hospitalization was complicated only by a brief episode of
demand ischemia. She was transferred out of the MICU on
post-operative day number four. The geriatric service followed
the patient for her entire hospital course. Her hospital course
by problems is as follows:
1) Respiratory Support: The patient spent the first night
following surgery on SIMV and was converted to pressure support
in the morning. On pressure support she had excellent tidal
volumes and was breathing spontaneously. She was thus extubated
without difficulty on post-operative day number one. Her oxygen
requirement was subsequently weaned and at the time of discharge
she had a good saturation on room air.
2) S/p hemiarthroplasty: The patient tolerated the procedure
well, although she did require transfusion of several units of
packed red blood cells post-operatively especially in the
setting of demand ischemia. However, by postoperative day
number three her hematocrit had stabilized at between 27 and 30.
She received one dose vancomycin postoperatively and 48 hours
of Ancef as prophylaxis. When she began tolerating POs,
Coumadin was started with a Lovenox bridge. She was maintained
in an abduction pillow at all times, with anterior hip
precautions, no active abduction, and 33% weightbearing.
However, as of post-operative day number five physical therapy
was only able to get the patient to sit at the edge of the bed.
The therapists attributed her slow progress to a combination of
deconditioning, pain, and her weight. She was given oxycodone,
Tylenol, and tramadol for pain.
3) CHF with EF 40-45%: The patient was over one liter positive
early in her postoperative course and had a chest x-ray
consistent with mild volume overload. However, diuresis was
restarted with Lasix on post-operative day number two. At no
point did she clinically appear to be acutely in heart failure.
4) Type II DM: The patient's blood sugars were slightly high
usually in the mid 100s and occasionally in the low 300s.
However, given that her oral intake was less than usual we
decided to err on the side of conservative management by keeping
her on half of her usual dose of standing NPH and a gentle
regular insulin sliding scale.
5) CRI: The patient's creatinine remained below baseline for
the majority of her admission. She did require several fluid
boluses early in her post-operative course.
6) Demand Ischemia: On postoperative day number two the patient
began to complain of chest pressure. Her EKG demonstrated some
mild ST depression. This pressure quickly abated after
sublingual nitrate. Her troponin increased to 0.2 and was 0.2
and 0.3 on subsequent tests. The cardiology service was
consulted and they attributed her symptoms to ischemia secondary
to demand. They recommended only restarting aspirin, her
statin, and titrating up her beta blocker.
Medications on Admission:
asa ec 325mg qday
furosemide 80 qam, 40 qpm
insulin 70/30 44 qam, 29 qpm
imdur 30mg qday
lorazepam 1mg qhs
MOM
[**Name (NI) 31013**] 50 tid
oxycodone 2.5 q6h prn
simvastatin 20 qpm
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q24H (every 24 hours): Please d/c when therapeutic
with coumadin (INR=2-2.5). mg
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
for 6 weeks: Please check INR at least twice weekly with
goal=2-2.5.
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QHS (once a day (at bedtime)).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for breakthrough pain.
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Eighteen (18) units Subcutaneous QAM.
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eleven
(11) units Subcutaneous QPM.
19. Regular insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
left hip fracture nonunion
diabetes mellitus
hypertension
demand ischemia
congestive heart failur
chronic renal insufficiency
cerebrovascular disease
Discharge Condition:
stable
Discharge Instructions:
1) Please keep wound covered with dry sterile dressing. OK to
shower. Do not bathe.
2) Please take lovenox to prevent blood clot until INR is
between
2 and 2.5 and then take coumadin for 6 weeks.
3) Please follow-up with Dr. [**Last Name (STitle) **] as directed for staple
removal Call doctor sooner if you devlop fevers, shaking
chills, or increasing wound redness, drainage, or pain not
controlled by pain medications.
4) Only bear 33% weight on left leg, no active abduction, and
anterior hip precautions.
Physical Therapy:
Activity: Out of bed to chair tid
Pneumatic boots
Right lower extremity: Full weight bearing
Left lower extremity: Partial weight bearing
Right upper extremity: Full weight bearing
Left upper extremity: Full weight bearing
33% WEIGHTBEARING ON LEFT LOWER EXTREMITY, ANTERIOR HIP
PRECAUTIONS, NO ACTIVE ABDUCTION, PLEASE KEEP TOWEL UNDER CALF
TO KEEP HEELS OFF THE BED
Treatments Frequency:
Site: LEFT HIP
Type: Surgical
Comment: SURGERY WILL CHANGE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2184-11-8**] 8:30
|
[
"413.9",
"401.9",
"733.82",
"585.9",
"362.01",
"285.1",
"428.0",
"250.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"81.52",
"78.65"
] |
icd9pcs
|
[
[
[]
]
] |
8141, 8206
|
2867, 6173
|
279, 432
|
8400, 8409
|
2104, 2844
|
9455, 9611
|
1727, 1737
|
6405, 8118
|
8227, 8379
|
6199, 6382
|
8433, 8948
|
1752, 2085
|
8966, 9345
|
9368, 9432
|
226, 241
|
460, 1339
|
1361, 1671
|
1687, 1711
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,352
| 194,749
|
44952
|
Discharge summary
|
report
|
Admission Date: [**2126-6-22**] Discharge Date: [**2126-6-24**]
Date of Birth: [**2059-7-16**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Lisinopril / Levaquin / Vicodin / Tylenol/Codeine
No.3
Attending:[**First Name3 (LF) 49413**]
Chief Complaint:
swollen Tongue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 66 yo female with h/o of HTN, CHF (current EF55%) on
ACE, obesity, CHF, hemoptysis and ? of swollen tongue was in her
USOH when this morning, noted difficulty in swallowing her
morning pills. She looked into the mirror and was startled that
her tongue appeared very swollen. She was able to swallow her
secretions and her am pills (took her am dose of lisinopril),
and did not note any lip/facial edema. She recently had a FNA of
a thyroid nodule that was uncomplicated (no new medications).
The following day, the patient went to her PCP with complaints
of dysuria and increased urinary frequency and was prescribed
Levaquin (has never taken this mediation in the past) which she
took x4 days.
.
In the ED, ENT was consulted. Laryngoscopy revealed bilateral
arytenoid edema, but patent airway. No supraglottic edema with
normal vocal cords.
.
On review of systems, the pt. denied odynophagia, +mild
dysphagia. No recent fever or chills. No night sweats or recent
weight loss or gain. Normal BM, dysuria has resolved. No pedal
edema. No recent new foods (no seafood) no other OTC
medications. No rash, or atopy. no Bee stings.
.
In the ED, patient received DiphenhydrAMINE, Dexamethasone and
Famotidine 20mg.
Past Medical History:
1. Asthma. [**5-11**]: PFT's normal
2. Renal stone right side which passed spontaneously.
3. Peptic ulcer disease.EGD [**2121-7-8**]: c/w GERD
4. Ascending colon polyp (polypectomy): Path c/w Adenoma.
5. Urinary incontinence, the patient wears undergarments
chronically.Urgency and urge incontinence.
Detrusor instability and possible Detrusor hyper reflexia. with
cysto on [**2121-9-17**]
6. Congestive heart failure: EF in [**2123**] was 35%: [**2125-12-11**]: now
55%
7. hemoptysis. ENT evaluation neg. 8. Thyroid nodule: FNA on
[**2126-6-18**] non diagnostic.
8. Morbid Obesity.
9. Thyroid nodule (incidentally found on CT of chest) Recent FNA
non-diagnostic.
Social History:
Patient has eight children in the area. Quit tobacco. No
alcohol, no drugs. Lives by herself in [**Hospital1 **]. Not employed. She
worked as a nurse assistant many
years ago.
Family History:
+ CAD, The mother is 81 and has congestive heart failure. Father
died at the age 65 of a myocardial infarction.
Physical Exam:
Vitals: T:98.0 P:80-85 R:16-22 BP:147/90 SaO2: 100% 2L NC
General: Awake, alert, NAD, AA female, with mildly garbled
voice. Adentous except for 2 upper incisors, No stridor: Tongue
is edematous, L>R, most predominantly anteriorly, but
nontender.. Uvula is non-edematous, midline. Appears to be s/p
tonsillectomy.
HEENT: PERRLA, EOMI, no scleral icterus noted,
Neck: no parietal, submandibular swelling, no tenderadenopathy
noted.
Pulmonary: Lungs CTA bilaterally without R/R/W. No stridor
Cardiac: RR, nl. S1S2, no M/R/G noted
Abdomen: Obese, soft, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ DP and PT pulses b/l.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3.
Pertinent Results:
Laboratory Data:
141 103 14 91 AGap=15
3.7 27 1.1
.
...11.5 87
6.3>--<179
...33.7 (baseline 34)
N:68 Band:1 L:25 M:6 E:0 Bas:0
.
Echo: [**2125-12-11**]: LVEF 60%.
.
Stress test: [**2125-5-3**]: Normal. No ischemic changes.
.
PFT:s [**2126-5-20**]:
FVC 2.17 (87%Pred)
FEV1 1.59 (88%Pred)
FEV1/FVC 73 (101%Pred)
.
US of Thyroid: [**5-11**]: Multinodular thyroid with dominant nodule
in the lower pole of the left thyroid.
.
Recent FNA of thyroid: NON-DIAGNOSTIC. Blood only. No follicular
cells.
Brief Hospital Course:
66-year-old female with h/o of HTN, h/o of cardiomyopathy (now
normal EF) on ACE-I therapy who presents with acute onset of
"tongue swelling". She was seen by ENT in the ermegency
department and larygnoscopy revealed a patent airway and
significant anterior oropharyngeal edema. It was felt that her
tongue swelling likely represented angioedema (no evidence of
Ludwig's on exam - clinical hx did not fit). Her airway
remained patent and she did not require intubation at any time.
She was placed on Decadron 10mg IV q6, Pepcid 20mg IV bid, and
Benadryl IV prn to decrease her angioedema, along with holding
her levaquin, aspirin and lisinopril. She was observed overnight
in the [**Hospital Unit Name 153**] and was called out to the floor once her angioedema
had improved significantly. ENT continued to perform periodic
laryngoscopy which revealed improving edema. They recommended
tapering Decadron to 10mg IV q8 prior to arrival on the floor.
Her angioedema improved significantly, and she was felt to be
safe for discharge without any additional steroids with ENT
follow-up. She was given a prescription for EpiPens and was
given instructions on how and when to use the pen.
.
Her other medical issues included a recent UTI which should have
been adequately treated by 4 days of Levaquin, and a thyroid
nodule for which she is undergoing an outpatient work-up. She
also has a history of systolic congestive heart failure, but her
most recent ECHO revealed a normal LVEF. She was discharged on
her Toprol XL without her ACE-I.
Medications on Admission:
1. Levaquin
2. Lisinopril
3. ASA
4. Toprol
Discharge Medications:
1. EpiPen 0.3 mg/0.3 mL Syringe Sig: One (1) Prefilled Syringe
Intramuscular X1 as needed for shortness of breath or wheezing
for 1 doses: Use as directed for an emergency if your throat
starts to swell. Call 911 if you use this EpiPen.
Disp:*3 Pens* Refills:*0*
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
3. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Angioedema
Hypertension
Hyperlipidemia
Thyroid nodule(s)
Discharge Condition:
stable
Discharge Instructions:
Please follow-up with Dr. [**Last Name (STitle) 4888**] [**Telephone/Fax (1) 8955**] in one
week.
Please follow-up with Dr. [**Last Name (STitle) 3878**] (ENT) in one week. Call ([**Telephone/Fax (1) 53978**] to schedule an appointment.
Please follow-up with your endocrine doctor regarding your
thyroid nodules.
Do not take your Lisinopril as this medicaiton caused your
allergic response. Even though we believe that the Lisinopril
caused your allergy, you should not take Levaquin (antibiotic)
or Aspirin until you discuss it with Dr. [**Last Name (STitle) 48276**].
You have been given an EpiPen to use for emergencies. If you
have throat or tongue swelling you should use this EpiPen and
call 911 as the EpiPen will only work temporarily. It gives you
time to get to the emergency department in an ambulance.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 4888**] [**Telephone/Fax (1) 8955**] in one
week.
Please follow-up with Dr. [**Last Name (STitle) 3878**] (ENT) in one week. Call ([**Telephone/Fax (1) 53978**] to schedule an appointment.
Please follow-up with your endocrine doctor regarding your
thyroid nodules.
|
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[
[]
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[
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icd9pcs
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,084
| 140,363
|
9126
|
Discharge summary
|
report
|
Admission Date: [**2174-11-28**] Discharge Date: [**2174-12-13**]
Date of Birth: [**2121-6-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Estrogens / Ancef / Tegretol / Keflex / [**Doctor First Name **] /
Tequin / Minocin / Forteo
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
- Intubation (extubated [**2174-12-9**])
- Right nephrostomy tube placement [**11-30**]
- PICC placement [**2174-12-13**]
History of Present Illness:
53-Year-old female with history of diabetes, kidney stones,
neurogenic bladder status post urinary diversion/urostomy.
Presenting today with fevers which started acutely at 2 PM on
day of admission, she also has been flushed for most of the day.
Originally thought it was hypoglycemia but checked a finger
stick and it was 150. She also mentioned that 1 week prior to
admission she noticed foul smelling urine coming from her
urostomy drain when it was being drained. She regularly changes
her urostomy dressings weekly at her [**Hospital1 1501**]. She has been nauseous
but denies vomiting. Denies any back pain, nausea or vomiting,
rashes, diarrhea or constipation. States that she feels
generally weak. Some abdominal discomfort near urostomy site.
Has noted some debris in her urostomy of late. Of note she has
had multiple episodes of UTI and has had urosepsis in the past.
She also has a known stage [**Doctor Last Name 534**] caliculi in the Left kidney.
In the ED, initial VS were:T 100.4 HR 135 BP 130/71 RR 20 99%RA.
Her temp rose to 103 while in ED and she has been persistently
tachycardic. She was noted to be hypovolemic on exam and was
given a total of 4L IVF in ED prior to coming to floor. Her
mental status was normal during her ED course. Her presenting
labs were notable for lactate 3.2, Na 127, bicarb 20, WBC 20.5
w/ 79 PMNs and 14 Bands. U/A showed many bacteria, 168WBC, neg
nitrates. She was started on Meropenem in the ED for
UTI/urosepsis.
.
On arrival to the MICU, she had a temp of 101, tachy to 140s and
a BP of 90s/50s. She was feeling malaise and nauseous but alert
and oriented.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
1) SLE. Complicated by neuromyelitis optica and pericarditis.
Followed by Dr. [**Last Name (STitle) **]. Had been treated with cytoxan.
2) Right ureteral stone requiring urostomy and lithotripsy.
Urostomy tube removed in [**2167**].
3) Right lower extremity DVT '[**55**], treated with coumadin
4) Steroid-induced hyperglycemia
5) Transverse Myeltiis diagnosed in [**2149**] after patient presented
with fall. Complicated by neurogenic bladder requiring illeal
loop diversion '[**60**]. On steroids. Had baclofen pump placed in
[**2165**].
6) Urosepsis with Klebsiella (blood and urine) Pyelonephritis in
[**9-8**], admitted to MICU. Also had MRSA pyelo (blood and urine)
in [**2165**]
7) h/o nephrolithiasis (type unknown) s/p lithotripsy and h/o
left
ureteropelvic junction stone '[**65**]
8) Blindness in right eye with optic neuritis
9) Bilateral knee arthritis
10) Suspected glaucoma in left eye, turned out to be capsular
ossification or a secondary cataract, corrected w/ laser surgery
[**2168-8-29**]
11) Hypothyroid
12) Osteoporosis
13) Liver hemangioma
Social History:
Retired ICU nurse. [**First Name (Titles) **] [**Last Name (Titles) 31437**] x 15 yrs but maintains her
certification. Lives at [**Location 86**] Home NH x 11 yrs due to chronic
med issues. Her doctor there is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31438**]. No h/o
tobacco, alcohol, or IVDA. Wheelchair dependent + requires [**Doctor Last Name 2598**]
lift. UE strength intact but poor motor movements due to loss of
sensation.
Family History:
Mother died at 51 metastatic [**Name (NI) 31439**]
Father died at 36 aplastic anemia
only child
Physical Exam:
Admission Physical Exam:
Vitals: T:101 BP:95/53 P:143 R:20 18 O2:100 2L
General: Alert, oriented, sleepy, comfortably lying in bed
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI
Neck: supple, JVP low, no LAD
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops
Lungs: crackles present at bases, no wheezes, rales, ronchi
Abdomen: soft, mild tenderness lateral to urostomy site,
non-distended, bowel sounds present, no organomegaly, baclofen
pump in LLQ
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: 5/5 strength upper extremities, [**2-6**] RLE, [**3-9**] LLE strength
Discharge Exam:
VSS WNL
GEN: Resting in bed in NAD.
HEENT: Supple
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB over anterior fields. No c/w/[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]: Nephrostomy tube in R flank. Ostomy noted. +NABS in 4Q.
Soft, NTND.
EXT: [**12-5**]+ LE edema. Immobile lower extremities.
Pertinent Results:
Labs on Admission:
[**2174-11-28**] 07:40PM BLOOD WBC-20.5*# RBC-4.11* Hgb-12.4 Hct-36.9
MCV-90 MCH-30.2 MCHC-33.6 RDW-12.8 Plt Ct-313
[**2174-11-28**] 07:40PM BLOOD Neuts-79* Bands-14* Lymphs-2* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2174-11-28**] 07:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2174-11-28**] 07:40PM BLOOD PT-10.5 PTT-32.4 INR(PT)-1.0
[**2174-11-28**] 07:40PM BLOOD Glucose-155* UreaN-19 Creat-0.7 Na-127*
K-4.2 Cl-95* HCO3-20* AnGap-16
[**2174-11-28**] 07:40PM BLOOD ALT-17 AST-23 AlkPhos-74 TotBili-0.5
[**2174-11-28**] 07:40PM BLOOD Albumin-3.6
[**2174-11-28**] 07:40PM BLOOD Cortsol-32.8*
[**2174-11-28**] 07:45PM BLOOD Lactate-3.2*
Pertinent Labs:
[**2174-11-29**] 01:09AM BLOOD WBC-5.2# RBC-3.50* Hgb-10.7* Hct-32.2*
MCV-92 MCH-30.5 MCHC-33.2 RDW-13.0 Plt Ct-95*#
[**2174-11-29**] 06:17AM BLOOD WBC-11.9*# RBC-3.03* Hgb-9.3* Hct-28.6*
MCV-94 MCH-30.8 MCHC-32.6 RDW-13.5 Plt Ct-127*
[**2174-11-29**] 09:57AM BLOOD Hct-31.4*
[**2174-11-29**] 02:18PM BLOOD Hct-32.8*
[**2174-11-29**] 06:41PM BLOOD WBC-41.7*# RBC-3.18* Hgb-9.8* Hct-29.3*
MCV-92 MCH-30.7 MCHC-33.3 RDW-13.7 Plt Ct-98*
[**2174-11-29**] 01:09AM BLOOD Plt Ct-95*#
[**2174-11-29**] 06:17AM BLOOD PTT-70.2*
[**2174-11-29**] 06:17AM BLOOD Plt Ct-127*
[**2174-11-29**] 04:33PM BLOOD PT-21.9* PTT-55.1* INR(PT)-2.1*
[**2174-11-29**] 06:41PM BLOOD Plt Smr-LOW Plt Ct-98*
[**2174-11-29**] 04:33PM BLOOD Fibrino-117*
[**2174-11-29**] 05:41PM BLOOD FDP-160-320*
[**2174-11-29**] 01:09AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-134
K-3.4 Cl-109* HCO3-12* AnGap-16
[**2174-11-29**] 06:17AM BLOOD Glucose-134* UreaN-18 Creat-1.0 Na-135
K-3.8 Cl-114* HCO3-14* AnGap-11
[**2174-11-29**] 11:21AM BLOOD Na-133 K-4.5 Cl-113*
[**2174-11-29**] 04:24PM BLOOD Glucose-207* UreaN-25* Creat-1.6* Na-133
K-4.9 Cl-109* HCO3-12* AnGap-17
[**2174-11-28**] 07:40PM BLOOD Lipase-61*
[**2174-11-29**] 06:26AM BLOOD Lactate-2.6*
[**2174-11-29**] 08:30AM BLOOD Lactate-2.9*
[**2174-11-29**] 10:06AM BLOOD Lactate-3.1*
[**2174-11-29**] 03:33PM BLOOD Lactate-3.2* K-4.6
[**2174-11-29**] 07:00PM BLOOD Lactate-3.6*
[**2174-11-29**] 08:49PM BLOOD Lactate-4.3*
[**2174-11-29**] 11:49PM BLOOD Lactate-4.5*
Chest X-Ray ([**2174-12-13**]):
IMPRESSION:
1. Right subclavian central venous catheter with the catheter
tip at the
lower SVC.
2. Improved aeration of bilateral lung bases, with decrease in
bilateral
pleural effusions.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
53 yo F w/ h/o neurogenic bladder s/p urostomy presents w/ fever
and flushing to the ED found to have positive UA and CT was
concerning for pyelonephritis.
.
#Septic Shock/Urinary Tract Infection/Bacteremia - Admission
blood cultures were positive [**3-8**] for gram negative rods. She was
started on Vancomycin and meropenem and agressively volume
resuscitated with NS IVF. A CT abd/pelvis shows hydronephrosis
w/ obstructing stricture and calcification at R ureteral=ileal
anastamosis site. IR placed a nephrostomy tube to relieve the
obstruction. Upon return from IR procedure the pt developed
respiratory distress then respiratory failure requiring
intubation. Following sedation for intubation her blood pressure
decreased and she was sequentially placed on phenylepherine,
norepinepherine and vasopressin. Pressors were weaned within 48
hours. ID was consulted, and recommended changing antibiotics to
ceftazidine. Because she has a cephalosporin allergy, she
underwent ceftaz desensitization on [**12-8**]. ID also recommends
that, once she clinically improved, she should undergo
lithotripsy of large staghorn calculi to prevent further UTI.
The patient will continue with the R nephrostomy tube & IV
ceftazidime until the ureteral obstruction in resolved as an
outpatient. She was given a follow up appointment with urology
to address this. A PICC was placed on [**2174-12-13**]. The placement
was confirmed by chest xray.
.
#Hypoxic Respiratory Failure - Following IR procedure the pt
developed respiratory failure most likely flash pulmonary edema
in the setting of aggressive volume resuscitation. CXR showed
fluffy bilateral infiltrates c/w ARDS. She was initially
ventilated with the ARDSnet settings. Her FiO2 was gradually
weaned down.
.
# Prolonged altered mental status: she remained very sedate and
unalert, even once sedation from mechanical ventilation had been
held for days. An EEG did show slowing consistent with
toxic/metabolic encephalopathy. Delirium improved with
resolution of her critical illness.
.
# Thrombocytopenia: dropped to a low of 17. Thought to be [**1-5**]
sepsis vs autoimmune disease vs drug effect (meropenem). She was
switched to ceftaz per above. She was transfused multiple units
of platelets, as she developed substantial bloody leakage from
her catheter insertion sites. Platelets stable in normal range
on discharge.
.
# Renal failure: she became aneuric in setting of hypotension,
possibly [**1-5**] ATN. Renal was consulted and she was initiated on
HD. Renal function improved and dialysis was discontinued prior
to leaving the MICU.
.
#Devics Neuromyelitis - This is a chronic issue, has resulted in
right eye blindness, lower extremity immobility and weakness. We
continued her intrathecal baclofen pump and placed her on stress
dose steroids briefly, then she was continued on prednisone 10mg
daily alternating with 30 mg. She will follow up with neurology
as an outpatient
.
#Hypothyroidism - cont levothyroxine
.
#HTN - Diovan held in setting of sepsis. Resumed on discharge.
.
#Glaucoma - continue Cosopt eye drops
.
#Diabetes - ISS
====================================
# Transitional issues: needs f/u on baclofen pump with her usual
provider.
# Please check CBC and chem 7 on [**2174-12-20**] and call Dr. [**Last Name (STitle) 9449**]
with results at [**Telephone/Fax (1) 14328**].
Medications on Admission:
baclofen pump infusion of 320 mcg during day w/ extra bolus of
50 mcg h.s.; should have 6 month supply as of [**2174-11-7**] per OMR
note
Cosopt eyedrops OS twice a day
vitamin D 50,000 units monthly
levothyroxine 88 mcg daily
lorazepam 0.5 mg q.6h. as needed for anxiety
nitrofurantoin 100 mg three times per week
oxazepam 10 mg at bedtime
prednisone 10 mg tablets, alternating with 30 mg every other day
Diovan 40 mg daily.
Colace 5 mg one tablet daily as needed for constipation
calcium citrate and vitamin D two tablets three times a day
cranberry pills
Benadryl up to 50 mg p.r.n.
famotidine 10 mg daily
ibuprofen 400 mg as needed for neck pain
magnesium oxide supplements
Citrucel prn
fenu soy prn,
Fleet enema prn
multivitamin daily
Discharge Medications:
1. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety, muscle tightness.
5. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. oxazepam 10 mg Capsule Sig: One (1) Capsule PO at bedtime.
7. Citrucel 500 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. famotidine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Benadryl 25 mg Capsule Sig: [**12-5**] Capsules PO once a day as
needed.
11. CefTAZidime 1 g IV Q8H
12. 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.
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. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO three times a day.
15. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] ().
16. docusate sodium 50 mg/5 mL Liquid Sig: One (1) tablet PO BID
(2 times a day).
17. baclofen 2,000 mcg/mL Solution Sig: 13.3 mcgs Intrathecal
INFUSION (continuous infusion): Additional 50 mcgs QHS.
18. prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
19. prednisone 20 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY
(Every Other Day).
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
21. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
22. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
23. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: 1-2 puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
24. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
25. insulin regular human 100 unit/mL Solution Sig: sliding
scale Injection ASDIR (AS DIRECTED).
26. famotidine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Home - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Urosepsis with Multiple-Organ System Failure
SECONDARY DIAGNOSES:
- Neurogenic Bladder
- Devic's Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. [**Known lastname 31440**], it was a pleasure to participate in your care
while you were at [**Hospital1 18**]. You came to the hospital because you
had fevers which were due to an infection in your urinary
system. This infection was caused by a blockage in your ureter
which prevented your urine from draining normally. On [**11-30**] you
had a nephrostomy tube placed to relieve the obstruction. Your
infection caused you to be critically ill with septic shock.
YOu were in the ICU where you needed to be intubated and started
on dialysis. Fortunately, you improved significantly with these
measures in addition to IV antibiotics.
There is still a calcified stricture/stone in your ureter which
will need to be addressed on an outpatient basis. Until then,
you will remain on IV antibiotics to prevent further infection.
MEDICATION CHANGES:
- Medications ADDED:
---> Ceftazidime 1 gm Q8H
- Medications STOPPED:
---> Please stop taking magnesium oxide while your kidneys are
recovering
---> Please stop taking nitrofurantoin while you are taking IV
antibiotics
---> Please stop taking ibuprofen while youre kidneys are
recovering
- Medications CHANGED: None.
Followup Instructions:
Here are your follow-up appointments:
Department: RADIOLOGY CARE UNIT
When: TUESDAY [**2174-12-27**] at 8:00 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: TUESDAY [**2174-12-27**] at 9:30 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2174-12-28**] at 10:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
In addition to these appointments, please make an appointment to
see your neurologist to discuss management of your prednisone &
baclofen pump.
|
[
"244.9",
"283.9",
"V44.6",
"250.02",
"348.30",
"710.0",
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"276.2",
"785.52",
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"590.80",
"V58.65",
"584.5",
"995.92",
"592.1",
"591",
"276.1",
"041.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.97",
"96.04",
"39.95",
"96.6",
"96.72",
"55.03",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
14322, 14401
|
7767, 9544
|
374, 498
|
14573, 14573
|
5230, 5235
|
15903, 15917
|
4156, 4253
|
11908, 14299
|
14422, 14422
|
11143, 11885
|
14708, 15542
|
4293, 4889
|
14510, 14552
|
4905, 5211
|
15942, 16834
|
2159, 2578
|
15562, 15880
|
329, 336
|
526, 2140
|
14441, 14489
|
5249, 5956
|
14588, 14684
|
5972, 7744
|
10923, 11117
|
2600, 3666
|
3682, 4140
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,357
| 119,355
|
55206
|
Discharge summary
|
addendum
|
Name: [**Known lastname 349**], [**Known firstname 350**] L Unit No: [**Numeric Identifier 351**]
Admission Date: [**2187-6-8**] Discharge Date: [**2187-6-29**]
Date of Birth: [**2160-7-23**] Sex: F
Service:
Please see previous full note for hospital course.
Subsequent hospital course by system:
1. Cardiovascular - The patient was continued on varying
doses of Labetalol and Lopressor for blood pressure control.
2. Pulmonary - The patient was continued on intravenous
Heparin, Coumadinized and subsequently discharged on Lovenox
until INR became therapeutic.
3. Renal - The patient was continued on Lasix with good
diuresis and decreased peripheral edema. Hydrochlorothiazide
was used intermittently. She was subsequently started on
Cozaar for gross nephrotic syndrome.
4. Infectious disease - The patient was subsequently found
to have large left lower lobe necrosis with probable MSSA
superinfection. She was seen in consultation by Infectious
Disease and Pulmonary who decided in conjunction with the
team to attempt to treat through this with long term Unasyn,
however, if the patient has relapse, she would be a probable
candidate for partial lobectomy. However, given her
comorbidities, this was felt to be a less desirable outcome.
5. Gastrointestinal - The patient had no further
complications and was eating well at the time of discharge.
6. Genitourinary - Hematuria had resolved without any
subsequent complication.
7. Hematology - The patient continued to have transient
hematocrit drops and despite extensive hematology workup,
there was subsequently found to be no evidence of hemolysis.
Subsequent blood transfusions did not keep hematocrit up for
the duration that would be expected, however, this was never
quite figured out. The present plan is to transfuse as
needed and follow this on a long term basis.
8. Endocrine - The patient was continued on Prednisone to be
discharged on a long term taper. Rheumatologically, the
patient's lupus is to be managed with Prednisone, Plaquenil
and follow-up with Rheumatology. When acute medical issues
are resolved, she will likely undergo Cytoxan therapy again.
9. Neurology - The patient had no subsequent epileptic
activity. She was therapeutic on her Dilantin.
DISCHARGE DIAGNOSES:
1. Idiopathic angioedema.
2. Bilateral pulmonary embolus.
3. Left lower lobe pulmonary abscess.
4. Seizure disorder likely secondary to lupus cerebritis.
5. Hematuria of unclear etiology.
6. Systemic lupus erythematosus with nephrotic syndrome and
lupus nephritis.
The patient will have subsequent follow-up with Infectious
Disease, Pulmonary Clinic, Neurology, Rheumatology and her
primary care physician.
DISCHARGE MEDICATIONS:
1. Unasyn 3 grams intravenous q6hours.
2. Coumadin 7.5 mg to be titrated to INR of 2.5.
3. Lovenox 60 mg subcutaneous q12hours to be discontinued on
therapeutic INR.
4. Niferex 150 mg p.o. b.i.d.
5. Vitamin D 400 units p.o. q.d.
6. Nystatin swish and swallow 15 cc p.o. t.i.d.
7. Prilosec 20 mg p.o. q.d.
8. Multivitamin one tablet p.o. q.d.
9. Calcium Carbonate 500 mg p.o. t.i.d.
10. Lasix 80 mg p.o. b.i.d.
11. Plaquenil 200 mg p.o. b.i.d.
12. Dilantin 200 mg p.o. t.i.d.
13. Labetalol 400 mg p.o. b.i.d.
14. Lipitor 20 mg p.o. q.d.
15. Magnesium Oxide 140 mg p.o. q.d.
16. Potassium Chloride 60 meq p.o. q.d.
17. Prednisone 40 mg p.o. q.d. to be tapered over the next
month.
18. Cozaar 25 mg p.o. q.d.
19. Hydrocortisone 1% cream topical b.i.d. as needed.
20. Robitussin AC 10 ml p.o. q6hours p.r.n.
21. Percocet 5/325 one to two tablets p.o. q4-6hours p.r.n.
22. Compazine 10 mg p.o. q6hours p.r.n.
23. Benadryl 25 mg p.o. q4-6hours p.r.n.
Commode and rolling folding walker.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 353**]
MEDQUIST36
D: [**2187-6-29**] 14:44
T: [**2187-6-30**] 09:09
JOB#: [**Job Number 354**]
|
[
"780.39",
"518.81",
"478.6",
"276.8",
"513.0",
"443.0",
"710.0",
"415.19",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
2309, 2728
|
2751, 3979
|
333, 2288
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,412
| 155,151
|
2112
|
Discharge summary
|
report
|
Admission Date: [**2115-8-10**] Discharge Date: [**2115-8-22**]
Date of Birth: [**2055-7-21**] Sex: M
Service: MEDICINE
Allergies:
Crixivan
Attending:[**Last Name (un) 11220**]
Chief Complaint:
hypotension, dyspnea on exertion, fever
Major Surgical or Invasive Procedure:
L subclavian central line placed in ED [**2115-8-10**]
Bronchoscopy [**2115-8-16**]
History of Present Illness:
60 yo male with pmhx of HIV/AIDS (last CD4 count of 9 [**2115-8-4**])
presenting with DOE and hypotension. The patient was admitted
from [**2115-8-4**] [**2115-8-8**] with the diagnosis of esophagitis of
unclear etiology.He recieved an EGD for odynophagia/dysphagia,
s/p biopsy on [**2115-8-8**] with no complications. He was discharged
home where he started to have fevers up to 103 and experienced
some dizziness. He presented to the ED where he was noted to be
initially mentating well with SBP in the 70's. He recieved [**3-14**]
liters of IV NS and after persistently low blood pressures a
left subclavian central line was placed with Levophed started.
He was transferred to the [**Hospital Unit Name 153**] for further management.
In the ED, initial VS were: 99.2 74 121/98 20 100%. CXR was
reported to be without acute cardiopulmonary process and no
subdiaphragmatic free air. Blood cultures and urine culture
were sent. Vancomycin and Zosyn were started. .
His chief complaint is dyspnea on exertion ever since being
discharged from the hospital.He has not been able to take more
than 15-20 steps before experiencing dyspnea and chest
discomfort. He has no symptoms at rest. He does endorse some
nausea and 1 episode of bilious vomitus this morning while
waiting for the ambulance. His dysphagia since discharge has
improved and he denies any dyspepsia, melena, [**Hospital Unit Name 11395**] or oral
ulcers. He denies cough, but does endorse fevers up to 103. He
denies abdominal pain, dysuria, current diarrhea, leg
swelling,orthopnea, lower extremity swelling, headache. The
patient notes some chronic diarrhea which has actually improved
over the past few days and 40Ib weight loss over the past few
months. His last BM was yesterday and was formed, brown.
On arrival to the MICU, patient's VS: BP 94/65 P-75 and 96% RA.
The above hx and below review of systmes was obtained.
Past Medical History:
PAST MEDICAL HISTORY:
-HIV (diagnosed in 8/94 via PCP [**Name Initial (PRE) 1064**])
-History of PCP, [**Name10 (NameIs) 11395**], [**Name10 (NameIs) **], [**Name10 (NameIs) 1074**] retinitis, [**Name10 (NameIs) 1074**] pancreatitis,
enterobacter sepsis, wasting syndrome
-HIV neuropathy
-Chronic renal insufficiency
-Hepatitis B
-Nephrolithiasis [**1-10**] crixivan 8 yrs ago
-PTX [**1-10**] pentamidine
-Depression
-HTN
PAST SURGICAL HISTORY:
-Right nephrectomy (kidney donor for brother) [**2079**]
-Retinal implants bilaterally
Social History:
He lives with his girlfriend [**Name (NI) **] in [**Location (un) 686**], MA in his
house with his two daughters and his grandchildren. Works as
substance abuse counselor for drug abusers with HIV/AIDS. He has
not used drugs, tobacco, or alcohol for 22 years.
Drugs: None currently. Heroin 2g/d IV from age 14-38 (quit 22
years ago). Cocaine 0.5 g/d (speedball) IV from age 21-38.
Tobacco: 2 packs per day for 20 years (40 pack-years), quit 22
years ago.
Alcohol: quit 22 years ago.
Family History:
Father killed, died of head trauma at age 25. Mother died of
stomach CA at age 62. 2 brothers deceased from [**Name (NI) 11398**] (one of which
had juvenile DM and received a kidney from pt). 1 brother alive
at 57 with DM1.
Physical Exam:
Admission:
Vitals: BP 94/65 P-75 and 96% RA
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear no [**Name (NI) 11395**] or
ulcers, EOMI, PERRL, Right EJ placed, left subclavian CVL.
Neck: supple, JVP not elevated, no LAD. Left subclavian in
place.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: exp rhonki which cleared after forced cough, fine
bibasilar rales b/l
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley with yellow urine
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.
Pertinent Results:
[**2115-8-10**] 07:52PM LACTATE-0.8
[**2115-8-10**] 07:39PM GLUCOSE-91 UREA N-31* CREAT-3.4* SODIUM-137
POTASSIUM-4.4 CHLORIDE-117* TOTAL CO2-13* ANION GAP-11
[**2115-8-10**] 07:39PM CALCIUM-6.4* PHOSPHATE-2.0* MAGNESIUM-1.2*
[**2115-8-10**] 10:33AM PT-11.4 PTT-35.1 INR(PT)-1.1
[**2115-8-10**] 09:00AM ALT(SGPT)-23 AST(SGOT)-22 LD(LDH)-206 ALK
PHOS-71 TOT BILI-0.5
[**2115-8-10**] 09:00AM ALBUMIN-2.4*
[**2115-8-10**] 05:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2115-8-10**] 05:15AM URINE RBC-0 WBC-<1 BACTERIA-MOD YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2115-8-10**] 05:15AM URINE EOS-NEGATIVE
[**2115-8-10**] 04:50AM WBC-3.3* RBC-1.97*# HGB-6.4*# HCT-19.4*#
MCV-99* MCH-32.6* MCHC-33.1 RDW-14.2
[**2115-8-10**] 04:50AM NEUTS-93.3* LYMPHS-2.2* MONOS-3.3 EOS-1.1
BASOS-0.1
[**2115-8-12**] CT Chest -- IMPRESSION: 1. Multiple scattered
ground-glass opacities with a more confluent consolidation in
the right middle lobe as described above suggests multifocal
infection. Given the patient's immune compromised status,
atypical infections can be considered. Please follow to
radiographic resolution with follow-up imaging. 2. Mediastinal
lymphadenopathy is only minimally increased in size compared
with [**2110**] and is likely reactive. 3. Small bilateral pleural
effusions with associated atelectasis.
[**2115-8-13**] TTE -- IMPRESSION: Mild symmetric LVH with normal global
and regional biventricular systolic function. Indeterminate
pulmoanry pressures. No clinically significant valvular disease
seen. Compared with the report of the prior study (images
unavailable for review) of [**2108-4-9**], the findings appear
similar.
[**2115-8-14**] LE dopplers -- IMPRESSION: No evidence of DVT in
bilateral lower extremity veins.
[**2115-8-16**] Bronchoscopy -- The airway anatomy was grossly normal.
All airways were visualized. The mucosa was slightly friable,
with scant secretions throughout.
[**2115-8-16**] BAL -- 42% Polys, 0% Lymphs, 9% Monos, 37% Eos, 1% Basos,
11% Macro
[**2115-8-19**] STOOL OVA + PARASITES-FINAL negative
[**2115-8-19**] STOOL OVA + PARASITES-FINAL negative
[**2115-8-18**] Immunology ([**Month/Day/Year 1074**]) [**Month/Day/Year 1074**] Viral Load-FINAL negative
[**2115-8-16**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL negative; Respiratory Viral Antigen
Screen-FINAL negative
[**2115-8-16**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL negative{YEAST}; LEGIONELLA CULTURE-PRELIMINARY;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL negative; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL negative; ACID FAST CULTURE-PRELIMINARY; VIRAL
CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY; CYTOMEGALOVIRUS EARLY
ANTIGEN TEST (SHELL VIAL METHOD)-FINAL negative
[**2115-8-14**] CATHETER TIP-IV WOUND CULTURE-FINAL negative
[**2115-8-14**] BLOOD CULTURE Blood Culture, Routine-FINAL negative
[**2115-8-13**] BLOOD CULTURE Blood Culture, Routine-FINAL negative
[**2115-8-13**] BLOOD CULTURE Blood Culture, Routine-FINAL negative
[**2115-8-11**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL
INPATIENT
[**2115-8-11**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT
[**2115-8-11**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
LEGIONELLA CULTURE-FINAL; Immunoflourescent test for
Pneumocystis jirovecii (carinii)-FINAL INPATIENT
[**2115-8-11**] Immunology ([**Month/Day/Year 1074**]) [**Month/Day/Year 1074**] Viral Load-FINAL INPATIENT
[**2115-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2115-8-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
LEGIONELLA CULTURE-FINAL; Immunoflourescent test for
Pneumocystis jirovecii (carinii)-FINAL INPATIENT
[**2115-8-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2115-8-10**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2115-8-10**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT
[**2115-8-10**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2115-8-10**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
[**2115-8-10**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
Brief Hospital Course:
60 yo male with pmhx of HIV/AIDS (last CD4 count of 9 [**2115-8-4**])
presenting [**2115-8-10**] with hypotension (SBP 70s), fevers and dyspnea
on exertion.
.
Sepsis due to aspiration pneumonia
- the patient was admitted to the ICU, and required aggressive
fluid resuscitation and a pressor as well as albumin. Testing
for adrenal insufficiency was negative.
Given his recent hospitalization, he was treated with pip/tazo
([**Date range (1) 11404**]), azithro ([**8-10**], d/c??????ed [**8-11**] due to concern for resistant
[**Month/Day (2) **] with monotherapy), and vancomycin ([**8-10**]-). Bactrim also
started on admission due to concern for PCP in setting of low
CD4 count; it was later decreased to prophylactic dose. His
pip/tazo was changed to meropenem ([**Date range (1) 11405**]) to cover ESBL. All
culture data was negative/no growth by the time of discharge
(see results section). Beta glucan was negative, galactomannan
was negative. [**Date range (1) 1074**] viral load was negative x 2. Further testing
included lower extremity dopplers which were negative, and a
bronchoscopy was performed [**8-16**]. See results section.
- Infectious Disease and Pulmonary followed the patient.
.
Blurry vision with history of [**Month/Day (4) 1074**] retinitis
- the patient was seen by Ophthalmology who found only old
retinal lesions
.
HIV/AIDS (CD4 9 on [**2115-8-4**], not on [**Date Range 2775**])
- not on [**Date Range 2775**] per patient preference, CD4 9 for 6 months
- TMP/SMX ppx
- no [**Date Range **] ppx despite low CD4 given that he has had [**Date Range **] before
and monotherapy with [**Date Range **] could lead to [**Date Range **] resistance
- ID followed, genotype sent this hospitalization, will consider
[**Date Range 2775**] in the future at outpt f/u with Dr. [**Last Name (STitle) **]
.
Recent gastritis/esophagitis s/p EGD w/bx
- omeprazole [**Hospital1 **]
- bx unremarkable
.
Leukopenia and eosinophilia of unclear etiology, transient
thrombocytopenia
- ddx included rxn to recent pip/tazo, neoplasia, allergy,
autoimmune dz, parasite
- pip/tazo was d/c'd, urine eos were negative, and this was
ultimately attributed to his HIV
- his thrombocytopenia was ultimately felt to be due to his
sepsis and had resolved by discharge
.
Increased alkaline phosphatase and GGT near discharge
- could be [**1-10**] meropenem
- suggest recheck as an outpatient
.
Orthostasis
- near discharge, the patient had some orthostasis
- this was successfully treated by encouraging him to take PO
liquids until his urine was a light yellow color
- he ambulated alone several times prior to discharge without
difficulty and was encouraged to continue to keep himself well
hydrated
.
Other
- the patient was continued on his home bupropion
.
FEN w/stage IV CKD s/p R nephrectomy
- he was given a regular diet w/supplements tid
.
Dispo: discussed with [**Name (NI) **] [**Name (NI) **] (pt's case manager) at [**Telephone/Fax (1) 11406**]
.
DAY OF DISCHARGE
Interval history: The patient felt fairly well on the day of
discharge. He had successfully hydrated himself and had
ambulated without difficulty alone several times. I answered
his questions.
.
Exam:
Vitals reviewed in bedside chart, some mild orthostasis, but no
tachycardia, afebrile, no O2 req
Gen: middle aged AAM seated next to bed, alert, cooperative, NAD
HEENT: PERRL, anicteric
Chest: equal chest rise, CTAB posteriorly x for occ crackles in
bases
Heart: RRR, no obvious m/r/g
Abd: soft, NTND
Extr: WWP, no edema
Skin: no rashes
Neuro: no obvious focal deficits
Psych: normal affect
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Omeprazole 20 mg PO BID
2. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR)
3. Fluconazole 200 mg PO Q24H
4. BuPROPion (Sustained Release) 150 mg PO QAM
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR)
4. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]:PRN dry/itchy eyes
RX *artificial tear (hypromellose) 0.4 % 1-2 DROPS OU twice a
day Disp #*1 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aspiration pneumonia after recent EGD
HIV/AIDS, CD4 count 9, not on [**Hospital 2775**]
Esophagitis
Leukopenia and eosinophilia
Orthostasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with low blood pressure and
found to have a pneumonia. You were treated for this and
improved.
Followup Instructions:
You currently have an appointment with:
Name: [**Name6 (MD) 3577**] [**Last Name (NamePattern4) 11407**], MD
When: Tuesday [**8-27**] at 12pm
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
You told us that you're moving your primary care to [**Hospital1 3278**], and
that you have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Infectious
Disease at [**Hospital 3278**] Medical Center, on [**8-30**]. Phone
[**Telephone/Fax (1) 11408**], Fax: [**Telephone/Fax (1) 11409**]. It's very important you go to
this appointment for ongoing care. Please call Dr.[**Name (NI) 11410**]
office to cancel that appointment if you do not intend on going.
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Completed by:[**2115-8-22**]
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
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13126, 13184
|
8841, 12412
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308, 394
|
13368, 13368
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4424, 8818
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13673, 14616
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3395, 3621
|
12720, 13103
|
13205, 13347
|
12438, 12697
|
13519, 13650
|
2790, 2878
|
3636, 4405
|
229, 270
|
422, 2322
|
13383, 13495
|
2366, 2767
|
2894, 3379
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,164
| 131,934
|
17358
|
Discharge summary
|
report
|
Admission Date: [**2180-11-24**] Discharge Date: [**2180-12-15**]
Date of Birth: [**2104-12-20**] Sex: M
Service: NEUROLOGY
Allergies:
Demerol / Lactose
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
HA, nausea/vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a 75 year old man with numerous vascular
risk
factors presenting with one day of nausea, vomiting, diarrhea,
and headache. He was feeling well until 0400 on [**2179-11-24**] when he
woke up with nausea and vomiting which recurred throughout the
day (nonbloody, nonbilious). He had associated watery diarrhea
at
least 4 times. He also had an associated headache that worsened
with vomiting; it was right frontal, monotone, and without any
associated neurologic symptoms such as visual change, weakness,
numbness, or severe or progressive lethargy. He didn't feel
tired
at all until he was evaluated in an OSH. This AM while
showering,
he experienced a fall: he felt that he lost his balance while
feeling nauseated and fell onto his back. There was no head
strike or loss of consciousness. He denies any other antecedent
symptoms. He denies any vertigo but did feel dizzy
("imbalanced"); this did not worsen with position change, but he
does feel more nauseated when sitting up.
He went to an OSH where his head was scanned and the NCHCT
showed
a large R cerebellar hypodensity, prompting a transfer to [**Hospital1 18**]
for further care. He was given Decadron 10 and Lorazepam after
which he felt drowsy.
On neurologic review of systems, the patient endorses headache.
Denies lightheadedness or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
Endorses a fall.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Endorses nausea, vomiting, diarrhea. Denies constipation or
abdominal pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
[] Cardiovascular - CAD s/p CABG x 4, PAF, HTN, HL, CHF
[] Endocrine - DM2
[] Gastrointestinal - Ulcerative colitis, s/p inguinal hernia
repair (bilateral)
[] Renal - s/p nephrolithiasis
[] MSK - s/p R ankle surgery
Social History:
Lives with fiancee. Uses a cane to walk.
Family History:
Mother with hx of aneurysm
Physical Exam:
Physical Examination on Admission:
VS T: 98.2 HR: 116 BP: 193/87 RR: 18 SaO2: 97% RA
General: NAD, lying in bed comfortably but intermittently turns
over. / Head: NC/AT, no conjunctival icterus, no oropharyngeal
lesions / Neck: Supple, no nuchal rigidity, no meningismus /
Cardiovascular: initially irregularly irregular rhythm and then
RRR with occasional premature beats/ Pulmonary: Equal air entry
bilaterally, poor effort / Abdomen: Soft, NT, ND, +BS, no
guarding / Extremities: Warm, BLE pitting edema edema, palpable
radial pulses / Skin: Stasis dermatitis BLE
Neurologic Examination:
- Mental Status - Awake, drowsy with eyes closed but easily
arousable, oriented x 4. Recalls a coherent history.
Registration
[**1-20**] and recall [**1-20**]. Attention easily attained and maintained.
Follows two step commands, midline and appendicular. Language
fluent with intact repetition and verbal/[**Location (un) 1131**] comprehension,
normal writing. Normal prosody. No paraphasic errors. High and
low frequency naming intact. No dysarthria. No apraxia or
neglect.
- Cranial Nerves - [II] Pupils 4->3 L, R 3->2 brisk. VF full to
number counting. Funduscopy obscured by eye movement but no
papilledema. [III, IV, VI] EOMI, 3-4 beats extreme lateral
end-gaze nystagmus, slow saccades. [V] V1-V3 without deficits to
light touch bilaterally. [VII] No facial asymmetry with
volitional smile/forced eye closure/puffing cheeks, but looks
slightly droopy on right at rest (notably edentulous, leaning to
right in bed). [VIII] Hearing intact to finger rub bilaterally.
[IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength
5/5 bilaterally. [XII] Tongue midline.
Unable to tolerate [**Last Name (un) **]-Hallpike maneuver. No reproducible
symptoms with head jerk.
- Motor - Normal bulk. Increased tone in both legs. No
pronation,
no drift. No tremor or asterixis.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory - No deficits to light touch, pinprick,
proprioception.
Decreased vibratory sensation at least to knees bilaterally, ~ 6
seconds..
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response equivocal bilaterally.
- Coordination - Minimal dysmetria on finger to nose testing,
but
prominent overshoot R > L with mirrored movements with hands and
feet. Dysdiadochokinesia with R > L. Minimal or no truncal
ataxia
when sitting up with arms wrapped around torso.
- Gait - Refused.
=================================
Pertinent Results:
Labs
[**2180-11-24**] 03:00PM SODIUM-137 POTASSIUM-4.7 CHLORIDE-98
[**2180-11-24**] 03:00PM cTropnT-0.05*
[**2180-11-24**] 03:00PM OSMOLAL-324*
[**2180-11-24**] 07:57AM GLUCOSE-266* UREA N-26* CREAT-1.2 SODIUM-142
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13
[**2180-11-24**] 07:57AM CK-MB-3 cTropnT-0.03*
[**2180-11-24**] 07:57AM CALCIUM-7.4* PHOSPHATE-3.3# MAGNESIUM-1.8
CHOLEST-88
[**2180-11-24**] 07:57AM %HbA1c-8.2* eAG-189*
[**2180-11-24**] 07:57AM TRIGLYCER-71 HDL CHOL-27 CHOL/HDL-3.3
LDL(CALC)-47
[**2180-11-24**] 07:57AM OSMOLAL-320*
[**2180-11-24**] 07:57AM WBC-9.5 RBC-3.36* HGB-10.5* HCT-31.1* MCV-93
MCH-31.3 MCHC-33.8 RDW-15.2
[**2180-11-24**] 07:57AM [**Name (NI) 8255**] TO PTT-UNABLE TO INR(PT)-UNABLE
TO
[**2180-11-24**] 07:57AM PLT COUNT-119*
[**2180-11-24**] 07:57AM [**Name (NI) 8255**] TO PTT-UNABLE TO INR(PT)-UNABLE
TO
[**2180-11-24**] 01:15AM GLUCOSE-311* UREA N-29* CREAT-1.4* SODIUM-139
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-29 ANION GAP-17
[**2180-11-24**] 01:15AM estGFR-Using this
[**2180-11-24**] 01:15AM ALT(SGPT)-23 AST(SGOT)-26 LD(LDH)-259* ALK
PHOS-95 TOT BILI-0.4
[**2180-11-24**] 01:15AM LIPASE-31
[**2180-11-24**] 01:15AM OSMOLAL-314*
[**2180-11-24**] 01:15AM URINE HOURS-RANDOM
[**2180-11-24**] 01:15AM URINE GR HOLD-HOLD
[**2180-11-24**] 01:15AM WBC-9.7 RBC-3.62* HGB-11.3* HCT-33.1* MCV-92
MCH-31.1 MCHC-33.9 RDW-15.0
[**2180-11-24**] 01:15AM NEUTS-93.8* LYMPHS-4.3* MONOS-1.6* EOS-0
BASOS-0.2
[**2180-11-24**] 01:15AM PLT COUNT-118*
[**2180-11-24**] 01:15AM PT-13.0* PTT-30.9 INR(PT)-1.2*
[**2180-11-24**] 01:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2180-11-24**] 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2180-11-24**] 01:15AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2180-12-10**] 06:14AM BLOOD WBC-6.7 RBC-2.53* Hgb-7.7* Hct-23.9*
MCV-94 MCH-30.5 MCHC-32.3 RDW-14.9 Plt Ct-242
[**2180-12-12**] 06:05AM BLOOD WBC-6.7 RBC-2.67* Hgb-8.0* Hct-24.4*
MCV-91 MCH-29.9 MCHC-32.8 RDW-15.8* Plt Ct-246
[**2180-12-13**] 05:17AM BLOOD WBC-6.7 RBC-2.72* Hgb-8.2* Hct-25.1*
MCV-92 MCH-30.1 MCHC-32.6 RDW-15.9* Plt Ct-251
[**2180-12-14**] 04:40AM BLOOD WBC-9.7 RBC-2.72* Hgb-8.0* Hct-25.2*
MCV-93 MCH-29.6 MCHC-31.9 RDW-15.6* Plt Ct-255
[**2180-12-15**] 06:57AM BLOOD WBC-11.5* RBC-2.79* Hgb-8.9* Hct-25.8*
MCV-92 MCH-31.8 MCHC-34.4 RDW-15.4 Plt Ct-238
[**2180-12-10**] 06:14AM BLOOD Glucose-142* UreaN-32* Creat-1.3* Na-141
K-4.2 Cl-100 HCO3-34* AnGap-11
[**2180-12-12**] 06:05AM BLOOD Glucose-74 UreaN-29* Creat-1.3* Na-139
K-4.5 Cl-100 HCO3-33* AnGap-11
[**2180-12-13**] 05:17AM BLOOD Glucose-87 UreaN-30* Creat-1.3* Na-141
K-4.5 Cl-102 HCO3-37* AnGap-7*
[**2180-12-14**] 04:40AM BLOOD Glucose-101* UreaN-28* Creat-1.3* Na-139
K-4.2 Cl-100 HCO3-35* AnGap-8
[**2180-12-15**] 06:57AM BLOOD Glucose-116* UreaN-26* Creat-1.2 Na-143
K-4.1 Cl-103 HCO3-36* AnGap-8
[**2180-12-12**] 06:05AM BLOOD ALT-12 AST-19 AlkPhos-106 TotBili-0.3
[**2180-12-8**] 07:10PM BLOOD CK-MB-2 cTropnT-0.03* proBNP-2864*
[**2180-11-24**] 07:57AM BLOOD %HbA1c-8.2* eAG-189*
[**2180-11-24**] 07:57AM BLOOD Triglyc-71 HDL-27 CHOL/HD-3.3 LDLcalc-47
MR head [**2180-11-24**]:
1. Extensive right cerebellar acute infarct extending into the
tonsil and
vermis with narrowing of the cerebral aqueduct, placing patient
at increased risk for obstructive hydrocephalus.
2. No current evidence for tonsillar herniation.
3. Highly motion degraded MRA evaluation revealing
nonvisualization of distal V4 segment of right vertebral artery.
Recommend further assessment by CTA if feasible and clinically
relevant.
4. Bilateral cerebral volume loss and corpus callosal thinning,
likely age
related involution.
5. Remote left frontal infarct.
6. Small vessel ischemic disease.
CT head [**2180-11-25**]:
IMPRESSION:
1. Extensive right cerebellar infarct with extension into the
tonsil and
vermis, with a similar degree of effacement of the cerebral
aqueduct. No
short interval change in ventricular size.
2. New small focus of hemorrhage in the right cerebellar
infarct, concerning for impending hemorrhagic conversion or
petechial hemorrhage.
3. Slightly low lying tonsils without definite current tonsillar
herniation.
4. Remote left frontal infarct.
5. Age-related involution.
CXR [**2180-11-27**]:
IMPRESSION: New mild pulmonary edema with otherwise stable left
[**Doctor Last Name **] lobe
atelectais and bilateral pleural effusions.
CXR [**2180-11-28**]:
FINDINGS: As compared to the previous radiograph, the evidence
of
mild-to-moderate pulmonary edema is unchanged. The presence of a
left pleural effusion still cannot be excluded. Mild
cardiomegaly, left-sided PICC line. No newly appeared focal
parenchymal opacities.
CT head [**2180-11-28**]:IMPRESSION:
1. No significant interval change in right cerebellar infarction
with foci of
hemorrhagic transformation.
2. Mild interval increase in effacement of the aqueduct of
Sylvius and 4th
ventriclefrom increasing edema/mass effect.
3. Hypodense lesion in the left frontal lobe with a pattern
resembling
vasogenic edema is again noted. A post-contrast study might help
differentiate
whether this lesion is secondary to ischemic changes vs.
underlying neoplastic
lesion.
4. Chronic conditions including small vessel ischemic disease
and cerebral
volume loss are again noted.
CT Head [**2180-12-2**]: IMPRESSION: Continued evolution of right
cerebellar infarction with hemorrhagic transformation. No new
foci of hemorrhage are identified. Similar configuration of the
ventricles as compared to the prior examination.
Video Swallow [**12-5**]: IMPRESSION: Aspiration and penetration with
thin and nectar liquids. Mild penetration, mild to moderate
pharyngeal residue with puree. For details, please refer to
speech and swallow note in OMR.
Posterior parapharyngeal lesion at level of C3-C4 may represent
a lymph node or less likely, a stent. Neck radiographs would be
helpful in evaluating this finding.
Neck Radiograph [**2180-12-5**]: IMPRESSION: Extensive DISH with
associated cervical spine fusion C3-7. These findings probably
account for findings noted on swallowing study
Video Swallow [**2180-12-7**]: IMPRESSION: Penetration, but no
aspiration, with thin and nectar thick-liquids, which is an
improvement since the prior study. No penetration with
honey-thick liquids.
CT Head [**12-8**]: IMPRESSION:
Stable evolution of a right cerebellar infarct. No new acute
process.
CXR [**12-12**]: FINDINGS: As compared to the previous radiograph,
there is unchanged evidence of moderate-to-severe bilateral
effusions. Unchanged signs of mild fluid overload. In the
interval, the nasogastric tube has been removed, the left PICC
line remains in place. Unchanged moderate cardiomegaly
Video Swallow [**12-14**]: Report IMPRESSION: Deep penetration with
thin liquids. Normal swallowing with other barium consistencies.
********
Brief Hospital Course:
The patient is a 75yoM h/o PAF, CAD s/p CABG, CHF, DM2, HL, UC
who presented on [**2180-11-24**] with a 1-day history of nausea,
vomiting, diarrhea and headache. Exam notable for R facial
droop, ?R Horner's, mild rebound/overshoot on R without frank
dysmetria, no strength deficits. CT head showed large right
cerebellar hypodensity with significant edema and mass effect.
The patient was started on Mannitol and admitted to the neuro
ICU for close monitoring. He was seen by neurosurgery who did
not feel that there was any indication for acute surgical
intervention.
.
ICU COURSE:
.
# NEURO:
MRI on [**11-24**] showed large acute infarct in R cerebellar hemisphere
with extension into vermis and significant surrounding edema
with narrowing of aqueduct of Sylvius. There was no evidence of
hydrocephalus. MRA showed poor visualization of distal R
vetebral. Repeat CT on [**11-25**] showed stable appearance of infarct
with small area of hemorrhagic conversion. Mannitol was stopped
on [**11-26**] due to worsening renal function. His neurologic exam
remained stable, with mild R-sided dysmetria with overshoot on
FNF as well as slow and clumsy [**Doctor First Name **] on the R. He remained rather
lethargic but was easily arousable and responded appropriately
once awoken. He was continued on aspirin 300mg PR; the rest of
his home medications were held initially due to his dysphagia.
These were restarted once oral access was obtained. An
echocardiogram showed no cardioembolic source. HbA1c was 8.2,
and lipids were at goal with LDL of 47.
.
On [**11-28**] a repeat head CT was obtained as he appeared slightly
more lethargic than before. This showed no significant interval
change in cerebellar infarct with mild interval increase in
effacement of the aqueduct of Sylvius without any evidence of
hydrocephalus. His neurologic exam was otherwise stable, and on
repeat evaluation he was more arousable and responding
appropriately, consistent with prior examinations.
.
# CV:
He was maintained on telemetry monitoring, which showed
intermittent irregular heart rate likely [**12-21**] a fib. He was
maintained on aspirin 300mg PR while NPO and restarted on his
home aspirin 325mg and atorvastatin 80mg daily for his history
of CAD once PO access was obtained. BP was initially allowed to
autoregulate up to 160. He was maintained on metoprolol 10mg IV
Q6, which was then converted to 25mg [**Hospital1 **] once able to take PO.
Transthoracic echo showed a moderately dilated LA, normal
systolic function with EF > 55%, mild LVH, and mild MR. There
was no evidence of PFO.
.
# Pulm:
His course was complicated by the development of likely
aspiration pneumonia. CXR showed bilateral pleural effusions
without clear infiltrate. He was placed on supplemental O2 and
started on Vanc/Zosyn with improvement.
.
# ID:
He developed a low grade fever to 100.3 on the morning of [**11-26**],
after noted to have been coughing on sips of thin liquids. His
WBC increased to 14.2. Blood and sputum cultures were sent. UA
was negative. CXR showed slight progression in bilateral pleural
effusions and left basal atelectasis without clear infiltrate.
He continued to have low grade fevers with leukocytosis and also
developed a new oxygen requirement. On [**11-27**] he was started on
Vanc and Zosyn for empiric coverage for likely aspiration
pneumonia. He subsequently defervesced and his WBC normalized.
.
# Renal:
Mannitol was stopped on [**11-26**] due to acute renal failure with a
peak Cr of 3.6. Nephrology was consulted and he was started on
gentle IV hydration with improvement in his renal function.
.
# ENDO:
HbA1c was 8.2%. He was maintained on fingersticks Q6 with
insulin sliding scale as needed.
.
# GI/FEN:
He was initially cleared for a regular diet by bedside swallow
evaluation but was subsequently noted to be coughing with sips
of liquid. He was made NPO and started on maintenance IVF. He
subsequently failed formal swallow eval and a Dobhoff tube was
placed. Tube feeds were started on [**11-28**].
.
# PROPHYLAXIS:
He was maintained on heparin SC and pneumoboots for DVT
prophylaxis. He was maintained on a bowel regimen for GI
prophylaxis
.
# CODE STATUS: full
.
.
Patient was transferred to the neurology step-down unit on
[**2180-11-28**].
.
FLOOR COURSE:
He was transferred to the neurology floor on [**11-28**]. His
neurologic exam remained stable, with mild R-sided dysmetria and
overshoot on FNF as well as slow and clumsy [**Doctor First Name **] on the R. He
remained rather lethargic but was easily arousable and responded
appropriately once awoken. Overnight between [**Date range (1) 48570**] he
desaturated to the 80's and was placed on NRB. He was then
placed on humidified face mask and maintained sats 90-95%.
However throughout the day he remained tachypneic with
increasing O2 requirements. He was transferred back to the ICU
on [**11-29**] for increasing respiratory distress.
.
ICU COURSE:
In the ICU he was initially started on BiPap which he reportedly
did not tolerate well. He was then placed on 100% humidified
fask mask and has been maintaining his saturation well in the
90's. He also received 2 doses of lasix 40mg IV for likely
component of volume overload. This am he has been weaned to 70%
face tent. He remains somewhat tachypneic with RR in the 20's
and appears tired. Other than his lethargy his neurologic exam
is unchanged.
Once stable the patient was again transferred to the floor.
While on the floor, the patient continued to have issues with
his respiratory status and was difficult to wean off of oxygen.
He was on TFs to maintain an adequate nutritional status. He
underwent a video swallow study on [**2180-12-5**] which showed
aspiration and penetration with thin and nectar liquids, mild
penetration, mild to moderate pharyngeal residue with puree. The
patient's diet could not be advanced at this time. He was
re-evaluated with another video swallow on [**2180-12-7**] which showed
penetration, but no aspiration, with thin and nectar
thick-liquids, which is an improvement since the prior study.
The patient was started on pureed with honey-thickened liquids
at this time.
On [**2180-12-8**], the patient was much more somnolent than usual. He
was difficult to arouse late in the day, and his oxygen
requirements increased. At this time he was transferred to the
ICU for management of his somnolence and increased oxygen
requirement. A stat head CT was done which did not showed stable
evolution of a right cerebellar infarct with no new acute
processes. He was started on BiPap to maintain adequate oxygen
saturation. He was also diuresed with both lasix and
acetazolamide while in the ICU.
He was transferred back to the stepdown unit on [**2180-12-10**].
Diuresis was continued with lasix. His goal fluid balance should
be even to 1 L negative daily while at rehab and lasix dosing
should be adjusted accordingly in rehab. He was switched to face
mask during the day and BiPap at night to maintain adequate
oxygenation. Pulmonary recommended advair, spiriva, and duonebs
to assist his respiratory status. He pulled his DHT on [**2180-12-11**].
It was decided to not restart his TFs. A discussion with the
patient and family about PEG placement was pursued, but
ultimately the family decided to hold off and give the patient a
chance to advance his diet. His diet was advanced to ground
solids and nectar liquids on [**2180-12-14**], but the patient continued
to have poor intake. During this time his respiratory status
continued to improve and he was gradually weaned off oxygen. The
patient's foley was d/c'ed on [**2180-12-14**]. The patient was started
on coumadin 5mg qd on [**2180-12-14**].
The day of discharge the patient's PICC line was pulled. His
diet was ground pureed solids and nectar thickened liquids. He
was requiring 2L NC oxygen at time of discharge.
Medications on Admission:
ASA 325, Atorvastatin 80, Valsartan 160 daily,
?Metoprolol tartrate 100 qhs, Furosemide 40 daily, Insulin 70/30
63 units qAM and 33 units qPM Allopurinol 100 q8h, Docusate,
Ferrous sulfate 325 [**Hospital1 **], Fluticasone 50 [**Hospital1 **], Lidoderm patch,
MVI,
Klorcon 10 mEQ daily, Sulfasalaine 1000 q6h, Prochlorperazine 5
PRN, Cholecalfirerol, Omega 3 fish oils
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/HA.
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
14. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. furosemide 10 mg/mL Solution Sig: Two (2) Injection DAILY
(Daily).
16. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Right cerebellar infarct
Aspiration pneumonia
Acute renal failure
atrial fibrillation
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 **],
You were admitted to [**Hospital1 69**] on
[**2180-11-24**] with headache, nausea, and unsteady walking. You were
found to have a stroke affecting your right cerebellum in the
back of your brain. We believe the most likely cause of your
stroke was cardioembolic in nature.
.
You had several imaging studies including a head CT, head MRI,
multiple chest x-rays, and video swallow studies. The imaging of
your head showed a right cerebellar infarct. A chest x-ray in
the ICU showed a possible aspiration pneumonia for which you
received treatment. Video swallow studies initially showed
aspiration, but improved during your hospital course.
.
During your admission you were treated for pneumonia and kidney
dysfunction which have now improved. Your pneumonia was treated
with a full course of antibiotics, vancomycin and zosyn. Your
kidney dysfunction was likely medication induced by mannitol,
which was used to decrease swelling in your brain after your
stroke. Your kidney dysfunction has improved and is now at
baseline.
.
Your respiratory status was an ongoing issue during your stay.
You were sent back to the ICU twice for increased oxygenation
requirements. A contributor to this was excess fluid in your
lungs called pulmonary edema. You were given a medication called
lasix to pull some of this fluid out of your lungs. While at
rehab your goal fluid balance should be even to negative 1 liter
daily. You were also started on spiriva, advair, and duonebs as
recommended by the pulmonary service. Another component may be
either an underlying sleep apnea or new onset sleep apnea
related to your stroke. You were started on BiPap at night to
assist your breathing and oxygen requirements.
You received your nutrition via a dobhoff tube during your stay.
This was removed and your diet was slowly advanced as tolerated.
You will go to rehab on ground solids and nectar liquids diet.
.
During your stay you had several new medications started. Advair
and spiriva were added to assist your breathing. You were also
started on coumadin as we believe the newly diagnosed atrial
fibrillation potentially caused a clot to form in your heart and
was released to your blood circulation in your brain causing
your stroke. You will need your INR followed closely after
discharge from rehab. You should also get a sleep study and
pulmonary function testing done as an outpatient.
.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
.
Thank you for allow us at [**Hospital1 18**] to particpate in your care.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2181-2-16**] 11:00
Upon discharge from rehab you will need close followup for
management of coumadin at Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office located
at [**Hospital 48571**] Medical in [**Location (un) 8973**], MA Phone number [**Telephone/Fax (1) 48572**].
This should be scheduled before discharge from rehab.
At some point after your discharge from rehab, you should get
pulmonary function tests done. Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1391**] will be
able to refer you for this testing.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"428.0",
"434.11",
"276.4",
"427.31",
"276.0",
"327.23",
"V45.81",
"518.83",
"V45.82",
"507.0",
"250.02",
"E944.4",
"274.9",
"428.31",
"584.9",
"403.90",
"348.5",
"585.9",
"263.9",
"787.20",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
22210, 22292
|
12460, 20301
|
312, 318
|
22422, 22422
|
5469, 12437
|
25238, 26037
|
2611, 2639
|
20720, 22187
|
22313, 22401
|
20327, 20697
|
22605, 25215
|
2654, 2675
|
243, 274
|
346, 2298
|
2689, 3222
|
22437, 22581
|
3247, 5450
|
2320, 2537
|
2553, 2595
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,556
| 191,718
|
25630
|
Discharge summary
|
report
|
Admission Date: [**2135-8-12**] Discharge Date: [**2135-10-3**]
Date of Birth: [**2061-6-23**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Demerol
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic pseudocyst
Major Surgical or Invasive Procedure:
1. Pancreatico pseudocyst gastrostomy.
2. Open cholecystectomy.
3. Common bile duct exploration with stone removal.
4. T tube placement.
5. Small bowel resection.
6. Umbilical hernia repair.
7. J tube placement.
8. EGD
9. Angiography w/ embolization left gastric artery
History of Present Illness:
This 74-year-old gentleman was felled by acute gallstone
pancreatitis in [**Month (only) 116**] of this year. He had approximately a 1
month long stay in the hospital at that point in time, including
a protracted intensive care unit stay. He recovered quite nicely
in the big picture but has suffered from failure to thrive over
the last 3 months with weight lost of approximately 40 pounds.
He was known to have a pancreatic pseudocyst. This was followed
but recently he developed fevers and generalized fatigue and
malaise. Work-up showed an interval decrease in size of the
pancreatic pseudocyst. However, a percutaneous drainage attempt
yielded fungal elements. He was transferred to [**Hospital1 18**] for
thorough evaluation and treatment of his complex
pancreaticobiliary problem. Furthermore, there is evidence of
bile duct obstruction and early jaundice. Lastly he had a small
umbilical hernia.
He was accepted five days prior to prior to his operation. We
imaged
him with a CAT scan here that showed a large, complex
pancreatic pseudocyst with the SMA coursing directly through
the middle of it. It was multilocular but generally it sat
directly behind the stomach and had good possibilities for a
pseudocyst gastrostomy. Secondly, he had a bile duct close to
2 cm in diameter and jaundice which advanced each day during
his hospitalization. He was treated with antibiotics and
antifungal medication and prepared for an operative
intervention. This patient had never had an ERCP procedure
performed during his original hospitalization.
Past Medical History:
PMH:
1. h/o MI w/ V Fib arrest
2. HTN
3. hyperlipidemia
4. GERD
5. degenerative joint dz
6. TIAs
7. COPD
8. Pulm HTN
9. ETOH withdrawal
10.gallstone vs ETOH pancreatitis [**5-19**]
11.pancreatic pseudocsyt
12.Hypothyroidism
13.Lactose intolerance
14.BPH
15.Anemia
PSH:
tonsills
Aortic Valve replacement w/ Bovine valve for aortic stenosis
[**2-17**]
Social History:
History of alcohol abuse, quit smoking
Retired High School Math Teacher
Family History:
Diabetes in 2 maternal uncles
HTN mother (died at 52 from suicide)
Stomach CA (other relatives?)
Physical Exam:
VS: AFVSS
Gen: elderly man, looks younger than stated age, mild jaundice
and scleral icterus
HEENT: PERRL, EOMI. No thyromegaly or neck mass
Chest: CTAB
CV: RRR no m/r/g
Abd: soft, NT, no HSM, palpable edge of pseudocyst 3-4 cm below
costal margin bilaterally. No fluid wave or shifting dullness
present. +BS. Moderately distended.
EXT: NT, no edema
Neuro: no focal defecits
Pertinent Results:
[**2135-8-13**] 12:06AM BLOOD WBC-12.5* RBC-3.65* Hgb-10.8* Hct-31.7*
MCV-87 MCH-29.6 MCHC-34.1 RDW-17.3* Plt Ct-478*
[**2135-8-17**] 05:55PM BLOOD WBC-21.9*# RBC-4.22* Hgb-12.5*# Hct-36.6*
MCV-87 MCH-29.7 MCHC-34.2 RDW-17.2* Plt Ct-371
[**2135-8-30**] 07:02AM BLOOD WBC-11.5* RBC-3.26* Hgb-9.5* Hct-30.0*
MCV-92 MCH-29.1 MCHC-31.7 RDW-16.8* Plt Ct-271
[**2135-9-5**] 05:24AM BLOOD WBC-10.7 RBC-2.79* Hgb-8.3* Hct-25.2*
MCV-90 MCH-29.8 MCHC-33.0 RDW-16.6* Plt Ct-282
[**2135-9-20**] 11:46AM BLOOD WBC-7.9# RBC-3.79*# Hgb-11.5*# Hct-33.0*
MCV-87 MCH-30.4 MCHC-34.9 RDW-16.6* Plt Ct-164
[**2135-9-20**] 02:02AM BLOOD WBC-18.1*# RBC-3.03* Hgb-8.9* Hct-26.3*
MCV-87# MCH-29.4 MCHC-33.9 RDW-18.1* Plt Ct-262
[**2135-9-21**] 06:57PM BLOOD Hct-37.8*
[**2135-9-21**] 09:59PM BLOOD WBC-13.6*# RBC-4.29* Hgb-13.4* Hct-38.3*
MCV-89 MCH-31.3 MCHC-35.0 RDW-16.4* Plt Ct-227
[**2135-9-22**] 10:32AM BLOOD Hct-33.3*
[**2135-9-28**] 06:50AM BLOOD WBC-7.1 RBC-3.30* Hgb-10.8* Hct-30.4*
MCV-92 MCH-32.8* MCHC-35.6* RDW-16.0* Plt Ct-225
[**2135-8-13**] 12:06AM BLOOD PT-14.9* PTT-28.2 INR(PT)-1.5
[**2135-8-17**] 05:55PM BLOOD PT-16.2* PTT-29.2 INR(PT)-1.7
[**2135-9-20**] 08:17PM BLOOD PT-13.8* PTT-31.1 INR(PT)-1.3
[**2135-9-21**] 03:25AM BLOOD Plt Ct-169
[**2135-9-28**] 06:50AM BLOOD Plt Ct-225
[**2135-8-13**] 12:06AM BLOOD ALT-71* AST-110* LD(LDH)-190 AlkPhos-872*
Amylase-28 TotBili-4.8*
[**2135-9-19**] 08:43PM BLOOD ALT-45* AST-40 LD(LDH)-167 AlkPhos-787*
TotBili-1.2
[**2135-9-23**] 06:30AM BLOOD ALT-20 AST-19 LD(LDH)-159 AlkPhos-407*
TotBili-1.0
[**2135-8-13**] 12:06AM BLOOD Glucose-108* UreaN-12 Creat-0.8 Na-134
K-4.2 Cl-92* HCO3-32 AnGap-14
[**2135-8-21**] 08:40AM BLOOD Glucose-117* UreaN-4* Creat-0.5 Na-137
K-3.8 Cl-101 HCO3-28 AnGap-12
[**2135-9-4**] 06:32AM BLOOD Glucose-124* UreaN-14 Creat-1.3* Na-136
K-3.1* Cl-102 HCO3-22 AnGap-15
[**2135-9-19**] 08:43PM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-131*
K-4.7 Cl-101 HCO3-18* AnGap-17
[**2135-10-3**] 06:27AM BLOOD K-3.5
Brief Hospital Course:
Mr [**Known lastname 63951**] was brought to the operating room on the morning of
[**2135-8-17**] and underwent pancreatico pseudocyst gastrostomy with open
cholecystectomy, Common bile duct exploration with stone
removal, T tube placement, Small bowel resection, Umbilical
hernia repair, and J tube placement.
Post-operatively, the patient was extubated on POD #1 and
transferred to the floor on POD #2. Infectious Disease followed
and recommended the antibiotic regimen of Aztreonam, Vancomycin,
and Diflucan for surgical cultures growing C. Albicans and coag
negative staph. He did very in well in his first week
post-operatively. He was started on J-Tube tube feeds on POD
#10. Nutrition was following. The patient did have
intermittant episodes of nausea and vomiting, however, and he
had a CT scan on POD 13 which showed generalized stranding of
the greater omentum in the right upper quadrant with a trace of
free fluid in the upper abdomen with inflammatory stranding
along the left posterior retroperitoneum and some small amount
of fluid in the pelvis. He also began spiking fevers and having
loose stools at this time and ID followed closely. Bile culture
returned +VRE and the patient was started on Linezolid. His
fluids were followed and balaned closely as he was having high
T-tube output and low urine output. His volume status improved.
Antibiotics were stopped.
On POD 21 Mr [**Known lastname 63951**] began to feel nauseated again and had
mulptiple episodes of vomiting. The nausea persisted for
several days despite treatment with intermittant emesis, but he
was tolerating tube feeds. The patient refused an NGT. GI was
consulted and an EGD was obtained on [**9-14**], showing an intrinsic
narrowing of the proximal second part of the duodenum with
diffuse eythema and congestion of the duodenal and gastric
mucosa consistent with gastritis and duodinitis. He did well
for several days, but then had intermittant vomiting again (once
every few days), Pt continued to refuse NGT.
On POD 33 ([**2135-9-19**]), Mr [**Known lastname 63951**] began to have hememetis and was
transferred to the SICU for aggressive rescusitation, intubation
for airway protection, and EGD with GI fellow. A single ulcer
at GE junction was identified and cauterized, along with
erosions in the antrum and lesser curve of the stomach. The
following day, angiography did not show active bleeding and
rophylactic embolization of the left gastric artery with Gelfoam
slurry was performed. His bleeding stablized and he improved
gradually. Repeat EGD showed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 63952**] [**Doctor First Name **]-[**Doctor Last Name **] tear.
He was able to be extubated on POD 35 and underwent
internilaztion of CBD stent. He was trasferred back to the
floor after a few days. NGT remained as patient had continued
N/V when NGT clamped. An UGI with swallow study on [**9-28**] showed
2 cm proximal duodenal stricture with eventual passage of
contrast after a few minutes. He tolerated clampged NGT for
several days and on POD 44 his NGT was removed. He continued to
do well without nausea vomiting, and was able to be discharged
to Rehab on POD #46.
Social Work and Psychiatry also followed along with this
admission for depressed mood secondary to long hospital course.
His TSH was followed closely (elevated at 28), he was treated
with Levoxyl and Ritalin, and gradually improved.
Medications on Admission:
ECASA 81QD
Toprol XL 100 QD
Enalopril 20 QD
Levoxyl 137mcg QD
Lipitor 10 QD
Folic Acid 1mg QD
HCTZ 25mg QD
Prevacid 30 mg QD
Ambien 10mg QHS
Glucosamine and chondoitin
[**Doctor First Name **] 60mg [**Hospital1 **] prn allergies
Flonase, 2 sprays each nostril [**Hospital1 **] prn allergies
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
3. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: [**1-16**] Nasal
[**Hospital1 **] (2 times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic PRN (as needed).
5. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
6. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
7. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO
once a day.
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed.
9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
12. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
13. Benzocaine 20 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane PRN (as needed).
14. Loperamide 2 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
16. 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:
Pancreatic Pseudocyst
UGI bleed secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear
Duodenal stricture
Bile duct stricture s/p stent
hypothyroidism
gastritis
duodentitis
Depression
Discharge Condition:
stable, tolerating tube feeds, no nausea/vomiting, afebrile
Discharge Instructions:
Please, nothing by mouth until follow-up with Dr. [**Last Name (STitle) **].
You may shower, keep J-Tube dry.
Ambulate several times a day.
Return to the hospital or call your physician [**Name Initial (PRE) **]:
Return of nausea/vomiting, fevers >101.5. severe abdominal pain,
lightheadedness, signs of infection at J-tube including
increased pain or redness/drainage of pus.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**3-18**] wks, call to schedule
an appintment [**Telephone/Fax (1) 1231**]
|
[
"244.9",
"535.41",
"250.00",
"416.8",
"530.7",
"309.0",
"577.1",
"537.3",
"567.8",
"496",
"401.9",
"574.41",
"V42.2",
"553.1",
"293.0",
"112.5",
"577.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"46.39",
"53.49",
"38.93",
"52.96",
"45.62",
"45.13",
"51.22",
"42.33",
"87.54",
"51.41",
"51.98",
"44.43",
"45.91",
"44.44"
] |
icd9pcs
|
[
[
[]
]
] |
10419, 10498
|
5142, 8584
|
302, 574
|
10738, 10800
|
3142, 5119
|
11226, 11360
|
2632, 2730
|
8926, 10396
|
10519, 10717
|
8610, 8903
|
10824, 11203
|
2745, 3123
|
241, 264
|
602, 2152
|
2174, 2527
|
2543, 2616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,906
| 165,631
|
1695
|
Discharge summary
|
report
|
Admission Date: [**2190-10-29**] Discharge Date: [**2190-11-3**]
Date of Birth: [**2135-11-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Migraine headaches
Major Surgical or Invasive Procedure:
[**2190-10-29**] Minimally-invasive closure of patent foramen ovale
[**2190-10-30**] Right VATS evacuation of hemothorax, placement of left
chest tube placement, and flexible bronchoscopy.
History of Present Illness:
This is a 54 year old male with history of severe migraine
headaches. They currently have become more frequent that he has
to remain constantly medicated. He is followed by a neurologist,
Dr. [**Last Name (STitle) 656**]. Outside evaluation revealed a patent foramen ovale
by echocardiogram. Cardiac catheterization in [**2190-10-9**]
showed normal coronary arteries and normal LV function. He now
presents for cardiac surgical intervention.
Past Medical History:
Migraine headaches, Cold induced Asthma, s/p appendectomy, s/p
knee surgery
Social History:
Denies tobacco. Denies excessive ETOH - social drinker. He is
married. He works as an attorney.
Family History:
Father and sister suffered from migraine headaches.
Physical Exam:
Vitals: BP 110/78, HR 65
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple, no jvd, no carotid bruits
Heart: regular rate, s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: benign
Ext: warm, no edema
Pulses: 2+ distally
Neuro: alert and oriented, CN2-12 intact, no focal deficits
noted
Pertinent Results:
[**2190-11-3**] 06:15AM BLOOD Hct-27.6*
[**2190-11-2**] 06:40AM BLOOD WBC-5.1 RBC-2.63* Hgb-8.8* Hct-24.1*
MCV-92 MCH-33.6* MCHC-36.7* RDW-13.4 Plt Ct-224
[**2190-11-3**] 06:15AM BLOOD K-4.4
[**2190-11-1**] 07:05AM BLOOD Glucose-104 UreaN-10 Creat-1.0 Na-132*
K-4.6 Cl-97 HCO3-29 AnGap-11
[**2190-11-1**] 07:05AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 9763**] was admitted and underwent a minimally invasive
closure of his patent foramen ovale. Surgery was uneventful and
he was brought to the CSRU in stable condition. Overnight, he
was noted to have a significant drop in hematocrit(28 to
20%)with increasing chest tube drainage. He was given multiple
blood products. A chest x-ray was also notable for a small left
apical pneumothorax. Due to concern for hemothorax, he returned
to the operating room for VATS procedure wth placement of chest
tubes. He tolerated the procedure and returned to the CSRU in
stable condition. He did well postoperatively and transferred to
the floor on postoperative day two. His pneumothorax completely
resolved and there was no further bleeding. His hematocrit
quickly improved and normalized. All chest tubes were eventually
removed without complication. He made excellent progress and was
medically cleared for discharge on postoperative day five. Chest
x-ray at discharge showed only small bilateral pleural effusions
with post-surgical changes and atelectasis in both lower lobes.
His room air saturations were 97% and all incisions were healing
well.
Medications on Admission:
Zomig 5 mg prn, Amytriptyline 100 mg qd, Indocin 50 mg prn,
Tramadol 50 mg prn
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*0*
4. Zomig 5 mg Tablet Sig: One (1) Tablet PO PRN (as needed).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 7 days.
Disp:*60 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PFO, Postoperative Hemothorax, Postoperative Pneumothorax,
Discharge Condition:
Good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving or lifting > 10 # for 1 month
no driving until follow up with surgeon
call with fever, redness or drainage from incision or weight
gain morethan 2 pounds in one day or five in one week
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 838**] in [**2-11**] weeks
Dr. [**Last Name (Prefixes) **] in [**4-13**] weeks
Dr. [**Last Name (STitle) 9764**] in [**2-11**] weeks
Completed by:[**2190-11-24**]
|
[
"511.8",
"998.11",
"998.12",
"512.1",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"34.04",
"35.71",
"34.21"
] |
icd9pcs
|
[
[
[]
]
] |
4512, 4561
|
1991, 3154
|
308, 499
|
4663, 4670
|
1619, 1968
|
1199, 1252
|
3283, 4489
|
4582, 4642
|
3180, 3260
|
4694, 4986
|
5037, 5228
|
1267, 1600
|
250, 270
|
527, 971
|
993, 1070
|
1086, 1183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,956
| 172,452
|
7407
|
Discharge summary
|
report
|
Admission Date: [**2165-10-19**] Discharge Date: [**2165-10-23**]
Date of Birth: [**2117-10-9**] Sex: F
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
Pacemaker insertion
History of Present Illness:
48 y/o F DM type 1, ESRD s/p CRT x 2 most recently in [**11-7**],
neurogenic bladder with frequent UTIs who was transferred from
[**Hospital **] Hospital for seizure evaluation. Patient reports 5
"spells" over the course of a couple weeks. She describes these
"spells" as episodes of fatigue that resolve in less than 1
minute and states she overall does not feel well. During the
spells she denies dizziness, chest pain, shortness of breath or
syncope. She is not able to elaborate any further describing her
spells. Per ED signout seizures were focal tremors, however
patient does not report this history. While in the ED she was
being evaluated by Neurology and experienced a "spell" onset
where tele demonstrated a 8 sec pause. Consequently patient was
admitted to the CCU for further care.
.
Other than spells described above patient reports usual state of
health. Patient was recently discharged from MICU for urosepsis
[**2165-10-5**] and completed antibiotic treatment (2 week
ciprofloxacin). She denies recent fever, chills, sore throat,
myalgias, cough or rash. She denies shortness of breath or chest
pain with exertion or rest. Patient reports no sick contacts.
She denies activity outside, recent tick bites or unusual rash.
.
On presentation to the ED patient VS were BP 138/77, HR 78, RR
21, O2 sat 99% RA. 6 sec pause was observed (see above, tele
script in chart). Prior to transfer patient become bradycardic
to 30s when bearing down and was given Atropine 0.5 mg IV.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools.She denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
-Diabetes type 1 with neuropathy nephropathy
-end-stage renal disease status post MI
-status post living-related renal transplant in [**2145**], repeat
living related transplant on [**2164-11-6**] from her brother
-hep C with mildly elevated liver function tests.Biopsy shows
grade I disease.
-Recurrent UTIs in the past, neurogenic bladder with
self catheterization QID
-hypertension.
Social History:
Lives w/ her husband and son; never smoked; does not drink
alcohol or use illicit drugs. Previously worked in commercial
banking, but does not currently work. Is supposed to be off of
her feet in wheelchair but reports she does walk around the
house. Husband works full time but is able to return home
frequently to her pt.
Family History:
non-contributory
Physical Exam:
GENERAL: NAD. Oriented x3.
PSYCH: Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No r/g. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. BB crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: s/p amputation left big toe. feet wrapped in
dressing, no exudate or bleeding.
NEUROLOGICAL: normal cranial nerve examination, normal muscle
strength, sensation and gait.
SKIN: No rashes, xanthomas or chronic venous stasis changes
Pertinent Results:
[**2165-10-23**] 06:30AM BLOOD WBC-4.3# RBC-2.78* Hgb-7.7* Hct-23.4*
MCV-84 MCH-27.7 MCHC-32.9 RDW-13.9 Plt Ct-172
[**2165-10-23**] 06:30AM BLOOD Plt Ct-172
[**2165-10-19**] 06:05AM BLOOD Neuts-64.8 Lymphs-24.0 Monos-9.2 Eos-1.2
Baso-0.8
[**2165-10-19**] 06:05AM BLOOD ESR-47*
[**2165-10-23**] 06:30AM BLOOD Glucose-275* UreaN-19 Creat-0.9 Na-136
K-5.2* Cl-110* HCO3-20* AnGap-11
[**2165-10-20**] 01:50AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2165-10-23**] 06:30AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.5*
[**2165-10-19**] 01:50PM BLOOD TSH-1.1
[**2165-10-21**] 04:59AM BLOOD tacroFK-12.2
.
CXR [**10-23**]:
Pacer placement with no evidence of complication. Small right
pleural effusion.
.
ECG [**10-22**]:
Normal sinus rhythm. Right bundle-branch block with QRS duration
of 122 milliseconds. The patient now has T wave inversion in
leads V3-V6 that was not seen in tracing #1. These changes are
non-specific.
.
ECHO [**2165-10-22**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2164-1-26**], a
pacer, TR and pulmonary hypertension are now seen.
.
Brief Hospital Course:
#1 Paroxysmal AV block S/P pacer: Etiology included ischemia,
viral myocarditis, lyme disease, endocarditis, thyroid disease
paroxysmal AV block, most likely infranodal block (vs. nodal).
Initially had temp wire placed by the bedside, pt now s/p dual
chamber pacemaker, right subclavian access. CXR showed good lead
placement. Lyme serolgy (-), blood culture (-), ESR mildly
elevated -> endocarditis unlikely; TSH normal. ECHO showed no
wall motion abnormalities, no vegetation. Pt was discharged home
with 1 day of prophylactic antibiotics and follow up with device
clinic and Dr. [**Last Name (STitle) **].
.
#2 CORONARIES: No chest pain or history of angina. [**2165-3-6**]
stress test demonstrated mild small perfusion defect in LAD
region. Patient being treated by Dr. [**Last Name (STitle) **] for medical
management. No evidence of ischemia during stay with negative
biomarkers. Pt was continued on Aspirin, Pravastatin and Zetia.
.
#3 S/P Renal transplant: Creatinine at baseline 08-1.2. No
fever, chills to suggest infection. Was followed by transplant
team during hospital stay. Tacro level OK. No changes in
immunosuppressant regimen.
.
#4 Diabetes type 1: Elevated BS on admission. A1C 10. Husband
and pt admit to poor control at home. Already involved with
[**Hospital **] clinic. No changes in insulin regimen. Pt was encouraged
to visit [**Last Name (un) **] endocrinologist and nutritionist after
discharge.
.
# Hypertension: Patient unaware she is on Valsartan 40 mg qd.
Hold now as patient is normotensive and told to speak to her PCP
about this medicine.
.
# Hyperlipidemia: Continued Pravastatin 20 mg and Ezetimibe 10
mg
.
# Recurrent UTI's 2 neurogenic bladder: Patient Ua on admission
negative. Recently completed two week course of ciprofloxacin.
.
# Hepatitis C: No stigmata of chronic liver disease on exam.
Most recent LFTs mildly elevated. Most recent Hep C viral load
[**2165-3-4**] 948,000.
Medications on Admission:
MEDICATIONS: confirmed with patient
1. Mycophenolate Mofetil 250 mg Capsule
2. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY
4. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous at bedtime.
5. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO BID
6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
7. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID
8. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY - patient
unsure if taking
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.)
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Medications:
1. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
2. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 days.
Disp:*4 Capsule(s)* Refills:*0*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale Subcutaneous four times a day.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Sinus block with pauses
End stage renal disease s/p transplant x2
Diabetes Mellitus Type 1
Discharge Condition:
stable, no ecchymosis or hematoma at pacer site or left chest
site.
Discharge Instructions:
You had long pauses in your heart rhythm and required a
pacemaker. You will need to take an antibiotice for one more day
to prevent an infection. No lifting your right arm over your
head for 6 weeks. You may transfer yourself into your wheelchair
but get help doing this if you feel a tugging around the
pacemaker or right shoulder. No showers or baths for one week,
the dressing must stay dry and clean. You will go to the device
clinic next week and they will take the dressing off. No lifting
more than 5 pounds with your right arm for 6 weeks.
Medication changes:
1. Cephalexin: an antibiotic to prevent infection at the pacer
site.
2. Please check with Dr. [**Last Name (STitle) **] to see if you need to be on
diovan.
.
Please call the device clinic or Dr. [**Last Name (STitle) **] if you have any
fevers, swelling or increasing pain at the pacer site, trouble
breathing, vomiting, or any other concerning symptoms. Please
schedule an appt with your endocrinologist to get your blood
sugar under better control. It may be helpful to meet with a
nutritionist as this was recommended at your last visit.
Followup Instructions:
Infectious Disease:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2165-10-28**]
9:30
Cardiology:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2165-10-28**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time:
[**11-29**] at 1:20pm.
[**Month (only) **]:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2165-11-6**] 9:45
Completed by:[**2165-10-24**]
|
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"426.13",
"427.31",
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icd9cm
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[
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[]
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icd9pcs
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[
[
[]
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9353, 9424
|
5496, 7419
|
316, 338
|
9559, 9629
|
3735, 5473
|
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9653, 10201
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3130, 3716
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10221, 10763
|
269, 278
|
366, 2330
|
2352, 2739
|
2755, 3081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,285
| 144,141
|
6105
|
Discharge summary
|
report
|
Admission Date: [**2105-8-13**] Discharge Date: [**2105-8-18**]
Date of Birth: [**2063-2-7**] Sex: F
Service: OMED
HISTORY OF PRESENT ILLNESS: This patient is a 42-year-old
woman with history of ovarian cancer status post
chemotherapy, who presented to [**Hospital3 3834**] with febrile
neutropenia and hypotension. The patient was started on
dobutamine for her hypotension at [**Hospital3 **], and
transferred to [**Hospital1 69**] for
further management.
Upon presentation to [**Hospital1 69**],
the patient complained of headache and emesis. The patient
was admitted directly to the Medical Intensive Care Unit at
[**Hospital1 69**], where she was started
on cefepime 2 grams IV q8h as well as Vancomycin 1 gram IV
q8h for sepsis. Blood cultures were collected prior to first
dose of antibiotics. Patient was also hypotensive and
started on a norepinephrine drip to titrate to a mean
arterial pressure of greater than 60. The norepinephrine
drip was started on admission to the MICU on [**8-13**], and
discontinued on [**8-14**]. The patient's Vancomycin was also
discontinued on [**8-14**] after [**5-1**] blood culture bottles
grew out gram-negative rods.
Upon admission to the MICU, the patient was also found to
have an AST of 14,023 and a LD of 14,025, a total bilirubin
of 2.6, and alkaline phosphatase of 185. The patient
underwent an ultrasound of the liver and gallbladder, which
showed no evidence of extrahepatic biliary ductal dilatation
or other obvious cause for the increased liver enzymes. CT
scan of the abdomen was also performed, which showed slight
decrease in ascites, no evidence of abscess, stable left
hepatic pneumobilia, unchanged pelvic and right inguinal
lymph nodes, unchanged nodular lymph node inferior to the
right kidney and a slightly increased soft tissue nodule in
the anterior abdominal wall.
While in the Medical Intensive Care Unit, the patient also
underwent a CT scan of the head to rule out abscess or
hemorrhage. The CT scan showed no evidence of intracranial
hemorrhage or mass effect.
Of note, the patient also was found to have a platelet count
of 30 on admission to the Medical Intensive Care Unit. On
[**8-17**], the patient was medically stable off pressors and
no longer with a septic picture, and she was transferred to
the regular OMED floor.
PHYSICAL EXAMINATION: Upon transfer to the floor, the
patient was afebrile, heart rate 100, blood pressure 100/65,
respirations 16 per minute, and 96% on room air. General:
Overweight woman lying in bed in no apparent distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round,
and reactive to light and accommodation. Extraocular muscles
intact. Oropharynx clear, moist mucous membranes, supple
neck with full range of motion and no lymphadenopathy.
Heart: Regular, rate, and rhythm, normal S1, S2, systolic
murmur. Lungs: Clear to auscultation bilaterally. Abdomen:
Distended and somewhat tense, nontender, normoactive bowel
sounds. Abdominal scar well healed. Back: No
costovertebral tenderness. Extremities: No clubbing,
cyanosis, or edema, 2+ pulses throughout. Neuropsych: Alert
and oriented times three, no focal deficits.
LABORATORIES AT ADMISSION TO THE MICU: White blood cell
count 0.6, hematocrit 20.2, platelets 30, MCV 87, RDW 16,
reticulocyte count 0.2%. INR of 1.6, PT of 15.6, PTT 28.7.
Sodium 141, potassium 3.1, chloride 104, bicarb 23, BUN 17,
creatinine 1.1, glucose 174, calcium 7.4, phosphorus 4.1,
magnesium 1.0, iron 70 within normal limits. ALT 1425, AST
1423, LDH 1456, CK 46, alkaline phosphatase 285, total
bilirubin 2.6, the direct bilirubin 2.1, indirect bilirubin
0.5, lipase 11, amylase 19, albumin 3.1. Hep panel negative.
TSH 1.2 within normal limits.
ULTRASOUND OF THE ABDOMEN: On [**8-14**]: Stable examination
when compared to prior CT and ultrasound from [**Month (only) **] and [**Month (only) 205**]
of this year with no evidence of extrahepatic biliary ductal
dilatation and unchanged appearance of limited amount of
intraabdominal ascites, pneumobilia, and an unchanged
appearance of the biliary collecting system within the left
lobe of the liver.
LABORATORY DATA UPON TRANSFER TO THE OMED FLOOR: White blood
cell count 11.8, hematocrit 32.0, platelets 23. PT 12.6, PTT
25.2, INR 1.0. Sodium 139, potassium 3.0, chloride 104,
bicarb 27, BUN 7, creatinine 0.6. ALT 335, AST 25, alkaline
phosphatase 178, total bilirubin 1.3, calcium 8.1, phosphorus
2.8, magnesium 1.6.
CONCISE SUMMARY OF HOSPITAL COURSE: [**Hospital **] hospital
course in MICU as outlined above. The patient was
transferred to the Medicine floor on [**8-17**], and remained
entirely medically stable through to her discharge the
following day on [**8-18**].
1. Gram-negative rod sepsis: Patient's cefepime was
discontinued and she was started on ciprofloxacin 500 mg q12.
The patient was changed to levofloxacin 500 mg po q24h after
a nursing error. The patient tolerated both antibiotics very
well with no ill effect. The patient remained afebrile with
no signs or symptoms of sepsis throughout her stay in the
medicine [**Hospital1 **].
2. Increased LFTs: The patient's baseline increased
bilirubin. Patient's liver enzymes continued to trend down
on the OMED floor and at discharge as well. The patient
continued to have no abdominal complaints and no signs or
symptoms of acute abdominal process.
3. Hypotension: Patient was off of pressors after one day in
MICU and her blood pressure remained stable upon trip to the
Medicine floor until discharge.
4. Nausea and vomiting: Patient's nausea and vomiting were
treated with antiemetics in the MICU. Patient had no further
episodes of nausea and vomiting on the medicine floor or on
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Gram-negative rod bacteremia.
2. Hypotension.
3. Ovarian cancer.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg every 24 hours for 10 days.
2. Ativan 0.5 mg 1-2 tablets every 4-6h as needed for anxiety
or nausea.
3. Prednisone 40 mg once a day for two days, prednisone 30 mg
once a day for five days, prednisone 20 mg once a day for
five days, prednisone 10 mg once a day for five days,
prednisone 5 mg once a day for five days.
4. Prochlorperazine 5 mg 1-2 tablets oral q6h as needed for
nausea.
5. Sennosides 8.6 mg tablet twice a day as needed.
6. Oxycodone 1-2 tablets q4-6h as needed.
7. Zofran 24 mg po once a day as needed.
8. MS Contin 15 mg po once a day as needed.
FOLLOW-UP PLANS: The patient has an appointment with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2105-8-24**] at 11:30. Patient also has
appointment with Hematology/Oncology on [**8-24**] at 12 noon.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**]
Dictated By:[**Name8 (MD) 6906**]
MEDQUIST36
D: [**2105-9-8**] 21:18
T: [**2105-9-11**] 08:07
JOB#: [**Job Number 23913**]
|
[
"183.0",
"038.40",
"276.8",
"789.5",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5798, 5867
|
5890, 6477
|
4519, 5743
|
2354, 4490
|
6495, 6939
|
161, 2331
|
5768, 5777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,816
| 186,615
|
44379
|
Discharge summary
|
report
|
Admission Date: [**2147-8-22**] Discharge Date: [**2147-9-6**]
Date of Birth: [**2072-1-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
75 y/o M with hx of tonsillar cancer, DM, HTN, GERD who
presented last Friday [**8-18**] to an OSH after a fall. The fall
sounded mechanical where he tripped, had no bowel/bladder
incontinence, chest pain, palpitations, shortness of breath or
other complaints. He was possibly hypoglycemic because he had
taken his insulin twice that morning because the first time he
injected it, he saw the needle was bent. He fell backwards on
an outstretched hand, hit his head and buttock and was unable to
get up for 7 hrs. He was finally able to call 911 for help. At
the OSH, he had a negative head CT, xrays of his hips which were
negative, CT c-spine which was negative, and was found to have
rhabdomyolysis with CK elevated aroubd 1500 and Cr to 2.0. He
was also found to have a troponin leak. He was treated with
IVFs and his rhabdo and Cr improved. On saturday, he was eating
cream of wheat and had an aspiration event. He was started on
moxifloxacin for pneumonia. He was also noted to be in afib
with RVR at times and started on digoxin and metoprolol.
.
On the floor, he arrived with mild tachypnea and no overt
complaints. Mostly, he had L wrist pain. His initial vitals
were T 100.4, 142/78, 89, 30, 93% on 6L. He triggered on
arrival for tachpnea. ABG was 7.46/38/71. Overnight, his
vitals were similar with Tm 100.6, SBPS 140s-170s, HR mostly
90s. Of note, patient triggered again this morning for RR >30
and nursing concern. ABG again was drawn and was 7.41/41/82.
He then went into RVR this morning to the 140s. He received IV
metoprolol x2 with resolution of his afib back into aflutter.
.
On evaluation by the MICU team, he is not complaining of
shortness of breath. His respiratory rate is variable and
ranges between normal mid teens to the thirties. He is on a 50%
face mask. He looks uncomfortable in general. He is using
accessory muscles, appears generally weak and his alertness
seems mildly depressed (although don't know baseline). He is
complaining of generalized weakness, wrist pain and hip pain.
Past Medical History:
DM2 with neuropathy
HTN (apparently used to be treated for this, then after
chemo/xrt, patient reports having low BP, no longer on meds)
Tonsillar cancer s/p neck dissection, Chemo/XRT [**2140**]/[**2141**]
New supraglottic mass [**11-17**]
s/p appendectomy
ruptured feeding tube
dysphagia
hematuria
Peripheral vascular disease
Remote history of gout
Social History:
Approximately 15 pack-year history of smoking and stopped 20
years ago.
-previously was a heavy alcohol user, drinking a fifth per day
of hard liquor. He stopped drinking alcohol ~[**2138**].
-retired security person for [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **], lives with sister
Family History:
Non-contributory
Physical Exam:
General Appearance: Well nourished, Anxious, Diaphoretic
Eyes / Conjunctiva: PERRL, R eye droop
Head, Ears, Nose, Throat: Normocephalic, dry mouth, no teeth
Lymphatic: radiation changes to neck
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: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases, Rhonchorous: throughout, L>R)
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Musculoskeletal: Muscle wasting, Unable to stand, L wrist pain,
hip pain
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
LUE u/s [**2147-9-3**]:No evidence of left upper extremity DVT.
Extensive left upper extremity swelling.
Bil lower extremity veins [**2147-8-31**]: No DVT identified.
MR spine [**2147-8-26**]: Multilevel disc degenerative changes
throughout the lumbar spine, more significant from L3/L4 through
L5/S1
levels. There is no evidence of abnormal enhancement. Possible
renal cystic formations.
CT chest w/o contrast [**2147-8-24**]: 1. Severe multifocal pneumonia,
in all lobes, no evidence of bronchial obstruction.
2. Severe atherosclerotic calcification involving all major
coronary
branches.
Brief Hospital Course:
Mr. [**Known lastname **] was a 74 yo man with a history of throat cancer who was
transferred to [**Hospital1 18**] from [**Last Name (un) 4199**] after treatment for rhabdo s/p
a fall. His course there was complicated by an aspiration event
on 4 prior to transfer and subsequent development of diffuse
bilateral infiltrates. He was also found to have new afib with
RVR. On arrival to MICU after his fall, had new O2 requirement,
that worsened over time and his CXR was concerning for
aspiration pneumonia. He also developed low grade fevers without
an elevated white count. He was followed by the ID service and
was treated with a 14 day course of vancomycin and cefepime for
HAP, as well as flagyl for aspiration pneumonia. Cefepime was
switched to ceftriaxone on [**9-2**] because of less concern for
pseudomonas, negative cultures. Sputum cultures and all other
cultures were negative, except for one bottle of group B strep
positive blood culture, which was treated with the vancomycin.
He was intubated for ten days, starting [**8-23**] when he was
intubated nasotracheally, until [**9-3**], after which he was satting
in the mid 90s on face tent oxygen. He had an aspiration event
after being extubated at which a family meeting was planned. The
meeting with him and his family on [**9-4**] determined that he
desired to change his code status to DNR/DNI, and comfort
measures only were initiated for him in the MICU. His face tent
was discontinued and standing and PRN morphine and ativan were
started. On [**2147-9-6**], he was transfered to a medicine floor and
expired shortly after arrival to the medicine floor .
Medications on Admission:
Asa 81 mg qdaily
omeprazole 40mg qam
lisinopril 40mg qam
temazepam 15mg 1-2 tabs qhs prn anxiety
simvastatin 20mg qhs
atenolol 25mg qam
humulin N 20U [**Hospital1 **]
humulin R 8U supper
MVI
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"V10.02",
"412",
"790.7",
"511.9",
"518.81",
"300.00",
"507.8",
"V66.7",
"V58.67",
"V15.88",
"276.3",
"443.9",
"584.9",
"250.60",
"V15.3",
"401.1",
"357.2",
"728.88",
"041.02",
"530.81",
"719.43",
"719.45",
"514"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.72",
"38.93",
"38.91",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6530, 6539
|
4627, 6256
|
335, 347
|
6590, 6599
|
4008, 4604
|
6655, 6665
|
3137, 3155
|
6498, 6507
|
6560, 6569
|
6282, 6475
|
6623, 6632
|
3170, 3989
|
275, 297
|
375, 2420
|
2442, 2795
|
2811, 3121
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,315
| 196,327
|
24131
|
Discharge summary
|
report
|
Admission Date: [**2198-1-15**] Discharge Date: [**2198-1-22**]
Date of Birth: [**2134-12-28**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Gammagard Liquid
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
chest discomfort; admitted to MICU for hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 61316**] is a 63y/o lady with history of relapsed refractory
multiple myeloma, status post allogeneic stem cell transplant in
[**9-/2194**], status post DLI in [**8-/2196**], [**10/2196**], and [**2-/2197**] and
ongoing Velcade/Revlimid/XRT who was transferred from an OSH due
to chest pain and tachycardia, and has been found to have
neutropenic fever.
.
Of note, she had a recent admission [**Date range (1) 61319**] (>1 week ago) for
back pain and urinary retention - she was found to have T10/T11
vertebral fracture but no cord compression. She was started on
steroids and T8-T12 spine radiation. She was also treated for
pan-S E.coli UTI with Cipro for 7d ([**Date range (1) 61320**]). Her last
Velcade infusion was 3 days prior to presentation.
.
On the day of presentation, she went to an Onc f/u appointment
and her temp was 98.6, BP 102/69, HR 101. Afterwards, she went
to XRT, and then she experienced chest pain on the way home.
She describes it as substernal, nonpleuritic "heaviness" that
did not radiate anywhere. Not associated with sweating, but did
come with some mild breathing discomfort. She first noticed the
pain when she was sitting in the car, and it lasted until she
got to [**Hospital6 3105**]. It resolved with Dilaudid 1.5
mg IV and Fentanyl 100 mcg IV. EKG was not concerning for
ischemia, and troponin was negative. For tachycardia she was
given 1L NS but due to persistent sinus tachycardia to 120 she
was transferred to [**Hospital1 18**].
.
In the ED, initial VS were: T99.4, HR 120, BP 122/74, RR 18, POx
99% 2L NC. Here, she had no complaints of chest pain. Labs
were notable for WBC 1.6 (ANC 1163), which on repeat was WBC 0.9
(ANC 715). Cr was 3.3 which is baseline. Troponin 0.2 and EKG
with NSR, no concern for ischemia. She was noted to spike to
102.2 and received Cefepime as well as Tylenol. CXR suggested
increased small b/l pleural effusions and old sternal/rib
fractures. UA was negative. Bedside FAST was negative (no
pericardial effusion, normokinetic heart). He triggered for SBP
80's after 2nd L NS. After the 3rd L NS, she improvement to SBP
110s but still intermittently dropped to SBP 80's. Given her
hypotension and febrile neutropenia, she was admitted to the
MICU. VS prior to transfer were T99.8, HR 106, BP 90/55, RR 13,
POx 99% 2L NC.
.
On arrival to the MICU, she feels exhausted, "wiped out." Mouth
is very dry. Notes that she did get a much milder form of the
chest discomfort when moving from stretcher to bed just now; it
is barely there but is bothersome. She is in disbelief about
having to be admitted again. Denies any fevers/chills at home,
rhinorrhea/URI, cough, loose stools, urinary discomfort. No
mouth ulcers or rash.
.
Review of systems:
(+) Per HPI. Also notable for chronic joint aches (which she
thinks is related to GVH). Chronic issues with constipation
(had small BM yesterday).
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies palpitations. Denies nausea, vomiting, diarrhea,
abdominal pain. Denies dysuria, frequency, or urgency.
Past Medical History:
Past Oncologic History:
Multiple Myeloma
--Presented in [**12/2190**] with a compression fracture and
hypercalcemia initially thought to be due to hyper-PTH, treated
with thyroidectomy and parathyroidectomy
--Presented again with anemia and renal failure with Bence-[**Doctor Last Name **]
proteinuria (5.9 g) but no serum M spike detectable
--BM biopsy showed multiple myeloma with 13q abnormalities
--Highly aggressive disease and many treatments since in the
following order: cycles - auto ([**2192-7-2**]) - cycles - allo
([**2194-10-8**]) remission until [**6-/2196**] then cycles this summer both
auto and allo transplants
--Cycle therapy: Since [**7-/2196**] Cyclophosphamide, Velcade,
Cytoxan, Velcade, Doxil, Velcade
--DLI [**2196-10-27**].
.
Other medical history:
# S/p Fracture of 4 vertebrae
# S/p Parathyroidectomy and accompanying thyroidectomy for
benign nodules seen at time of surgery in [**5-29**]
# Hyperparathyroidism
# Hypothyroidism (secondary to surgery), on Synthroid now
# Hypertension in context of multiple myeloma
# Tubal ligation
Social History:
-Home: Patient is retired and lives with husband and has 3 grown
children.
-Occupation: She is currently on disability, but was previously
an ICU nurse [**First Name (Titles) **] [**Hospital3 **] in [**Location (un) 7661**]. She is independent of
ADLS, IADLS except driving.
-EtOH: Denies drinking alcohol.
-Tobacco: Smoked in high school.
-Illicits: None.
Family History:
Mother died at 72 of metastatic breast cancer.
Father committed suicide.
No siblings.
Physical Exam:
ADMISSION EXAM
Vitals: T: 100.4 BP: 87/54 P: 110 R: 11 O2: 93% RA
General: Thin chronically ill-appearing lady, breathing
comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear with small 0.5cm
ulcer on left tongue, EOMI, PERRL
Neck: supple, neck veins flat, no LAD
CV: Tachycardic, regular, normal S1 + S2, diastolic murmur heard
best at LSB; no muffled heart sounds
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: protuberant but non-distended, soft, nontender, bowel
sounds present, no organomegaly
Ext: warm, well perfused, 2+ pulses, no cyanosis; 1+ pitting
edema to the knees bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE EXAM
Pertinent Results:
ADMISSION LABS
[**2198-1-15**] 10:55AM BLOOD WBC-1.6* RBC-2.88* Hgb-9.5* Hct-27.9*
MCV-97 MCH-33.1* MCHC-34.2 RDW-19.7* Plt Ct-64*
[**2198-1-15**] 10:55AM BLOOD Neuts-72.7* Lymphs-15.8* Monos-5.9
Eos-4.8* Baso-0.8
[**2198-1-15**] 09:55PM BLOOD WBC-0.9* RBC-2.91* Hgb-9.4* Hct-27.7*
MCV-95 MCH-32.2* MCHC-33.9 RDW-18.9* Plt Ct-64*
[**2198-1-15**] 09:55PM BLOOD Neuts-79.4* Lymphs-13.2* Monos-5.0
Eos-1.0 Baso-1.5
[**2198-1-15**] 09:55PM BLOOD Glucose-122* UreaN-40* Creat-3.3* Na-142
K-3.6 Cl-102 HCO3-24 AnGap-20
[**2198-1-15**] 10:55AM BLOOD ALT-25 AST-29 LD(LDH)-420* AlkPhos-85
TotBili-0.5
[**2198-1-15**] 09:55PM BLOOD CK(CPK)-540*
[**2198-1-15**] 10:55AM BLOOD Calcium-7.6* Phos-4.9* Mg-2.2
[**2198-1-15**] 09:55PM BLOOD cTropnT-0.02*
[**2198-1-15**] 10:15PM BLOOD Lactate-1.6
DISCHARGE LABS
(pending)
MICRO DATA
[**2198-1-15**]: UA - negative, UCx - pending
[**2198-1-15**]: BCx x2 - pending
EKG [**2198-1-15**]
NSR, rate 112, normal axis, QTc 457. No significant ST-T wave
changes compared to prior.
CXR [**2198-1-15**]
There are increased small bilateral pleural effusions, greater
on
the left than the right, with bibasilar atelectasis, underlying
consolidation,
particularly in the retrocardiac region, can not be exluced.
Cardiomediastinal silhouette remains mildly enlarged.
Myelomatous bony
changes as well as old sternal fracture of multiple vertebral
body wedge
compression fractures were better evaluated on prior CT from
[**2197-12-28**].
CT Chest [**2198-1-16**]
1. No new sternal fracture. Sternal body fracture healed,
unchanged since
[**2193**]. Pathologic right second rib fracture, new since [**Month (only) 1096**]
[**2196**], is
nondisplaced, shows increased callus formation since [**12-28**],
but no mass or hematoma. Healing right seventh rib fracture,
stable since [**Month (only) 1096**]. Multiple severe, longstanding pathologic
thoracic vertebral fractures; moderate T5 body fracture, new
since [**Month (only) 1096**], increased slightly over two weeks.
2. New moderate bilateral pleural effusions, new moderate
pericardial
effusion, absent any indication of tamponade, and worsening
anasarca,
presumably related. Mild increase in pulmonary artery caliber
could be due to increased left atrial pressure, although there
is no pulmonary edema.
LENI [**2198-1-17**] negative
V/Q 1/25 negative
CXR [**2198-1-19**] Pending read
Brief Hospital Course:
Ms. [**Known lastname 61316**] is a 63y/o lady with history of relapsed refractory
multiple myeloma, status post allogeneic stem cell transplant,
DLI, and ongoing Velcade/XRT who was transferred from an OSH due
to chest pain and tachycardia, and was found to have neutropenic
fever and hypotension. Pt was admitted to MICU from OSH with
septic shock ([**1-25**] UTI), which was treated with broad spectrum
antibiotics and responsive to fluids. Pt was subsequently
transferred to BMT floor, as hypotension resolved. On floor,
she was treated for neutropenic fever. On [**1-18**], she developed
mental status changes, becoming more and more lethargic. She
developed acute renal failure, likely [**1-25**] ATN. Pt ultimately
developed afib with RVR, which was controlled with diltiazem and
metoprolol. Mental status and renal function continued to
deteriorate and family meeting was arranged. Decision was made
not to pursue agressive treatment and LP and HD were determined
not to be keeping with goals of care. A morphine drip was
started and pt was continued on abx. On night of [**2198-1-21**],
family decided to make pt [**Name (NI) 3225**]. She expired on [**2198-1-22**].
Medications on Admission:
dexamethasone taper:
--[**Date range (1) 40543**] 2mg PO BID
--[**Date range (1) 61318**] 1mg PO BID
--[**1-15**] STOP Medication
REVLIMID 15 mg PO EVERY OTHER DAY (missed dose 1/23)
acyclovir 400 mg PO BID
pentamidine 300 mg inhaled once a month
levothyroxine 112 mcg daily
gabapentin 300 mg QHS
oxyCONTIN 15 mg [**Hospital1 **]
oxyCODONE 5 mg PO Q6H PRN
zolpidem 5 mg PO HS PRN
lorazepam 0.5-1 mg PO Q6H PRN Anxiety/Nausea/Insomnia
ondansetron 8 mg Rapid Dissolve PO Q8H PRN
calcium acetate 667 mg PO TID W/ MEALS
calcium carbonate-vitamin D3
multivitamin daily
docusate sodium 100 mg PO BID
senna 17.2 mg PO BID
polyethylene glycol 1 packet PO DAILY PRN
bisacodyl 10 mg (E.C.) PO daily PRN
pantoprazole 40 mg (E.C.) daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"564.09",
"785.0",
"458.9",
"203.02",
"403.90",
"V87.41",
"786.50",
"780.61",
"423.9",
"348.30",
"585.9",
"V15.3",
"427.31",
"244.0",
"V49.86",
"288.00",
"V13.51",
"584.5",
"284.19",
"V42.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
10374, 10383
|
8378, 9567
|
364, 371
|
10435, 10444
|
5987, 8355
|
10500, 10510
|
5072, 5159
|
10342, 10351
|
10404, 10414
|
9593, 10319
|
10468, 10477
|
5174, 5968
|
3159, 3598
|
273, 326
|
399, 3140
|
3620, 4681
|
4697, 5056
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,554
| 118,852
|
43887
|
Discharge summary
|
report
|
Admission Date: [**2139-7-21**] Discharge Date: [**2139-7-26**]
Date of Birth: [**2094-5-12**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: Hematemesis.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43251**] is a 44 year old
man with HIV on HAART therapy and a history of pancreatitis
who initially presented with three episodes of hematemesis on
the afternoon of [**2139-7-21**]. He was seen at the [**Hospital1 346**] Emergency Department that same
evening for further evaluation. While in the Emergency
Department, the patient was found to have a hematocrit of
29.4. An nasogastric lavage was performed which revealed
1200 cc. of clotted blood and fresh blood which did not
clear. Of note, the patient also had a large maroon bowel
movement, about 300 cc., while in the Emergency Department.
He was guaiac positive.
The patient, at the time of presentation, denied any chest
pain or new shortness of breath, abdominal pain or diarrhea.
He does have mild shortness of breath at baseline. He has no
history of previous gastrointestinal bleed. He denies having
any history of liver disease.
The patient had two large bore intravenous lines placed and
received a total five liters of Crystalloid, two units of
packed red blood cells and four units of fresh frozen plasma.
The patient was emergently scoped by the GI team and found to
have Grade II esophagitis in the GE junction and a 10
millimeter ulcer in the posterior duodenal bulb which was
cauterized and injected with epinephrine. Hemostasis was
achieved and the patient was subsequently transferred to the
Medical Intensive Care Unit.
He received an additional four units of packed red blood
cells in the Medical Intensive Care Unit. He displayed no
evidence of further bleeding and serial hematocrits were
stable. He received intravenous Protonix for ulcer treatment
and prophylaxis. His INR was also noted to be 2.0 and to
avoid further re-bleeding, Vitamin K was administered to
reverse his coagulopathy. The patient remained
hemodynamically stable and was then transferred to the
General Medical Floor for further care.
PAST MEDICAL HISTORY:
1. Human Immunodeficiency Virus with recent PCP pneumonia
and on HAART on admission but held currently.
2. Pancreatitis.
3. Asthma.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION:
1. Zerit.
2. Bactrim.
3. Ritonavir.
4. 3-TC.
5. Viread.
MEDICATIONS ON TRANSFER:
1. Vitamin K intravenously.
2. Bactrim DS, two tablets p.o. q. day.
3. Protonix 40 mg p.o. q. 12 hours.
SOCIAL HISTORY: Positive for alcohol use.
LABORATORY: Pertinent labs and studies were hematocrit 34.2
(up from 29.4 on [**2139-7-21**]); white blood cell count 6.0;
platelets 76; PTT 39.1, PT 15.4, INR 1.6, BUN 21, creatinine
1.4, AST 174, ALT 53, alkaline phosphatase 138, albumin 2.2.
Hepatitis B surface antigen negative. Hepatitis B antibody
pending. Hepatitis C antibody: Negative. Hepatitis A
antibody: Positive. Helicobacter pylori antibody:
Negative.
Abdominal ultrasound with small ascites, no portal vein
thrombosis. Amylase 318, lipase 48, total bilirubin 3.0.
HOSPITAL COURSE: Since transfer to the General Medical
Floor:
1. Gastrointestinal: The patient has been stable and
tolerating a p.o. diet. No evidence of free bleeding on
serial hematocrits has been noted with the most recent
hematocrit 37.7. We are attempting to keep his INR at less
than 1.4 with Vitamin K supplementation subcutaneously. The
patient is also on Protonix 40 mg p.o. twice a day.
The patient's upper gastrointestinal bleed was thought to be
secondary to the duodenal ulcer found on EGD; however, it is
unclear as to the etiology of the ulcer since the patient
denied any history of non-steroidal anti-inflammatory drug
use and since the patient's H. pylori antibody was negative
(biopsy results still pending).
Regarding the patient's abnormalities found on his liver
function tests, the cause of his liver dysfunction is unknown
at this time. The patient does have a history of having a
liver biopsy performed at an outside hospital although we
were unable to obtain the pathology report. His hepatitis B
and C serologies were negative. His liver dysfunction as
manifested by a tranaminitis, defects in coagulation and low
albumin all suggests a picture consistent with cirrhosis.
His abdominal ultrasound also revealed a small amount of
ascites. The patient may benefit from a repeat outpatient
liver biopsy for further evaluation.
The patient was given a one time dose of Levofloxacin 500 mg
p.o. for SBP prophylaxis given the ascites demonstrated on
ultrasound.
2. Infectious Disease: The patient was formerly on HAART
for his HIV, however, these medications were held
temporarily. He is to follow-up with Dr. [**Last Name (STitle) **] at [**Hospital6 38031**] Hospital to see if he should initiate his therapy
again.
3. Hematologic: The patient had an elevated INR on
admission that has been slow to correct with Vitamin K
administration. He will be discharged with p.o. Vitamin K
supplementation. His folate and B12 levels were also checked
and neither were deficient with a B12 of greater than [**2137**]
and a folate of 14.6. His anemia may be consistent with
anemia of chronic disease since patient has a normal iron of
163 and a low TIBC of 176. His hematocrit has been stable
after a total of six units packed red blood cells since
admission. His anemia may be worked up further as an
outpatient.
4. Renal: The patient, on admission, had an elevated
creatinine. His FEna was 5.4 based upon calculations from
his urine electrolytes. This suggests that his elevated
creatinine is due to intrinsic renal disease rather than a
prerenal cause. He will also need further evaluation when he
is discharged.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed secondary to a duodenal
ulcer.
2. Human Immunodeficiency Virus; currently not on HAART.
3. Renal insufficiency.
4. Anemia.
5. Coagulopathy.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. twice a day.
2. Bactrim Double Strength two tablets p.o. q. day.
3. Vitamin K 10 mg p.o. q. day.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is to be discharged to Safe
[**Hospital1 **].
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with Dr. [**Last Name (STitle) **] in one to two
weeks to discuss initiation of his HAART regimen.
2. He is to follow-up with the [**Hospital 6283**] Clinic in
four to six weeks.
3. He should avoid all non-steroidal anti-inflammatory drug
use.
4. He is to have his PT/INR level to insure that his INR
remains below 1.4.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 7861**]
MEDQUIST36
D: [**2139-7-26**] 16:52
T: [**2139-7-26**] 20:42
JOB#: [**Job Number 46518**]
cc:[**Last Name (NamePattern1) 94220**]
|
[
"789.5",
"571.5",
"532.40",
"042",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
5811, 5989
|
6012, 6136
|
2347, 2409
|
3147, 5790
|
6271, 6918
|
2314, 2321
|
168, 182
|
212, 2131
|
2434, 2542
|
2153, 2289
|
2560, 3128
|
6162, 6247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,460
| 115,202
|
8047
|
Discharge summary
|
report
|
Admission Date: [**2101-10-3**] Discharge Date: [**2101-10-6**]
Date of Birth: [**2052-8-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 25876**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Implantation of L-sided pleural bases pigtail catheter.
History of Present Illness:
49 yo female with metastatic melanoma dx in [**2093**], found to have
mets to the lung by CXR in [**2099-11-18**], CT confirmed
a right lower lobe and left lower lobe nodules. She underwent
bilateral VATS resection with pathology consistent with
melanoma. In [**2101-1-19**], follow-up CT revealed a
right pleural abnormality and she underwent a repeat bronc
and right VATS with talc poudrage on [**2101-2-18**]. Biopsy
confirmed recurrent melanoma. Pt presented to ED today with
increasing dyspnea for the past 3-4 days and new cough
productive of white sputum. Pt did note blood in sputum on one
occasion over the weekend. Denies fevers or chills, chest pain.
Has had poor appetite and decreased po intake. No black or
bloody stools reported. Further ROS negative.
.
In the [**Name (NI) **], pt was found to have B/L multi-loculated pleural
effusions, with L>R. IP was consulted and pt underwent
thoracentesis with placement of pigtail catheter under CT
guidance. Patient was admitted to MICU for further observation
given episodes of tachycardia, transient hypotension, tachypnea.
Past Medical History:
metastatic melanoma s/p Flex Bronch, VATs, TALC, Pleurex Cath
PMH/PSH:HChol, Migraines, metastatic melanoma, s/p L vats c
pleural bx and bilateral lower lobe nodule wedges [**9-22**], s/p
L-heel excision c STSG '[**93**], s/p R VATS w/ pleural biopsies and
talc pleurodesis [**2101-2-18**]
Social History:
lives in [**Location 686**] w/ 2 sons
separated from husband, has 3 sons. Pt lives in [**Location 686**].
former smoker- quit [**2083**], glass of wine 3x/week
Family History:
NC
Physical Exam:
PE: vitals 99.2/hr 100/bp 152/90/ rr 30/ 100% oxygen sat
GEN: thin, pale, anxious female
HEENT: atraumatic, anicteric, EOMI, mmm, PERRLA, OP clear
NECK: no JVD
CV: tachy, no murmurs, no rubs
LUNGS: decreased BS at bases, + conversational dyspnea, + wheeze
ABD: soft, nt, hypoactive BS, non-distended
EXT: warm, dry. No [**Location (un) **]. Proximal muscle strength 5/5 and intact
B/L in both UE and LE. DP pulses palpable B/L
NEURO: A/O X3, CN II-XII grossly intact, no focal deficits
Pertinent Results:
[**2101-10-3**] 10:15AM BLOOD WBC-3.0* RBC-2.67*# Hgb-7.4*# Hct-20.7*#
MCV-78* MCH-27.9 MCHC-35.8* RDW-15.4 Plt Ct-81*#
[**2101-10-3**] 10:15AM BLOOD Neuts-64.9 Lymphs-24.0 Monos-11.0 Eos-0.2
Baso-0
[**2101-10-3**] 10:15AM BLOOD PT-14.8* PTT-22.0 INR(PT)-1.3*
[**2101-10-3**] 10:15AM BLOOD Glucose-145* UreaN-18 Creat-0.7 Na-133
K-4.0 Cl-93* HCO3-23 AnGap-21*
[**2101-10-3**] 10:15AM BLOOD CK(CPK)-45
[**2101-10-3**] 10:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2101-10-4**] 03:45AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.2*
[**2101-10-3**] 09:14PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
Brief Hospital Course:
The patient with past medical history as detailed above with
initially admitted to the ICU for shortness of breath. She had
a placement of a L pleural based pigtail catheter for palliative
purposes. She was transferred to OMED and while on the floor,
it was decided that the patient was to receive comfort measures.
While being made comfortable the patient passed on [**2101-10-6**].
.
Family was present at the bedside.
Medications on Admission:
Discharge Disposition:
Home With Service
Facility:
VistaCare
Discharge Diagnosis:
Primary Diagnosis: Metastatic Melanoma
Discharge Condition:
Expired
Completed by:[**2101-10-11**]
|
[
"197.2",
"V15.82",
"427.89",
"285.22",
"V10.82",
"458.9",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"99.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
3657, 3697
|
3181, 3606
|
305, 363
|
3780, 3819
|
2513, 3158
|
1986, 1990
|
3718, 3718
|
3634, 3634
|
2005, 2494
|
262, 267
|
391, 1478
|
3737, 3759
|
1500, 1792
|
1808, 1970
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,404
| 182,530
|
32033
|
Discharge summary
|
report
|
Admission Date: [**2146-9-9**] Discharge Date: [**2146-9-29**]
Date of Birth: [**2067-5-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Cool lower extremities over two days
Major Surgical or Invasive Procedure:
1) Axillary bifemoral bypass [**2146-9-10**]
2) Diagnostic abdominal and celiac and mesenteric arteriograms,
brachial artery second order catheterization, percutaneous
angioplasty and stenting of both the celiac and SMA [**2146-9-13**]
3) Left brachial thrombectomy and patch angioplasty [**2146-9-14**]
4) Exploratory laparotomy [**2146-9-14**]
5) Exploratory laparotomy [**2146-9-16**]
6) Exploratory laparotomy, abdominal closure [**2146-9-19**]
History of Present Illness:
HPI: 79 F admitted to [**Hospital **] Hospital 3 weeks ago s/p fall
suffered non-displaced left pelvic fx + LLL PNA (one week
hospital stay). Transferred to [**Location (un) 12595**], [**Hospital 582**] rehab for 2
weeks. Now presenting with increasing bilateral pain and
coolness x2 days. Pt reports several month history of
claudication on walking. Of note pt is a poor historian.
Past Medical History:
PMH: COPD, HTN, A-fib, Osteo, Hyperchol, h/o CVA [**2133**],
hyperthyroid, T10 compression fx
Physical Exam:
On admission:
.
PE: 96.6 62 118/54 18 96%RA
Gen: cachectic, NAD
Chest: CTAB
CV: afib, no murmurs
Abd: soft, non-tender, non-distended
Ext: BLE cool,
Pulses: Fem: bilat faintly palp.
R [**Doctor Last Name **]/DP/PT = 0
L [**Doctor Last Name **]/DP/PT = 0
Brief Hospital Course:
Upon arrival to [**Hospital1 18**], a CT angiogram was performed on arrival
here and this showed an occlusion of the aorta and the entire
iliac system starting just distal to the renal arteries. There
was reconstitution of the common femoral arteries in the groin
with profunda femoris runoff as the only obvious vessels. She
has COPD and has been ill for several days, recently had
pneumonia and was advised to have an axillary [**Hospital1 **]-femoral graft.
She underwent bypass and, post-operatively, she did relatively
well, although she was in rate controlled atrial fibrillation
and her left leg was quite ischemic. She was stable enough to be
transferred to the VICU on POD#2. A CT angiogram was performed
on [**9-13**], and this showed a tight SMA stenosis with
reconstituted distal blood flow, along with chronic celiac/[**Female First Name (un) 899**]
narrowing. Based on these findings, she was taken to the
operating room on [**9-13**] and an SMA stent was placed to restore
flow.
On [**2146-9-14**], the patient suffered respiratory failure, was
intubated and was transferred back to the CVICU. She was noted
to have a distended abdomen and bowel gas pattern consistent
with ileus; her lactate level was 2.0. Out of concern for
mesenteric ischemia, the patient was taken to the operating room
on [**9-14**] for an exploratory laparotomy. Intra-operatively, her
bowel was viable and there were no signs of ischemia/infarct.
Afterward, she was noted to be quite fluid avid, but hypotensive
despite aggressive fluid resuscitation. She was administered
pressors and a pulmonary artery catheter was placed. Her peak
inspiratory pressures were in the 40s. The resulting clinical
picture revealed abdominal compartment syndrome, and the patient
was again taken to the operating room on [**9-16**]. Her intestines
were again found to be viable, and her abdomen was left open.
The remainder of her hospital course was characterized by a
waxing and [**Doctor Last Name 688**] course during which she remained on pressors,
and her limbs remained ischemic. With increasing doses of
pressors, her limb ischemia would worsen, and perfusion would
improve as doses were lowered. She also was noted to have
steadily rising liver function tests, and she was increasingly
coagulopathic.
On [**9-27**], she took a turn for the worse when, for the first time
in her hospital course, she was noted to be oliguric. Her
pressor requirement began to increase as well. She was notably
more cyanotic and was reverted to full ventilatory support due
to tachypnea. An urgent family meeting was called, and the 3
children, one of whom was designated health care proxy, made the
decision to make the patient "DNR". Over the next 2 days, she
steadily worsened in her hemodynamics, and expired on [**2146-9-29**] at
14:52. Family declined autopsy.
Discharge Disposition:
Expired
Discharge Diagnosis:
1) acute thrombosis of aorta
2) threatened limb ischemia
3) Right heart failure
4) Respiratory failure
5) Acute renal failure
6) Hepatic dysfunction
7) Coagulopathy
Discharge Condition:
Expired
Completed by:[**2146-9-29**]
|
[
"707.11",
"458.29",
"438.9",
"995.92",
"584.9",
"444.81",
"401.9",
"444.21",
"428.0",
"557.0",
"733.00",
"491.20",
"573.9",
"286.9",
"560.1",
"997.4",
"272.0",
"038.9",
"242.90",
"287.5",
"787.03",
"518.5",
"444.0",
"958.93",
"427.31",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.01",
"00.41",
"00.46",
"96.04",
"39.90",
"38.93",
"99.07",
"39.50",
"93.59",
"83.65",
"54.11",
"99.04",
"38.03",
"54.12",
"99.15",
"96.72",
"89.68",
"96.59",
"89.64",
"39.29",
"39.56",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
4491, 4500
|
1633, 4468
|
350, 800
|
4709, 4747
|
4521, 4688
|
1349, 1349
|
274, 312
|
828, 1216
|
1363, 1610
|
1238, 1334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,568
| 172,973
|
5878
|
Discharge summary
|
report
|
Admission Date: [**2191-3-18**] Discharge Date: [**2191-3-19**]
Service: MEDICINE
Allergies:
Heparin Sodium
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
s/p ppm placement for syncope
Major Surgical or Invasive Procedure:
PPM placement
Past Medical History:
Endovascular repair of abdominal aortic aneurysm with modular
stent graft, [**8-9**]
R eye cataract surgery
CAD s/p MI and CABGx4 (per grandson there was an episode of AF
perioperative requiring transient coumadin/dig in [**2179**])
[**Doctor First Name **]-weisee tear in [**1-9**], not requiring transfusion
Vertebral compression fractures, osteoporosis.
L CEA [**2179**]
S/p umbilical hernia repair
Prostate Ca, not actively treated
HTN
PMR on chronic steroids (saw rheumatologist less than 1 week
ago, on very slow prednisone taper)
Left hip surgery [**2190-1-1**]
GERD
Hyperlipidemia
Hypothyroidism
Bilateral knee surgeries.
Social History:
The patient lives with his daughter. Is widowed. Was in the
military for 5-6 years and then a firefighter. Quit tobacco 11
years ago but smoked <1 ppd x 50 yrs prior to this. No alcohol
use, past or current.
Family History:
Both parents died of cerebral hemorrhages. A grandson has DM.
Unsure of anyone elses' health.
Pertinent Results:
[**2191-3-18**] 01:27PM GLUCOSE-73 UREA N-34* CREAT-1.9* SODIUM-138
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
[**2191-3-18**] 01:27PM WBC-8.6 RBC-4.86# HGB-13.4*# HCT-41.0# MCV-85
MCH-27.6 MCHC-32.6 RDW-15.6*
[**2191-3-18**] 01:27PM PLT COUNT-319
[**2191-3-18**] 01:27PM PT-12.7 PTT-30.9 INR(PT)-1.1
Brief Hospital Course:
# RHYTHM: [**Company 1543**] PM for tachy-brady was placed. Cephalic
access. F/U CXR in AM showed a left transvenous pacemaker leads
terminate in standard position in the right atrium and right
ventricle. No PTX. Antiobiotics were continued for 3 days for
prophylaxis. Digoxin and pindolol were stopped. Patient was
started on amiodarone 200 tid for 1 month and then 200 mg daily
(TSH pnd on dc). Toprol XL was also initiated. Coumadin was
restarted. INRs will be checked in 2 days by patient's primary
care doctor who he has seen in the past for INR checks. He will
follow up with Dr. [**Last Name (STitle) 23246**] in 1 week for PPM check.
# AMS: Most likely etiology sedation during procedure. On
admission to CCU patient was A+OX3 consistent whit this. LFTs
and lytes were wnl; cre improved after one day in ccu. Sedating
medications were held overnight. Patient was A+OX3 prior to
discharge.
# CORONARIES: Known CAD with prior MI h/o CABG. Continued home
ASA, statin, ACE. Started toprol XL as below.
# PUMP: Normal EF in [**1-9**]. Remained euvolemic.
# Hypothyroidism: Please follow up the TSH/TFT while on amio.
Continued levoxyl.
Medications on Admission:
-fosamax 70 qFriday
-digoxin 125 qd
-lovenox 60 [**Hospital1 **] (coumadin was held for pacer placement)
-flonase
-levoxyl 25 qd
-lisinopril 5 qd
-prilosec 20 qd
-oxycodone 5 prn
-pindolol 10 [**Hospital1 **]
-prednisone 5 [**Hospital1 **]
zocor 20 qd
coumadin 5 qd -held
-aspirin 81 qd
TUMS 750 [**Hospital1 **]
colace
vit D 1000 units qd
iron 27 mg [**Hospital1 **]
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for PM impant for 3 days.
Disp:*6 Capsule(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO Q 12H (Every 12 Hours).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO HS (at bedtime) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
15. Iron 27 mg (Iron) Tablet Sig: Two (2) Tablet PO once a day.
16. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
17. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO four times a
day as needed for pain.
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
tachy-brady syndrome
altered mental status from sedating medications
Secondary:
CAD
HTN
Discharge Condition:
Patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital with fainting. You had a
pacemaker placed. You were a bit confused after the pacemaker
was placed probably from the medications you got during the
procedure. You stopped being confused very quickly.
Medication Changes:
STOP: Pindolol
STOP: Digoxin
STOP: Lovenox
START: Amiodarone 200mg twice daily for one month then 200mg
once daily
START: Toprol XL 50mg daily
Please call your doctor or come to the emergency room if you
have fevers, fainting or near fainting, palpitations, chest
pain, shortness of breath, abdominal pain, nausea, diarrhea,
blood in your stools or black tarry stools, leg swelling, or any
other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 17753**]) on [**2191-3-21**] to
have your INR (coumadin level) drawn and your coumadin dosed
appropriately.
Please follow up with Dr. [**Last Name (STitle) 23246**] ([**Telephone/Fax (1) 62**]) in 1 week to
have your pacemaker checked.
Completed by:[**2191-3-19**]
|
[
"E937.9",
"414.00",
"272.4",
"412",
"V45.81",
"185",
"496",
"V12.71",
"244.9",
"530.81",
"427.81",
"V58.65",
"725",
"780.97",
"V13.51",
"401.9",
"427.31",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
4879, 4885
|
1634, 2778
|
251, 267
|
5018, 5088
|
1292, 1611
|
5808, 6150
|
1177, 1273
|
3197, 4856
|
4906, 4997
|
2804, 3174
|
5112, 5346
|
5366, 5785
|
182, 213
|
290, 935
|
951, 1161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,572
| 148,089
|
33344
|
Discharge summary
|
report
|
Admission Date: [**2144-6-5**] Discharge Date: [**2144-7-9**]
Date of Birth: [**2069-4-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**6-5**] AVR(21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] porcine), CABGx2(SVG>PDA,LIMA>LAD)
History of Present Illness:
75 yo F with increasing DOE over past several years, known AS
followed by serial echos, cath showed 3VD, referred for
AVR/CABG.
Past Medical History:
PMH: HTN, sleep apnea on CPAP, DM2, ^lipids, Diverticulitis, AS,
poor balance w/frequent falls, L4 & L5 fractures, subdural
hematoma
PSH: ccy, appendectomy, partial colectomy, knee arthroscopy x3,
pilonidal cyst excision
Social History:
retired lab tech
no tobacco
no etoh
Family History:
father deceased from MI at age 41
Physical Exam:
Admission
HR 82 RR 16 BP 129/69
NAD
Lungs CTAB
Heart RRR, [**4-16**] HSM
Abdomen soft, NT, obese
Extrem 2+ edema
Discharge
VS T 99.3 HR 87 first degree AVB BP 110/44 RR 22 O2sat 97%
50% PSV
Gen NAD
Neuro Alert/responsive. Follows commands, answers(shakes head)
appropriately
Pulm course rhonchi throughout
CV RRR, sternum stable. Incision small open area at base
w/fibrinous tissue minimal drainage
Abdm soft, NT/obese. Midline incision w/staples-CDI. J tube
site-CDI.
Ext warm, 4+ edema bilat
TLD J tube, foley, PIV, Trach, PICC-lft anticub
Pertinent Results:
[**2144-7-9**] 03:25AM BLOOD WBC-7.9 RBC-3.28*# Hgb-9.6*# Hct-28.4*
MCV-86 MCH-29.1 MCHC-33.7 RDW-18.7* Plt Ct-295
[**2144-7-8**] 08:59PM BLOOD Hct-28.7*
[**2144-7-8**] 03:03PM BLOOD Hct-24.7*
[**2144-7-8**] 06:37AM BLOOD Hct-22.2*
[**2144-7-9**] 03:25AM BLOOD PT-13.4 PTT-27.1 INR(PT)-1.1
[**2144-7-9**] 03:25AM BLOOD Glucose-170* UreaN-24* Creat-0.5 Na-138
K-3.8 Cl-104 HCCOMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt Ct
[**2144-7-9**] 10:37AM 29.0*
O3-32 AnGap-6*
CHEST (PORTABLE AP) [**2144-7-8**] 7:25 AM
CHEST (PORTABLE AP)
Reason: ?ptx
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with s/;p cabg
REASON FOR THIS EXAMINATION:
?ptx
INDICATION: 75-year-old woman with status post CABG; evaluate
for pneumothorax.
COMPARISON: [**2144-7-7**].
SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST AT 7:40 A.M.: There
are moderate bilateral pleural effusions, slightly worse than
prior study. There are associated bibasilar opacities which are
also worse and may reflect worsening atelectasis and/or
pneumonia. Left PICC is terminating at the upper SVC. There is
no pulmonary edema or pneumothorax.
IMPRESSION: No pneumothorax. Worsening moderate bilateral
pleural effusions and bibasilar consolidation.
CT ABDOMEN W/O CONTRAST [**2144-7-8**] 4:38 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: r/o retroperitoneal bleed with drop in hct
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
r/o retroperitoneal bleed with drop in hct
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 75-year-old female after cardiac surgery with falling
hematocrit and concern for retroperitoneal hematoma. The patient
has known right groin hematoma after removal of a femoral
catheter.
COMPARISON: Right groin ultrasound [**2144-7-1**].
TECHNIQUE: MDCT axial images of the abdomen and pelvis without
oral or IV contrast. Coronal and sagittal reformats were
obtained.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: The patient is status
post sternotomy. There are small bilateral pleural effusions and
atelectasis of much of both lower lobes. Diffuse body wall edema
is noted. There are scattered pockets of ascites within the
abdomen. A drainage catheter enters the left upper abdomen and
terminates near the inferior liver edge. Evaluation of the solid
abdominal organs is limited without IV contrast. There is a
small subcentimeter hypodense focus of the left hepatic lobe,
too small to characterize. Gallbladder is not seen and may be
surgically absent or collapsed. Both kidneys are atrophic. The
pancreas, spleen, and adrenal glands are unremarkable. There are
numerous colonic diverticula, but no evidence of acute
diverticulitis. Oral contrast from prior examination is present
throughout the colon. There is no evidence of retroperitoneal
hematoma. There is extensive body wall edema.
CT OF THE PELVIS WITHOUT IV CONTRAST: Again seen is a large
right groin hematoma, which extends down the medial leg.
Assessment for change in size compared to recent ultrasound is
difficult due to differences in modalities. Today on greatest
axial dimension dimensions, it measures about 17 x 6 cm. The
hematoma has high-density component, suggesting more recent
hemorrhage. The bladder is decompressed by a Foley catheter. The
rectum, uterus, adnexa, and pelvic loops of bowel are
unremarkable.
BONE WINDOWS: No concerning bone lesions are seen. There are
degenerative changes of the spine. There is an old wedge
compression fracture deformity of L2 with hyperdense material
within it, probably from vertebroplasty.
IMPRESSION:
1. Right groin hematoma redemonstrated. Assessment for change in
size is difficult due to differences in modalities compared to
prior ultrasound [**2144-7-1**]. Maximal axial dimensions today are
17 x 6 cm. Presence of hyperdense material within the hematoma
suggest more recent hemorrhage into the hematoma. If clinically
indicated, further evaluation with a followup ultrasound to
assess for pseudoaneurysm is suggested.
2. Anasarca evidenced by small bilateral pleural effusions,
scattered pockets of intra-abdominal ascites and diffuse body
wall edema.
3. Atelectasis of a large portion of the lower lobes.
4. Atrophic kidneys.
5. Diverticulosis.
FEMORAL VASCULAR US RIGHT PORT [**2144-7-8**] 5:24 PM
FEMORAL VASCULAR US RIGHT PORT
Reason: evaluation of rt groin hematoma if changes and
evaluation of
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
evaluation of rt groin hematoma if changes and evaluation of
flow ? pseudoaneurysm - please compare to previous ultrasound
Right groin hematoma.
COMPARISON: [**2144-7-1**].
HISTORY: Hematoma.
FINDINGS: Panoramic images were obtained of the right groin to
assess the known complex fluid collection. This known complex
fluid collection measures 17.5 x 8.0 x 11.1 cm on today's
examination. Please note however that similar views were not
obtained on prior study and therefore not accurately comparable.
When comparing the most similar views from today's study to
prior study, the dimensions appear slightly decreased when
compared to prior exam. The right common femoral artery and vein
are patent with normal waveforms. There is no evidence of
pseudoaneurysm or AV fistula.
IMPRESSION: Large right groin hematoma, slightly decreased in
size as best can be compared to prior exam.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77397**]TTE (Complete)
Done [**2144-6-29**] at 4:12:19 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2069-4-18**]
Age (years): 75 F Hgt (in): 66
BP (mm Hg): 124/66 Wgt (lb): 280
HR (bpm): 100 BSA (m2): 2.31 m2
Indication: Prosthetic valve function. Endocarditis.
ICD-9 Codes: 424.90, V43.3
Test Information
Date/Time: [**2144-6-29**] at 16:12 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: Cardiology Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W9-9:9 Machine: Other
Sedation: Versed: 1 mg
Fentanyl: 50 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in aortic arch. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No masses or vegetations on aortic valve. No AS. No
AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). 0.1 mg of IV glycopyrrolate was given as an
antisialogogue prior to TEE probe insertion. No TEE related
complications. The patient appears to be in sinus rhythm.
Echocardiographic results were reviewed with the houseofficer
caring for the patient.
Conclusions
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. A bioprosthetic
aortic valve prosthesis is present. No masses or vegetations are
seen on the aortic valve bioprosthesis. There is no aortic valve
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
Conclusions: Normal bioprosthetic aortic valve without
echocardiographic evidence of vegetation or mass present.
Brief Hospital Course:
She was taken to the operating room on [**6-5**] where she underwent
an AVR/CABG x 2. Please see operative note for details. She was
transferred to the ICU in stable condition. She underwent
bronchoscopy that night for thick secretions and airway
obstruction. She had low urine output and was started on
natrecor and lasix drips. She remained intubated for hemodynamic
instability on epinephrine and levophed. She developed a fever
and was cultured. She was seen by renal for continued low urine
output. She was seen by cardiology for continued hypotension and
ectopy and bundle branch block, and she was seen by infectious
diseases for ?sepsis. She continued on vanocmycin for CNS from
arterial line, and was started on cefepime and flagyl for ? of
VAP and empiric GI coverage. She was started on tube feeds.
Chest tube insertion was attempted for pleural effusion but was
unsuccessful secondary to body habitus. Meropenum was added and
flagyl was dc'd. She received free water for hypernatremia.
Repeat bronchoscopy on [**6-18**] showed significant secretions and
airway collapse. She underwent thoracentesis for left pleural
effusion. She was extubated on [**6-19**] but required BiPAP. She was
seen by cardiology for SVT that converted with adenosine and
medications (lopressor) were adjusted. She was reintubated on
[**6-22**] for respiratory failure. She was seen by thoracic surgery
for tracheostomy placement, and on [**6-23**] she underwent an open
tracheostomy, flexible bronchoscopy and open jejunostomy. She
developed an acute abdomen and new pressor requirement and On
[**6-26**] she was taken to the operating room for A duodenal ulcer
with perforation
and succus throughout the abdominal cavity and she underwent a
Exploratory laparotomy and washout, Lysis of adhesions, and
Duodenal ulcer [**Location (un) **] patch with [**Doctor Last Name 406**] drain placement.
Tube feeds were advanced to goal. She was started on caspofungin
for fungemia and positive fungal wound cultures. She was
transfused multiple times. PICC line was placed.
She was seen by vascular surgery for blue right toes. Right
femoral artery ultrasound showed complex fluid collection with
no evidence of pseudoaneurysm or AV fistula and she was followed
with serial HCTs which remained stable.
he did not tolerate passy-muir valve placement on [**7-2**]. She
tolerated trach mask trials. PICC line was replaced given
candidemia after previous PICC placed. She was started on bumex,
and then aldactone and HCTZ for diuresis. On [**7-7**] she underwent
left thoracentesis for 1200 cc serous fluid.
She developed guaiac positive stools and PPI was increased to
[**Hospital1 **]. HCT fell and she was transfused. She was started on vanco
for coag negative staph in blood cultures from [**7-5**], the vanco
was subsequently dc'd as only 1 bottle was positive. Subsequent
cultures remained negative.
HCT subsequently remained stable and she was ready for transfer
to rehab.
Medications on Admission:
glucophage 850", avandia 8', glipizide 10", dumex 2', asa 81'
spironolactone/hctz 25/25', , paxil 40', lipitor 20',
amitryptiline 25', lopressor 25''', ranitidine 150'', serevent
inh [**Hospital1 **], mvi, vit c 500", vit e 400', calcium + d 600",
methadone 5""
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Paroxetine HCl 10 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-12**] PO BID (2 times a
day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): to sternal and coccyx wounds .
15. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous BREAKFAST (Breakfast).
16. Pantoprazole 40 mg IV Q12H
17. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q8H (every 8 hours): through [**7-10**].
18. Caspofungin 70 mg Recon Soln Sig: Fifty (50) mg Intravenous
Q24H (every 24 hours): Through [**7-12**].
19. Bumex 2 mg Tablet Sig: One (1) Tablet PO once a day: 30 min
after hctz.
20. Roxicet 5-325 mg/5 mL Solution Sig: 2.5-5 mls PO every [**5-17**]
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
AS, CAD s/p AVR, CABG
Respiratory failure s/p tracheostomy, jejunostomy
Perforated duodenal ulcer s/p exploratory laparotomy, [**Location (un) **]
patch
PMH: HTN, sleep apnea on CPAP, DM2, ^lipids, Diverticulitis,
poor balance w/frequent falls, L4 & L5 fractures, subdural
hematoma
PSH: ccy, appendectomy, partial colectomy, knee arthroscopy x3,
pilonidal cyst excision
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] [**Telephone/Fax (1) **] after discharge from rehab
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77398**] after discharge from rehab
Dr. [**Last Name (STitle) **] after discharge from rehab
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**]/General surgery clinic in [**3-15**] weeks
Patient to call for all appointments
Completed by:[**2144-7-9**]
|
[
"518.5",
"567.9",
"E879.8",
"327.23",
"486",
"117.9",
"424.1",
"519.19",
"414.01",
"401.9",
"429.1",
"250.00",
"998.12",
"276.0",
"532.10",
"511.9",
"999.31",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"96.72",
"38.93",
"88.72",
"34.91",
"96.6",
"35.21",
"31.1",
"36.15",
"44.42",
"46.39",
"39.61",
"33.24",
"00.13",
"96.04",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
15073, 15145
|
10082, 13037
|
281, 402
|
15559, 15569
|
1490, 2056
|
15882, 16350
|
873, 908
|
13349, 15050
|
5914, 5946
|
15166, 15538
|
13063, 13326
|
15593, 15859
|
923, 1471
|
238, 243
|
5975, 10059
|
430, 559
|
581, 804
|
820, 857
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,961
| 187,520
|
44630
|
Discharge summary
|
report
|
Admission Date: [**2168-7-27**] Discharge Date: [**2168-8-1**]
Date of Birth: [**2104-10-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2168-7-27**] Cardiac catherization
[**2168-7-28**] Urgent coronary artery bypass grafting
x2: Left internal mammary artery graft to the left anterior
descending, reverse saphenous vein graft to the marginal
branch.
History of Present Illness:
63 year old man with chest discomfort symptoms and a recent
positive stress test. During stress he developed mild chest
discomfort described as [**1-19**], with ischemic ECG changes with 1.5
to 2.0 mm of slow upsloping/horizontal ST segment
depression
Past Medical History:
Hyperlipidemia
Hypertension
Renal stone
Coronary artery disease s/p Stent LAD
Social History:
Occupation: independent management consultant
Lives with spouse
[**Name (NI) 1139**]: denies
ETOH equivalent of [**1-12**] glasses wine/day
Family History:
Father dying apparently from a myocardial infarction at age 58
Physical Exam:
Pulse: 65 Resp:16 O2 sat: 96% RA
B/P Right: 111/69 Left: 119/77
Height: 165cm Weight: 79.4 kg
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no lymphadenopathy
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] no mumur/rub/gallop
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2168-8-1**] 06:30AM BLOOD Hct-24.2*
[**2168-7-31**] 06:55AM BLOOD WBC-6.2 RBC-2.78* Hgb-8.0* Hct-23.6*
MCV-85 MCH-28.8 MCHC-34.0 RDW-13.5 Plt Ct-178
[**2168-7-28**] 12:35PM BLOOD WBC-6.2 RBC-3.17*# Hgb-9.3*# Hct-27.0*#
MCV-85 MCH-29.3 MCHC-34.4 RDW-13.3 Plt Ct-175
[**2168-7-27**] 11:30AM BLOOD WBC-4.5 RBC-4.62 Hgb-13.1* Hct-38.7*
MCV-84 MCH-28.4 MCHC-33.8 RDW-13.7 Plt Ct-237
[**2168-7-31**] 06:55AM BLOOD Plt Ct-178
[**2168-7-27**] 11:30AM BLOOD Plt Ct-237
[**2168-7-27**] 11:30AM BLOOD PT-12.9 PTT-30.9 INR(PT)-1.1
[**2168-8-1**] 06:30AM BLOOD UreaN-25* Creat-1.1 K-3.9
[**2168-7-31**] 06:55AM BLOOD Glucose-89 UreaN-19 Creat-1.0 Na-138
K-4.0 Cl-102 HCO3-27 AnGap-13
[**2168-7-27**] 11:30AM BLOOD Glucose-120* UreaN-19 Creat-1.1 Na-139
K-3.2* Cl-100 HCO3-33* AnGap-9
[**2168-7-27**] 11:30AM BLOOD ALT-28 AST-24 AlkPhos-47 TotBili-0.4
[**2168-7-31**] 06:55AM BLOOD Mg-2.2
[**2168-7-27**] 11:30AM BLOOD %HbA1c-5.8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 95528**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 95529**]Portable TTE
(Complete) Done [**2168-7-28**] at 1:17:45 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-10-20**]
Age (years): 63 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Coronary artery disease. Left ventricular function.
Intra-op TEE for CABG
ICD-9 Codes: 410.92, 424.0, 440.0
Test Information
Date/Time: [**2168-7-28**] at 13:17 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location: West OR
cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009W000-0:0 Machine: Other
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *0.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mild regional LV systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Prominent moderator band/trabeculations are noted in the RV
apex.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction (EF 40%) with apical hypokinesis. Right
ventricular chamber size and free wall motion are normal. A PA
catheter is seen. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Mild (1+) tricuspid regurgitation. There is no pericardial
effusion.
POSTBYPASS
Left ventricular systolic function is improved and now normal
(EF > 55%) without focal wall motion abnormalities.
Mild-moderate tricuspid regurgitation is seen and is slightly
increased. Mild (1+) mitral regurgitation is seen. Ascending
aorta is intact. There is no pericardial effusion.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.
[**Name10 (NameIs) 55496**] assigned to [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician
Cardiology Report ECG Study Date of [**2168-7-28**] 2:13:58 PM
Artifact is present. Sinus rhythm. There is a late transition
with
tiny R waves in the anterior leads consistent with possible
prior anterior
myocardial infarction. Non-specific ST-T wave changes. Low
voltage in the
precordial leads. Compared to the previous tracing low voltage
is new.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 172 92 420/435 34 -27 -18
Brief Hospital Course:
Transferred from outside hospital after cardiac catherization
for surgical evaluation. He underwent preoperative work up and
on [**2168-7-28**] was brought to the operating room and underwent
coronary artery bypass graft surgery. See operative report for
details. In operating room there was difficult with intubation,
see anesthesia report for details. He received vancomycin for
perioperative antibiotics as he was in the hospital
preoperatively. He was transferred to the intensive care unit
for hemodynamic management. In the first twenty four hours he
was weaned from sedation, awoke neurologically intact, and was
extubated. After extubation, his voice was hoarse and ENT was
consulted. His vocal cords were mobile bilaterally but there
was some swelling of L and R false cord, which would be
consistent with difficult intubation, and recent extubation, no
evidence of hematoma. He remained in the intensive care unit for
airway monitoring and placed on humidified oxygen and proton
pump inhibitor twice a day. Additionally he was started on beta
blockers and diuretics. On post operative day two he was
transferred to the floor for the remainder of his care.
Physical therapy worked with him on strength and mobility. He
continued to progress and voice improved. Speech and swallow
evaluated him for swallowing and cleared him for a soft diet
with thin liquids. He was instructed to follow up with ENT
and/or the swallow team if he experienced any further difficulty
with his voice or swallowing. He was ready for discharge home
with services on post operative day four.
Medications on Admission:
-HCTZ 25 mg daily
-Lisinopril 10 mg daily
-Atenolol 50 mg daily
-Aspirin 81 mg daily
-Lipitor 80 mg daily
-Bupropion XL 300 mg daily
-Diazepam 5-10 mg prn sleep
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 Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Wellbutrin XL 300 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:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
1 weeks.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p CABG
Difficult Intubation
Hyperlipidemia
Hypertension
Renal stone
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
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] in 1 week [**Telephone/Fax (1) 2205**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-12**] weeks
Dr. [**Last Name (STitle) 3878**] in 1 week [**Telephone/Fax (1) 31733**]
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2168-8-1**]
|
[
"V45.82",
"414.01",
"272.4",
"478.6",
"V17.3",
"413.9",
"V13.01",
"401.9",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"31.42",
"36.15",
"37.22",
"88.56",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10253, 10311
|
7257, 8850
|
339, 560
|
10449, 10456
|
1932, 7234
|
10995, 11520
|
1118, 1183
|
9062, 10230
|
10332, 10428
|
8876, 9039
|
10480, 10972
|
1198, 1913
|
282, 301
|
588, 842
|
864, 944
|
960, 1102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,824
| 105,359
|
19249
|
Discharge summary
|
report
|
Admission Date: [**2114-7-26**] Discharge Date: [**2114-8-8**]
Date of Birth: [**2054-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
CC - worsening appetite, ascites, worsening renal function
Major Surgical or Invasive Procedure:
TIPS
Therapeutic paracentesis
Fluoroscopy guided [**Last Name (un) **]-duodenal tube placement
History of Present Illness:
HPI: 60 y/o male with chronic liver failure [**1-17**] to Hep C/EtOH
cirrhosis, diagnosed 3 years ago admitted on [**7-26**] for worsening
ascites, poor appetite, worsening renal function. Pt had no
history of SBP or had not required paracentesis due to efficacy
of diuretics. Pt was ruled out for SBP with a
diagnostic/therapeutic paracentesis on [**7-27**]. Pt received 2 units
of PRBCS on [**7-29**] for Hct drop to 22 but his HCT has remained
stable since. Pt had a NJ tube placed on [**7-26**] by for nutrition
that was was replaced on [**7-30**] with EGD. EGD at that time showed
retained food in the stomach and also erythema, congestion,
friability and petechiae consistent with severe portal
gastropathy. Varices at the middle third of the esophagus, lower
third of the esophagus and gastroesophageal junction were also
noted. Given these findings and refractory ascites and concern
for renal dysfunction with diuretic use, it was decided that pt
should undergo TIPS.
Past Medical History:
PMH -
1. Cirrhosis
2. Hep c, [**2107**]
3. Ascites - no SBP, no paracentesis
4. Varices, grade 2 - no UGIB
5. CRI (Cr 1.8 -> 2.1)
6. Cholilithiasis
PSH -
1. s/p appy 30 yrs ago
2. Inguinal hernia repair, [**2112**]
3. Adenoids
4. L ankle fracture, [**2095**]
Social History:
SH - Pt is married, lives with his wife. [**Name (NI) **] two sons, healthy.
H/o heavy EtOH use, quit [**2103**]. Prior h/o smoking, quit [**2088**].
Prior IVDA, quit [**2088**]'s. Marijuana in past.
Family History:
FH - Cirrhosis in father, mother, and brother [**1-17**] EtOH; no
cancer
Physical Exam:
PE:
Vitals: AF 98.1 104/50 90 20 97% on RA I/O 1185+505/775 (24 hr)
General: A&O x 3, cachectic, NAD
HEENT: NC/AT, EOMI, sclera anicteric, NJ tube in place, top set
of dentures, MMM, OP clear
Neck - supple
Chest - CTAB anteriorly
CV - RRR s1 s2 normal, no m/g/r
Abd - distended, not tense; mild tenderness to palpation on R
over paracentesis site w/ min surrounding ecchymosis; good BS;
reducible umbilical hernia, left inguingal hernia palpable-
mildly tender
Ext - no c/c/e, pulses 2+ b/l
Skin - multiple spider angiomas over chest, palmar erythema
Neuro - Pt AO x 3, CN II-XII grossly intact; motor and sensation
wnl; no asterixis
Pertinent Results:
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p TIPS + parecentesis on [**2114-8-1**].
REASON FOR THIS EXAMINATION:
eval for possible TIPS failure; need liver u/s WITH DOPPLER;
please mark spot for paracentesis
INDICATION: 60-year-old post TIPS on [**8-1**], now with
increasing ascites.
COMPARISON: [**2114-8-2**].
Ascites is again noted throughout the abdomen which does not
appear significantly changed compared to the study of one day
earlier. A spot was marked in the right lower quadrant for
paracentesis to be performed by the clinical team. Grayscale
images demonstrate a nodular shrunken appearing liver. The
gallbladder is unremarkable. Pulsed color Doppler images
demonstrate a patent TIPS catheter with wall-to-wall color flow.
Flow velocity in the proximal portion of the TIPS is 93 cm per
second.
IMPRESSION:
No significant change in the extent of large amount of ascites
throughout the abdomen. Patent TIPS with wall-to-wall color
flow.
[**2114-7-26**] 07:15PM BLOOD WBC-2.5* RBC-2.76* Hgb-10.0* Hct-28.3*
MCV-103* MCH-36.4* MCHC-35.5* RDW-15.1 Plt Ct-64*
[**2114-7-27**] 05:35AM BLOOD WBC-2.2* RBC-2.55* Hgb-9.4* Hct-25.9*
MCV-101* MCH-36.9* MCHC-36.3* RDW-15.1 Plt Ct-57*
[**2114-7-27**] 12:18PM BLOOD Hct-29.6*
[**2114-7-28**] 05:50AM BLOOD WBC-2.8* RBC-2.47* Hgb-8.9* Hct-25.4*
MCV-103* MCH-36.0* MCHC-35.0 RDW-15.3 Plt Ct-50*
[**2114-7-28**] 01:00PM BLOOD Hct-25.0*
[**2114-7-28**] 09:12PM BLOOD WBC-2.9* RBC-2.65* Hgb-9.5* Hct-27.5*
MCV-104* MCH-35.7* MCHC-34.5 RDW-15.0 Plt Ct-44*
[**2114-7-29**] 05:55AM BLOOD WBC-2.3* RBC-2.28* Hgb-8.3* Hct-22.6*
MCV-100* MCH-36.5* MCHC-36.7* RDW-14.8 Plt Ct-44*
[**2114-7-30**] 05:07AM BLOOD WBC-3.1* RBC-3.21*# Hgb-11.1*# Hct-30.6*#
MCV-95 MCH-34.6* MCHC-36.3* RDW-17.2* Plt Ct-52*
[**2114-7-31**] 01:16AM BLOOD Hct-32.8*
[**2114-7-31**] 05:15AM BLOOD WBC-5.1# RBC-3.14* Hgb-11.0* Hct-29.9*
MCV-95 MCH-34.9* MCHC-36.7* RDW-16.7* Plt Ct-48*
[**2114-8-1**] 01:02AM BLOOD Hct-28.5*
[**2114-8-1**] 04:55AM BLOOD WBC-4.3 RBC-3.12* Hgb-10.7* Hct-29.8*
MCV-95 MCH-34.2* MCHC-35.8* RDW-16.4* Plt Ct-45*
[**2114-8-1**] 07:57PM BLOOD WBC-6.5# RBC-3.23* Hgb-11.3* Hct-30.7*
MCV-95 MCH-35.0* MCHC-36.9* RDW-16.5* Plt Ct-54*
[**2114-8-2**] 01:10AM BLOOD Hct-31.6*
[**2114-8-2**] 04:15AM BLOOD WBC-6.1 RBC-3.29* Hgb-11.1* Hct-32.1*
MCV-98 MCH-33.8* MCHC-34.6 RDW-16.8* Plt Ct-51*
[**2114-8-2**] 05:00PM BLOOD Hct-30.1*
[**2114-8-3**] 06:15AM BLOOD WBC-3.2* RBC-3.15* Hgb-11.1* Hct-30.6*
MCV-97 MCH-35.3* MCHC-36.4* RDW-16.3* Plt Ct-51*
[**2114-8-4**] 06:00AM BLOOD WBC-3.3* RBC-3.09* Hgb-10.4* Hct-30.1*
MCV-98 MCH-33.7* MCHC-34.5 RDW-16.6* Plt Ct-40*
[**2114-8-5**] 05:50AM BLOOD WBC-2.1* RBC-2.64* Hgb-8.8* Hct-25.8*
MCV-98 MCH-33.5* MCHC-34.3 RDW-16.7* Plt Ct-48*
[**2114-8-5**] 03:12PM BLOOD Hct-27.1*
[**2114-8-6**] 05:32AM BLOOD WBC-2.4* RBC-2.91* Hgb-9.9* Hct-28.6*
MCV-99* MCH-34.0* MCHC-34.5 RDW-16.7* Plt Ct-59*
[**2114-8-7**] 06:10AM BLOOD WBC-2.3* RBC-2.64* Hgb-9.0* Hct-26.2*
MCV-99* MCH-34.2* MCHC-34.5 RDW-17.0* Plt Ct-48*
[**2114-8-7**] 05:31PM BLOOD WBC-3.4* RBC-2.79* Hgb-9.4* Hct-27.8*
MCV-100* MCH-33.8* MCHC-34.0 RDW-17.3* Plt Ct-51*
[**2114-8-8**] 05:40AM BLOOD WBC-2.6* RBC-2.77* Hgb-9.7* Hct-27.9*
MCV-101* MCH-34.8* MCHC-34.6 RDW-16.8* Plt Ct-47*
[**2114-7-26**] 07:15PM BLOOD Glucose-123* UreaN-28* Creat-1.7* Na-135
K-3.4 Cl-102 HCO3-24 AnGap-12
[**2114-7-27**] 05:35AM BLOOD Glucose-103 UreaN-25* Creat-1.5* Na-133
K-3.5 Cl-104 HCO3-24 AnGap-9
[**2114-7-28**] 05:50AM BLOOD Glucose-100 UreaN-22* Creat-1.3* Na-137
K-4.1 Cl-108 HCO3-21* AnGap-12
[**2114-7-29**] 05:55AM BLOOD Glucose-167* UreaN-22* Creat-1.3* Na-132*
K-4.0 Cl-106 HCO3-22 AnGap-8
[**2114-7-30**] 05:07AM BLOOD Glucose-91 UreaN-24* Creat-1.4* Na-133
K-4.2 Cl-105 HCO3-24 AnGap-8
[**2114-7-31**] 05:15AM BLOOD Glucose-89 UreaN-33* Creat-1.5* Na-132*
K-4.2 Cl-104 HCO3-20* AnGap-12
[**2114-8-1**] 04:55AM BLOOD Glucose-94 UreaN-41* Creat-1.6* Na-132*
K-4.2 Cl-104 HCO3-20* AnGap-12
[**2114-8-1**] 07:57PM BLOOD Glucose-86 UreaN-37* Creat-1.3* Na-134
K-4.2 Cl-106 HCO3-18* AnGap-14
[**2114-8-2**] 04:15AM BLOOD Glucose-87 UreaN-35* Creat-1.3* Na-133
K-4.8 Cl-108 HCO3-17* AnGap-13
[**2114-8-3**] 06:15AM BLOOD Glucose-179* UreaN-34* Creat-1.2 Na-134
K-3.8 Cl-109* HCO3-20* AnGap-9
[**2114-8-4**] 06:00AM BLOOD Glucose-108* UreaN-32* Creat-1.1 Na-136
K-3.7 Cl-108 HCO3-23 AnGap-9
[**2114-8-5**] 05:50AM BLOOD Glucose-115* UreaN-29* Creat-1.1 Na-135
K-3.2* Cl-106 HCO3-22 AnGap-10
[**2114-8-6**] 05:32AM BLOOD Glucose-130* UreaN-23* Creat-1.1 Na-136
K-4.1 Cl-107 HCO3-24 AnGap-9
[**2114-8-7**] 06:10AM BLOOD Glucose-127* UreaN-25* Creat-1.1 Na-135
K-4.0 Cl-107 HCO3-22 AnGap-10
[**2114-8-8**] 05:40AM BLOOD Glucose-119* UreaN-29* Creat-1.2 Na-135
K-3.8 Cl-108 HCO3-23 AnGap-8
Brief Hospital Course:
This is a 60 y/o male who was initially admitted for management
of his cirrhosis, c/w ascites and increasing creatinine on the
diuretics and poor po intake. He had several
therapeutic/diagnostic paracentesis while in-house, which were
all negative for SBP. The diuretics were held initially [**1-17**]
worsening renal function, and were started again after
stabilization of his renal function. He had an NJ tube placement
at the beginning of his admission for poor nutritional status
for supplementation. During his stay, he developed a decreased
Hct (responsive to transfusion) and guiac positive stools. He
had an EGD which confirmed grade II varices (pt already with h/o
esophageal varices) and portal gastropathy. Due to his NJ tube
placement, the varices were not banded. He had a TIPS procedure
to alleviate the portal HTN. His TIPS was complicated by
post-procedure hypotension, for which he required an overnight
MICU stay with pressors to increased his blood pressure. He was
transferred back to the floor after stabilization. His Cr
dropped and stabilized after his TIPS [**1-17**] increased renal
perfusion and improvement in renal function. He had no further
episodes of bleeding, or decreased Hct. He was started on
lactulose s/p TIPS [**1-17**] risk of encephalopathy, although he had
no symptoms of encephalopathy at the time of discharge. He was
also restarted on low-dose diuretics for his ascites, as his
renal function was stable. His main issue was his poor
nutritional status, for which he was continued on TF and po
intake as much as possible. He had an episode of choking on food
s/p EGD with resulting aspiration PNA, for which he was started
on appropriate antibiotics. Speech and swallow evaluated the pt
following this, and recommended ground solids and thin liquids
(as pt had no aspiration risk with thin liquids). He was
discharged on [**2114-8-8**] in stable condition with VNA services to
aid with the TF, which he will continue for the time being. A
RUQ u/s showed a patent TIPS with good flow prior to discharge.
He will follow-up with Dr. [**Last Name (STitle) 497**] as scheduled and the
nutritionist when he sees Dr.[**Last Name (STitle) 497**].
Secondary issues -
1. New left-inguinal hernia - during his stay, the pt noted a
new left groin mass, which was nontender and not painful. Upon
exam, this was a new left inguinal hernia, which was reducible
while the pt was supine. Transplant surgery was consulted, who
decided to take the pt to the OR. His surgery was scheduled,
however cancelled several times [**1-17**] to the high risk. He will
instead follow-up with Dr. [**First Name (STitle) **] upon discharge to plan for
surgery in the future for the left inguinal hernia.
2. Aspiration PNA - by CXR and pt's symptoms of non-productive
cough, and recent choking s/p EGD. Pt was started on
Levo/Flagyl, and was discharged with these to complete a 14-day
course.
Medications on Admission:
MEDS -
1. CaCO3 600 mg qd
2. Protonix 40 mg qd
3. Nadolol 40 mg qd
4. Aldactone 25 mg qd
5. Bumex 1 mg qd
6. Mycelex troch 10 mg qd
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day) as needed for as needed for thrush.
Disp:*90 Troche(s)* Refills:*1*
3. Tubefeeds
Nepro Full strength
Sig: Sixty (60) cc/hr from 7PM to 11AM QD
per nasal-duodenal tube (=4 cans qQ)
Disp: One (1) month supply (44 cans), Eleven (11) refills
4. Pump Pole
Pump Pole for tube feeding
Disp: One (1)
5. NGT Supplies
[**Last Name (un) 1372**]-duodenal tube supplies
Disp: One (1) month supply, eleven (11) refills
6. Outpatient Lab Work
Please check a chemistry 7 panel this [**Last Name (LF) 2974**], [**2114-8-10**]
and fax results to Dr.[**Name (NI) 948**] office [**Telephone/Fax (1) **]
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for aspiration pneumonia for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
11. 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*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*1*
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary - s/p TIPS, Abdominal Ascites, Hepatitis C cirrhosis ,
Endstage liver disease
Secondary-
Chronic renal insufficiency
Malnutrition
Discharge Condition:
Good, ongoing ascites [**1-17**] liver failure, afebrile, HD stable
Discharge Instructions:
Continue taking your medications as directed. Call your doctor
or 911 if you have fever, chills, severe abdominal pain, fail to
urinate.
Continue to weigh yourself daily. If you gain more than 2lbs,
call your doctor for further advice in terms of your diuretic
doses.
Continue working with visiting nurses on your tubefeeds. Limit
sodium intake to 2 grams a day if possible.
Follow up with your doctor as previously directed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2114-8-15**] 3:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2114-9-10**] 3:20.
Completed by:[**2114-8-11**]
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12622, 12692
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,644
| 177,421
|
44764
|
Discharge summary
|
report
|
Admission Date: [**2173-3-2**] Discharge Date: [**2173-3-18**]
Date of Birth: [**2094-11-19**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Percocet
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
acute confusional state
Major Surgical or Invasive Procedure:
lumbar puncture
mechanical ventillation
History of Present Illness:
The patient is a 78 year old left handed man with hypertension,
status post aortic valve replacement in [**2166**] (porcine),
hypercholestrolemia, status post partial lung resection
[**2172-12-4**], who was brought to the ED [**3-2**] after confusion x1 day.
.
A fellow priest noted that the patient was confused in the
morning of the day of presentation. The confusion progressed and
by pm the patient was only able to mumble. He also had an acute
onset of frontal headache and eye pain that started 10 hours
following the onset of confusion.
.
The PCP was [**Name (NI) 653**] and after evaluation he was brought to the
ED per EMS. The code stroke team was activated as it was not
clear at that time that the confusion had [**Doctor First Name **] going on for half
a day. The patient was noted per ED note to have phonemic
paraphasias, R sided neglect, and ? R hemianopsia. NIHSS~6. A
CT head with motion artifact showed no apparent hemorrhage,
mass, edema, and no obvious infarct except for a chronic
appearing infarct in the L caudate head. At that time, the
patient was deemed a candidate for IV tPA. After tPA he was
tranferred to the unit for further observation and management.
.
Additionally, pt denied HA, diplopia, blurry vision, tinnitus,
vertigo, dysphagia, dysarthria, incoordination, focal
weakness/numbness. No fever or chills, weight loss, SOB, chest
pain or pressure, palpitations, nausea, vomitting, abdominal
pain, constipation, diarrhea, muscle aches, joint pains, rash or
dysuria.
Past Medical History:
1. Aortic valve replacement/Coronary artery bypass graft with
LIMA graft [**2166**]
2. Right-hip replacemt [**2164**] with revision
3. Hypertension
4. Ankylosing spondylitis
5. Right thoracoscopy with multiple wedge excisions [**2172-12-4**],
with multiple intercostal nerve blocks
6. Left pleural effusion, trapped left lower lobe (fibrothorax)
in [**10-12**]
7. Hypertension
Social History:
[**Hospital1 13820**] Priest x 60 [**Name2 (NI) 1686**], lives [**Street Address(1) 95767**]- [**Location (un) **]-
gets meals there
Is still working as a Priest. Drinks alcohol socially.
Family History:
non-contributory
Physical Exam:
Per ED note:
VS: afebrile 80s 194/90s 18 95%ra
General: WNWD, NAD
HEENT: Anicteric, MMM without lesions, OP clear
Neck: Supple, no LAD, no carotid bruits, no thyromegaly
CV: RRR s1s2 2/6 SEM
Resp: CTAB no r/w/r
Abd: +BS Soft/NT/ND no HSM/masses
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
.
MS: alert, oriented to person, place, cannot name date,
interactive, following most midline and appendicular commands
Memory [**4-9**] immediately & w/o prompting at 5 minutes
difficulty naming and repeating; multiple phonemic paraphsias
Evidence of R sided neglect with visual and tactile stimulation
CN: I - not tested, II,III - PERRL([**5-10**] bilat), apparent R
hemianopsia versus neglect; III,IV,VI - EOMI though attends
moreso to the left, no ptosis, no nystagmus; V- sensation
intact
to LT/PP, responds to nasal tickle, masseters strong
symmetrically; VII - no apparent facial weakness/asymmetry; VIII
- hears finger rub B; IX,X - voice normal, palate elevates
symmetrically, gag intact; [**Doctor First Name 81**] - SCM/Trapezii [**6-11**] B; XII - tongue
protrudes midline, no atrophy or fasciculations
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia.
No
pronator drift.
Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB
Axill mscut [**Month/Day (1) 21443**] [**Name6 (MD) 21443**] [**Name8 (MD) 21443**] md/ul ulnar medin
C5 C5-6 C7 C6-7 C7 C8 T1
C8-T1
L 5 5 5 5 5 5 5
5
R 5 5 5 5 5 5 5
5
Ilpso Qufem Hamst TibAn [**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
Femor femor [**First Name9 (NamePattern2) 21444**] [**Last Name (un) 18709**] tibil dpper
L1-2 L3-4 L5-S2 L4-5 S1-2 L5
L 5 5 5 5 5 5
R 5 5 5 5 5 5
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 2 2 2 2 2 down
R 2 2 2 2 2 down
Sensory: w/d to pinch throughout, though extinguishes to DSS on
right
Coord: no apparent dysmetria or ataxia with mvmnts
Gait: not assessed
Pertinent Results:
[**2173-3-2**] 10:00PM WBC-6.4 RBC-3.95* HGB-12.2* HCT-36.7* MCV-93
MCH-30.8 MCHC-33.2 RDW-13.4
[**2173-3-2**] 10:00PM NEUTS-76* BANDS-0 LYMPHS-9* MONOS-13* EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2173-3-2**] 10:00PM PLT COUNT-206
[**2173-3-2**] 09:00PM GLUCOSE-110* UREA N-23* CREAT-1.0 SODIUM-133
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-29 ANION GAP-16
[**2173-3-2**] 09:00PM CK(CPK)-104
[**2173-3-2**] 09:00PM CK-MB-3 cTropnT-<0.01
[**2173-3-2**] 08:00PM GLUCOSE-112* UREA N-23* CREAT-1.0 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-28 ANION GAP-16
[**2173-3-2**] 08:00PM PT-11.7 PTT-26.4 INR(PT)-0.9
.
CT head [**3-2**]: These images are all markedly limited by motion
artifact in spite of being repeated three additional times. Even
the last series is significantly limited. However, there is no
obvious intracranial hemorrhage. There are mild age-related
involutional changes, and greater atrophy within the cerebellum.
There is no mass effect, hydrocephalus or shift of the normally
midline structures. The [**Doctor Last Name 352**]-white matter differentiation
appears preserved but there are hypodensities in the right
subinsular cortex, and one in the left subinsular cortex as well
as left cerebellum, probably from small prior infarctions.
The visualized mastoid air cells and paranasal sinuses are
clear.
There are calcifications of the vertebral and cavernous carotid
arteries.
IMPRESSION: No evidence of intracranial hemorrhage or acute
process.
.
CT head [**2-22**]:
Comparison is limited by motion on the prior scan. However,
there appears to be a new focus of hyperdensity in a right
frontal gyrus (image 22). Although partly obscured by motion on
the prior study, this focus was not seen previously. A tiny
calcification in the left cental sulcus. In retrospect, this
focus was probably present on the prior study.
There is no evidence of infarction, and there are no other areas
of suspicion for hemorrhage.
Conclusion: Possible tiny focus of hemorrhage in the right
frontal lobe, possibly an acute bleed. This appears new since
[**2173-3-2**], but the prior scan was limited by motion. There is a
tiny calcification in the left central sulcus.
No other evidence of hemorrhage or infarction.
.
CXR: IMPRESSION: Markedly suboptimal film with possible process
involving the left parenchymal base.
.
ECHO: The left atrium is mildly dilated. There is asymmetric
left ventricular hypertrophy. The left ventricular cavity is
small. Left ventricular systolic function is hyperdynamic (EF
70-80%), with apical cavity obliteration. An apical
intracavitary gradient is identified (rest: 7 mmHg, Valsalva: 58
mmHg). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The aortic prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. No masses or vegetations are seen on
the aortic valve. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The left ventricular
inflow pattern suggests impaired relaxation. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2172-10-8**], probably no major
change. The absence of a vegetation by 2D echocardiography does
not exclude endocarditis if clinically suggested.
.
US Carotids: 40-59% right ICA stenosis. Less than 40% left ICA
stenosis
.
VIDEO SWALLOW [**2173-3-17**]:
Pt presents with a mild oral and pharyngeal dysphagia
characterized by mildly reduced oral control, mild swallow delay
and delayed laryngeal valve closure. The pt had one episode of
trace aspiration when taking a larger sip of thin liquid.
Aspiration was silent, but cued coughs were effective at
clearing
the aspirate material. The risk for trace aspiration was reduced
by taking single, small sips of thin liquid. The pt was also
noted to have increased oral control compared to the last
videoswallow and is now able to tolerate a PO diet of thin
liquids and soft consistency solids. Pt should only take single,
small sips of thin liquid. Pt was unable to swallow the barium
tablet whole during the study, and should continue to have his
pills crushed with purees.
.
RECOMMENDATIONS:
1. Suggest advancing to a PO diet of thin liquids and soft
consistency solids. 2. Pt should only take single, small sips of
thin liquid. No Straws! 3. Please crush all pills and give them
with purees.
Brief Hospital Course:
78M with hx of AVR/CABG, s/p lung resection who presented to
[**Hospital1 18**] on [**3-2**] with confusion and found to have global aphasia
s/p tPA for presumed stroke but no positive imaging who was
initially given TPA and admitted to the ICU. He was then
re-transfered to the ICU for acute bradycardia with hypotension
and unresponsiveness. The bradycardia and hypotension was felt
to be due to IV lopressor effect, and possibly due to pneumonia
and sepsis. An ABG at that time returned 6.94/151/101 and he
was emergently intubated. Femoral central access was obtained
and he was transiently on Levophed for pressure support. He was
intubated from [**3-8**] - [**3-11**], and his mental status then resolved
after treating his hypercapnea and pneumonia. He was continued
on a course of levaquin for staph aureus pneumonia, and his
mental status remained stable. He was re-evaluated by neurology
after his mental status improved and was felt to have no focal
neurologic deficits. In fact, there was sufficient doubt as to
whether or not he actually had a stroke on presentation since no
evidence of a stroke was ever found. His mental status changes
may have been due to sepsis and respiratory failure -
toxic/metabolic etiologies.
.
For the 3-4 days prior to discharge his mental status remained
clear and he continued to have improving swallowing function.
He completed a course of Levaquin for his penumonia, and he was
afebrile.
.
His code status is DNR/DNI.
Medications on Admission:
ASPIRIN 325MG--One tablet by mouth every day
ATENOLOL 25MG--Take [**2-8**] tablet daily
LIPITOR 20MG--One tablet by mouth every day
NAPROSYN 375MG--One tablet by mouth every day
UNIVASC 7.5MG--One tablet by mouth every day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain: not to exceed 4g/day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 59514**] Friary
Discharge Diagnosis:
stroke
respiratory failure
aspiration pneumonia
hypertension
Discharge Condition:
good
Discharge Instructions:
Please follow-up with your primary care doctor or with a new
primary care doctor in [**2-8**] weeks.
Followup Instructions:
Please follow-up with your primary care doctor or with a new
primary care doctor in [**2-8**] weeks.
.
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Date/Time:[**2173-3-8**] 2:30
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2173-3-8**] 4:00
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], MD Phone:[**Telephone/Fax (1) 7477**] Date/Time:[**2173-3-22**]
9:45
|
[
"995.92",
"518.81",
"401.9",
"E942.6",
"038.11",
"428.30",
"276.0",
"285.9",
"434.91",
"V09.0",
"427.89",
"V42.2",
"784.3",
"507.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"96.71",
"93.90",
"99.04",
"38.93",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11961, 12016
|
9528, 11003
|
306, 348
|
12121, 12128
|
4764, 9505
|
12277, 12794
|
2508, 2526
|
11277, 11938
|
12037, 12100
|
11029, 11254
|
12152, 12254
|
2541, 4745
|
243, 268
|
376, 1884
|
1906, 2285
|
2301, 2492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,873
| 149,271
|
6585+55768
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-12-8**] Discharge Date: [**2132-12-22**]
Date of Birth: [**2089-5-23**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 43 year old female
with history of HIV positive, hepatitis C and diabetes, with
recurrent history of hidradenitis suppurativa. She presents
with repeat episode of inflammation an drainage of the right
axilla. The patient noted a cystic lesion seven days prior to
admission. Pain continued to increase and she noted a cyst
burst three days prior to admission, with increasing pain.
The patient also noted some brownish, foul-smelling drainage.
No fevers, chills or sweats. Positive nausea and vomiting
times two, one day prior to admission. The patient noted
fluid on the first episode and second episode just slightly
bloody and bilious. No diarrhea or constipation. No bright
red blood per rectum. No urinary symptoms. The patient has
had prior episodes with self-described lancing times two,
with the last lancing of the right axilla one year prior.
The patient also has had past genital area involvement in the
past with a surgical procedure to that area greater than 5
years prior. The patient was seen in the infectious disease
clinic and admitted secondary to presentation.
PAST MEDICAL HISTORY: HIV positive with noninsulin dependent
diabetes mellitus, gastritis, lipidemia and hepatitis C.
PAST SURGICAL HISTORY: Right axillary lancing in [**2131**] and
also greater than five years prior to that. Anogenital
lancing greater than five years ago.
MEDICATIONS:
Esaverens 600 q h.s.
Lamivudine 300 mg q. day.
Lisinopril 5 q. day.
Tenoflavir disoproxyl 300 mg q. day.
Abecavier sulfate 300 mg twice a day.
Tylenol.
Sliding scale insulin and NPH 30 in the a.m. and 20 in the
p.m.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No smoking, no alcohol. The patient denied
any use of drugs.
PHYSICAL EXAMINATION: The patient was afebrile with slight
tachycardia, otherwise vital signs were stable. No acute
distress. Regular rate and rhythm. Lungs were clear to
auscultation. Abdomen was soft, nontender, nondistended.
There was a poor axillary examination secondary to pain. The
areas that were visualized showed some raw areas of skin with
indurated sections and copious purulent drainage expressed
but the source of the drainage was poorly visualized. The
patient was given some pain medication but was still unable
to obtain a good examination.
HOSPITAL COURSE: The patient was admitted to the medical
service and started on antibiotics. On hospital day number
two, the patient was noted to be febrile to 103.2. Still
unable to obtain a good examination. White count was noted to
be 3,600 with 12 bands. Mono cultures and blood cultures
were pending, with a wound swab showing organisms growing,
gram negative rods, gram positive rods and gram positive
cocci.
Examination under anesthesia with incision and drainage of
the right axilla was performed on hospital day number three,
with intraoperative plastic surgery and vascular surgery
consults for future reconstruction. A wide local debridement
was done. Drainage of thick fibrinous material of the axilla
was performed.
The patient was taken back to the operating room on
postoperative day number one for further examination and
further debridement which was performed and then again on
postoperative day number two and for a third operative
debridement of the right axilla. There was a small amount of
pus and necrotic tissue again noted but, the wound in
general, was looking improved and granulating.
The patient was admitted to the surgical Intensive Care Unit
for monitoring for elevated white count and also for further
dressing changes under anesthesia at bedside. Dressing
change was again performed on postoperative day number two
with continued improvement noted. Another small pocket of
purulent material was released and the wound was repacked
with wet to dry dressings. The patient continued on
antibiotics.
On postoperative day number four, three and two, the patient
was again taken to the operating room for further
debridement, incision and drainage. Clean tissue was found
with underlying muscle. We were able to contract no pus or
necrotic tissue. The patient continued to do well. Another
dressing change was done on postoperative day number five.
Vascular surgery was present. The patient continued with
daily dressing changes under anesthesia or conscious
sedation. On [**12-17**], postoperative day number seven,
the patient had a VAC dressing placed after a consult with
plastic surgery who concurred that the patient was ready for
a VAC placement. The patient continued with good VAC
suction. VAC was changed on postoperative day number nine
once again. Tissue granulation was seen and the patient
continued to do well on antibiotics and with the VAC
dressing. Dressing change was performed on [**2132-12-22**],
postoperative day number 12. It showed continued granulation
tissue. The patient was felt to be ready for discharge to a
rehabilitation facility for further VAC changes and
antibiotic continuation. In conclusion, the patient is to be
following up with infectious disease clinic and with Dr.
[**Last Name (STitle) **] as well as with the plastic surgery service for a
possible skin graft versus flap reconstruction of the right
axilla.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehabilitation facility.
DIAGNOSES:
Status post recurrent hidradenitis suppurativa with multiple
examinations under anesthesia with incision and drainage.
VAC placement.
SECONDARY DIAGNOSES:
HIV positive.
Insulin dependent diabetes mellitus.
Gastritis.
Dyslipidemia.
Hepatitis C.
The patient is to be following up with Dr. [**Last Name (STitle) **] in one to
two weeks and with plastic surgery, Dr. [**First Name (STitle) **], in one to two
weeks.
The patient will be going home with Percocet one to two
tablets p.o. every four to six hours prn for pain.
Continue on her sliding scale and NPH.
Will finish a 14 day course of Levofloxacin 250 mg p.o. q.
day.
Flagyl 500 mg intravenous q. 8 hours.
Vancomycin one gram intravenous q. day.
The patient will schedule to resume HIV medications as soon
as infectious disease department deems appropriate.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
MEDQUIST36
D: [**2132-12-22**] 09:31
T: [**2132-12-22**] 10:06
JOB#: [**Job Number 25184**]
cc:[**Name8 (MD) 25185**] Name: [**Known lastname 76**], [**Known firstname 2189**] Unit No: [**Numeric Identifier 4284**]
Admission Date: [**2132-12-8**] Discharge Date: [**2132-12-23**]
Date of Birth: [**2089-5-23**] Sex: F
Service:
ADDENDUM TO DISCHARGE SUMMARY
The patient with a recurrence of a hydradenitis suppurativa
with an infection and abscess status post multiple
examinations under anesthesia and incision and drainage.
This is an addendum to the discharge summary for her
admission on [**2132-12-7**]. The patient is to be discharged on
[**2132-12-23**], to a rehabilitation facility, [**Hospital3 4287**].
The above dictation is appropriate. The patient will be
discharged with medications being the following.
DISCHARGE MEDICATIONS:
1. Tylenol 325 mg one to two tablets p.o. q. four to six
hours p.r.n.
2. Colace 100 mg one tablet p.o. twice a day.
3. Iron sulfate supplement 375 mg tablet one q. day.
4. Percocet, one to two tablets p.o. q. four to six hours
p.r.n.
5. Sliding scale insulin.
6. NPH per blood sugar measurement.
7. Anti-retrovirals to be started by the rehabilitation
facility when all four anti-retrovirals are available and
there is minimized development of resistance: Tenofovir
fumarate 300 mg tablet one q day with meals.
8. Lamivudine 150 mg tablets, one tablet p.o. q. day with
dosage adjusted for renal function.
9. Abacavir sulfate 300 mg tablet, one tablet q. day.
10. Efavirenz 600 mg tablet p.o. q. h.s.; the patient is to
avoid taking this medication with fatty meals.
The patient will not be going home on her other antibiotics
and will not be going home with TPN as previously stated.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE INSTRUCTIONS:
1. The patient is to be following up with Dr. [**Last Name (STitle) **] in one
to two weeks or upon discharge from rehabilitation facility.
2. The patient will be following up with Dr. [**Last Name (STitle) 3682**] from
Infectious Disease on [**2133-1-12**] at 10:30 in the morning.
She is to have labs faxed to his office at [**Telephone/Fax (1) 1021**].
3. The patient is also to follow-up with Dr. [**First Name (STitle) **] from
Plastic Surgery in one week at [**Telephone/Fax (1) 4288**], with an
appointment on Monday [**12-29**] at 03:30 p.m. at [**Hospital 4289**] Clinic
at the seventh floor of the [**Hospital Ward Name **] Building.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 3676**]
Dictated By:[**Name8 (MD) 2182**]
MEDQUIST36
D: [**2132-12-23**] 18:04
T: [**2132-12-23**] 15:53
JOB#: [**Job Number 4290**]
cc:[**Name Initial (PRE) 4291**]
|
[
"705.83",
"070.54",
"V08",
"250.00",
"728.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.45",
"99.15",
"86.4",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
7320, 8226
|
2462, 5349
|
8321, 9230
|
1399, 1802
|
5596, 7297
|
1903, 2444
|
8242, 8297
|
160, 1255
|
1278, 1375
|
1819, 1881
|
5374, 5575
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,627
| 111,227
|
45052
|
Discharge summary
|
report
|
Admission Date: [**2170-10-29**] Discharge Date: [**2170-11-2**]
Date of Birth: [**2128-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42yo M PMH of IDDM, alcohol abuse, and question of seizure
disorder (in setting of hypoglycemia) who presented today to
[**Hospital **] hospital with substernal chest burning. He was found to
have hyperglycemia to 1008, HCO3 10, CK 45, troponin-I 0.03 (5
am) and ARF with creatinine 3.2. His ABG at that time was
7.36/29/97. At [**Location (un) **], he was given 10 units of regular insulin
and started on an insulin drip at 6 units/hr and received 2
liters of crystalloid. He was transferred to [**Hospital1 18**] ED.
He denies any recent infections, URI symptoms, diarrhea,
dysuria, skin infections. He denies SOB or back pain. He reports
persistent heartburn symptoms for which he takes Alka-Seltzer
regularly. He states that he takes his Lantus nightly and checks
his BG up to 4 times daily which runs around 200-300. He states
that he takes his Novolag "as needed," usually only if his blood
sugar is "out of control" or over 300. Last night he reports
that his heartburn symptoms were worse than usual and it was the
pain that prompted him to go to the hospital. He denies
shortness of breath but states that he doesn't want to take a
deep breath due to pain. He denies radiation of the pain or
associated nausea or diaphoresis. He does have acidic tasting
reflux into his mouth which he spits out. He also describes
upper abdominal pain that is nonradiating.
Of note, pt has had multiple visits to [**Hospital **] hospital for
hyperglycemia and recent [**Hospital1 18**] admission [**2170-5-10**] with similar
presentation.
.
In the ED, his VS were T 99.1, HR 100, BP 105/72, RR 18, O2 100%
on 3L, initial BG was 420 and he was continued on an insulin
drip (increased to 7 units/hr) with IVFs (NS). Chest X-ray on
preliminary read showed no acute abnormalities and EKG showed
sinus tachycardia and T wave inversions compared to prior
(though these appear to have normalized from [**5-17**]). His labs
were significant for a leukocytosis to 13.9, anion gap of 31
(+urine ketones), lipase of 1373.
Past Medical History:
Type I DM - poorly controlled
Seizure disorder, secondary to hypoglycemia or alcohol
withdrawal
.
Past surgical hx: inguinal hernia repair and appendectomy
Social History:
Previously incarcerated at [**Location (un) 912**] Jail. Works nights at Stop &
Shop, though hasn't been in 1+ weeks (unclear reason). Smokes
1.5ppd for many years. Drinks alcohol once per week (Tuesday's)
until he is drunk. Per PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] heavy drinking problem.
Endorses marijuana use. Past cocaine use, no IV drug use.
Family History:
Father died of lung cancer, mother died at 66.
Physical Exam:
Tmax: 36.6 ??????C (97.9 ??????F)
Tcurrent: 36.5 ??????C (97.7 ??????F)
HR: 79 (77 - 103) bpm
BP: 122/74(85) {105/51(63) - 138/77(88)} mmHg
RR: 15 (8 - 26) insp/min
SpO2: 96%
Height: 62 Inch
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Tachycardic, regular, systolic murmur [**3-15**] > apex, radial
pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, tender to palpation over epigastrium, +BS, no
HSM, no masses, no guarding or rebound tenderness
EXT: No C/C/E
NEURO: Alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
No ulcers or wounds
Pertinent Results:
[**2170-10-29**] 09:35AM BLOOD WBC-13.9*# RBC-4.23* Hgb-12.2* Hct-34.4*
MCV-81*# MCH-29.0 MCHC-35.6* RDW-13.8 Plt Ct-313#
[**2170-10-30**] 05:58AM BLOOD Glucose-244* UreaN-19 Creat-1.2 Na-133
K-3.8 Cl-95* HCO3-26 AnGap-16
[**2170-10-29**] 01:53PM BLOOD Glucose-177* UreaN-43* Creat-1.9* Na-137
K-3.4 Cl-93* HCO3-30 AnGap-17
[**2170-10-29**] 09:35AM BLOOD Glucose-535* UreaN-52* Creat-2.4*#
Na-132* K-4.1 Cl-83* HCO3-18* AnGap-35*
[**2170-10-30**] 05:58AM BLOOD Amylase-280*
[**2170-10-30**] 05:58AM BLOOD Lipase-84*
[**2170-10-29**] 09:35AM BLOOD Lipase-1373*
[**2170-10-29**] 01:53PM BLOOD CK-MB-7 cTropnT-<0.01
[**2170-10-29**] 01:53PM BLOOD Osmolal-306
[**2170-10-29**] 09:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-10-29**] 02:29PM BLOOD Type-[**Last Name (un) **] pH-7.48*
U/A: 150 ketones, 1000 glucose, tr protein, negative LE, nitr,
WBC, RBC, few bacteria
CXR [**10-29**]
IMPRESSION:
1. No acute intrathoracic process.
2. Mid thoracic vertebral compression, chronicity uncertain.
Brief Hospital Course:
This is a 42 year-old male with a history of Type I DM, ?seizure
d/o, and longstanding h/o alcohol abuse admitted with DKA, acute
renal failure and pancreatitis.
.
# Diabetic ketoacidosis: Pt with known Type I DM with multiple
hospitalizations both at [**Hospital **] hospital and [**Hospital1 18**]. The
possible precipitating factors include medicaiton
non-compliance, alcohol abuse, and/or pancreatitis. This was
unlikey an infectious process given the patient is afebrile, no
leukocytosis and no localizing symptoms. Pt was r/o for MI by
enzymes and no EKG changes. The anion gap at presentation was 31
with +ketones in urine. The patient was started on an insulin
gtt, given IVF and repleted lytes. His insulin regimen was
changed to his home lantus dose (34U) & ISS when his FS were
<100. The patient refused lab draws during the evening. The
patient's gap had closed by the morning AM (AG:12).
Addtionally, the patient's last pH was venous 7.48. The
diabetes endocrinology service was consulted, and patient was
placed on Lantus 25 units at night, with humalog sliding scale.
An appointment was made for him in the endocrinology clinic for
follow up. The patient was started on regular/diabetic diet and
tolerated this well.
.
# Acute renal failure: The patient's creatine was 3.2 at [**Location (un) **]
and 2.4 on presentation here. His creatine improved with fluids.
This is most likely a prerenal etiology given dehydration and
ketoacidosis. Pt denies any other medication use except for
antacids. On prior hospitalizations had similar bump in
creatinine.
.
# Alcohol abuse: The patient denies regular use (once weekly)
and denies ever having withdrawal symptoms but his history at
times is conflicting. He does take Valium 5 mg daily at home for
questionalbe anxiety. The patient was monitored on a CIWA
scale. Additionally the patient was given thiamine, folic acid,
and MVI. He did not require prn Valium.
.
# Pancreatitis: On admission the patient had elevated lipase to
>1000 with mild sx of upper abdominal pain. The patient's other
LFTs were otherwise unremarkable and no known hx of
pancreatitis. The pancreatic enzymes were trending down and the
patient tolerated regular diabetic diet.
.
# Chest pain: Pt describes chronic "burning" chest pain that
improves with antacids. He denies worsening with activity or
associated sx. The patient was ROMI. There were no ST-T
elevations or depressions on EKG, though does have T wave
inversions in lateral leads (now concordant). First set of CEs
at [**Hospital **] hospital wnl. CE here have been negative. The
patient was started on a PPI.
.
# Diabetes mellitus, Type I: As above. On history it appears
that the patient has very poor insight into his medical illness
and is not taking short-acting insulin as prescribed. He has
been refered to [**Last Name (un) **] in the past but does not keep regular
appointments. He was again seen by the inpatient service, and
again advised to follow up with [**Last Name (un) **] as an outpatient.
.
#. Dispo. He was discharged to home with services.
Medications on Admission:
- Insulin Glargine 34 units at bedtime.
- Insulin Aspart sliding scale qid
- Phenytoin 200mg po bid
- Valium 5mg po daily
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) dose
Subcutaneous four times a day: Per sliding scale.
5. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous QHS.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1. Acute pancreatitis
2. Alcohol use/withdrawal
3. Diabetic ketoacidosis
4. Diabetes mellitus type I with complications
5. Polysubstance abuse
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with pancreatitis with associated diabetic
ketoacidosis. In the setting of drinking alcohol, you developed
inflammation of your pancreas.
.
This led to poor control of your blood sugars.
Followup Instructions:
An appointment was made for you with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 89459**]y [**11-8**] at 10am.
.
An appointment was made for you at the [**Hospital **] [**Hospital 982**] clinic on
Monday [**11-2**] at 4:30pm. Please keep this appointment as it is
important to keep good control of your blood sugars.
|
[
"250.13",
"584.9",
"345.90",
"303.91",
"291.81",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8669, 8732
|
4947, 8012
|
319, 326
|
8919, 8928
|
3888, 4924
|
9181, 9532
|
2943, 2991
|
8185, 8646
|
8753, 8898
|
8038, 8162
|
8952, 9158
|
3006, 3869
|
276, 281
|
354, 2361
|
2383, 2541
|
2557, 2927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,513
| 119,766
|
164+165
|
Discharge summary
|
report+report
|
Admission Date: [**2141-1-4**] Discharge Date:[**2141-1-12**]
Date of Birth: [**2080-4-23**] Sex: M
Service:Oncology
CHIEF COMPLAINT: Short of breath times one week plus
weakness.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male with a history of metastatic lung cancer to brain,
failure to thrive. He had a recent diagnosis on [**11-5**] of
lung adenocarcinoma with metastases to [**Last Name (LF) 500**], [**First Name3 (LF) **],
pericardium. He had a recent admit for malignant pericardial
effusion with tamponade, status post drainage on [**11-5**]. Plan
for chemotherapy after patient completes XRT. Had an Lumbar
puncture on [**11-29**] with negative meningeal spread of cancer.
He has noted one week prior to admission progressive increase
He had a pulses paradoxus of 15 in the emergency department.
No fever, chills, chest pain, cough, nausea, vomiting,
diarrhea, abdominal pain. He had a normal p.o. intake but
decreased ambulation secondary to weakness post XRT. Can go
approximately 10 steps and then gets tired with short of
breath.
In the emergency department he got a dose of Levofloxacin for
concern of pneumonia and bronchitis and stress dose steroids.
Chest x-ray shows increased in cardiac silhouette.
Electrocardiogram showed alternans. Bedside echo concerning
for tamponade. Catheterization laboratory for pericardial
drain placement. Got 2500 cc's removed.
PAST MEDICAL HISTORY: Significant for hypertension,
hypercholesterolemia, mitral valve prolapse, status post
melanoma. Status post resection in [**2118**] and [**2138**]. Empyema
left lung [**2122**], status post thoracotomy and supraventricular
tachycardia. Lung adenocarcinoma with metastases to brain,
[**Year (4 digits) 500**], pericardium. Now undergoing brain XRT. Atrial
flutter, peripheral visual loss.
An echo on [**11/2134**] showed EF greater than 55%
MEDICATIONS ON ADMISSION:
1. Decadron 4 mg q AM, 2 mg q PM.
2. Zantac 150 mg b.i.d.
3. Sotalol 80 mg twice a day.
4. Ambien 10 mg q h.s.
5. Lipitor 80 mg q h.s.
6. Folate 1 mg q day.
7. Accupril 10 mg q day.
8. ASA 81 mg q day.
ALLERGIES: Penicillin which causes a rash.
SOCIAL HISTORY: Lives with a daughter at home. No tobacco
in the past 20 years, no alcohol.
PHYSICAL EXAMINATION: On admission in general no acute
distress, pleasant, slightly tachypneic. Vital signs 97.5,
heart rate 94, blood pressure 99/61. Respiratory rate 36,
99% on 100% face mask. Left pupil minimally reactive, down
visual acuity. OP clear. Neck: No jugular venous
distention. Pulmonary: Coronary artery disease bilaterally.
Carotids: Regular rate and rhythm. No murmurs. Abdomen:
Soft, nontender, no distension. Bowel sounds positive.
Extremities: No cyanosis, clubbing or edema. 2+ distal
pulses bilaterally. Neurological 5/5 strength bilaterally.
Pupils reactive.
Electrocardiogram on admission normal sinus rhythm,
electrical alternans. Normal intervals, no ST changes or
Q-waves, diffuse T-wave changes.
LABS: White blood count 9.6, hematocrit 36.1, platelets 128.
INR 1.3. NA 137, K 4.6. CL 104, CO2 20. BUN 31, creatinine
0.8. Glucose 140.
Chest x-ray shows increased in cardiac size, increased
pericardial effusion. Increased left pleural effusion.
Lymphangitic tumor spread unchanged. A left TTX new since
[**2140-11-19**].
The patient was taken from the Emergency Room to the CCU for
close monitoring. Given large pericardial effusion and
tamponade physiology. On cardiac catheterization he
demonstrated low pressure tamponade with equalization of
right atrium and pericardial pressures. After removal of
approximately one liter of bloody fluid his right atrial and
pericardial pressure decreased. Procedure was notable for
pericardial preparation and partial pneumothorax given low
atrial/pericardial pressures and evidence of a possible small
left pneumothorax. For this reason the drain was pulled.
However, subsequent review of the chest x-ray showed that the
finding of pneumothorax was present prior to the procedure.
Follow-up echocardiogram revealed resolution of electrical
alternans. CT Surgery was consulted for possibility of
placing a pericardial window for definitive treatment of
recurrent pericardial effusions however, it was felt that a
procedure of this degree of invasiveness would likely lead to
patient's deterioration rather than improvement.
The decision was made that the patient would be best served
by a balloon pericardiocentesis via catheter done by
Cardiology however, this would require waiting until the
pericardial effusion re-accumulated. Recommended that the
patient undergo q week transthoracic echocardiogram in order
to assess the size of pericardial effusion and when deemed
large enough the patient is to undergo balloon
pericardiocentesis.
The patient's cardiac status improved with this procedure
however, his respiratory status remained tenuous requiring
100% non-rebreather mask to maintain O2 saturations in the
mid-90% The patient had marked dyspnea on exertion
throughout hospitalization. It was felt that this is a
combination of intrinsic lung damage as well as lymphangitic
spread and some small degree of residual cardiac dysfunction.
Other than oxygen and nebulizers there is no further
therapeutic option for this patient at this time. The
patient remained on Sotalol 80 mg p.o. b.i.d. as he was as an
outpatient for an supraventricular tachycardia and remained
in a normal sinus rhythm throughout hospitalization.
Hem/Onc. The patient continued XRT as well as Decadron for
palliation. He will be followed by Hem/Onc as an outpatient.
There were no gastrointestinal issues throughout this
hospitalization.
Infectious Disease. The patient was not felt to be infected
and after the initial dose of Levofloxacin in the emergency
department antibiotics were discontinued. The patient
remained afebrile.
Dictation will be completed with discharge diagnosis and
discharge medications prior to discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1735**] m.d. [**MD Number(1) 1736**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2141-1-9**] 18:16
T: [**2141-1-9**] 19:22
JOB#: [**Job Number 1738**]
Admission Date: [**2141-1-4**] Discharge Date: [**2141-1-12**]
Date of Birth: [**2080-4-23**] Sex: M
Service:Oncology
DISCHARGE DIAGNOSES:
1. Non-small cell lung carcinoma metastatic to [**Last Name (LF) 500**], [**First Name3 (LF) **]
and pericardium.
2. Pericardial tamponade requiring pericardiocentesis.
3. Hypoxia due to multifactorial lung disease.
DISCHARGE MEDICATIONS:
1. Ambien 10 mg p.o. q.h.s.
2. Sotalol 80 mg p.o. b.i.d.
3. Multivitamin one p.o. q.d.
4. Tylenol 225 to 650 mg p.o. q. four to six hours p.r.n.
5. Colace 100 mg p.o. b.i.d.
6. Protonix 40 mg p.o. q.d.
8. Morphine Sulfate 1 to 5 mg IV q. four to six hours p.r.n.
9. Dibutoline one application TP q.i.d. p.r.n.
10. Methylprednisone 80 mg p.o. b.i.d..
11. Albuterol nebs q. four to six hours.
12. Atrovent nebs q. four to six hours.
13. Levofloxacin 500 mg p.o. q.d. till [**2141-1-19**].
13. Bactrim Double Strength tabs one p.o. b.i.d. till
[**2141-1-19**].
14. Percocet one to two tabs p.o. q. four to six hours p.r.n.
He was discharged to [**Hospital 1739**] Hospice in stable condition.
He is DNI, DNR and moving towards comfort care only.
[**Known firstname **] [**Last Name (NamePattern4) 1735**] m.d. [**MD Number(1) 1736**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2141-1-11**] 10:20
T: [**2141-1-11**] 10:15
JOB#: [**Job Number 1740**]
|
[
"287.5",
"424.0",
"423.9",
"198.5",
"198.3",
"427.31",
"198.89",
"401.9",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"99.25",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
6431, 6650
|
6673, 7689
|
1922, 2178
|
2296, 6410
|
153, 200
|
229, 1425
|
1448, 1896
|
2195, 2273
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,104
| 142,563
|
34185
|
Discharge summary
|
report
|
Admission Date: [**2143-1-25**] Discharge Date: [**2143-1-31**]
Date of Birth: [**2103-6-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia
Major Surgical or Invasive Procedure:
[**2143-1-25**]
Right thoracotomy, thoracic tracheoplasty with
mesh, right mainstem bronchus/bronchus intermedius
bronchoplasty with mesh, left mainstem bronchoplasty with
mesh, right lower lobe wedge resection, bronchoscopy with
bronchoalveolar lavage.
History of Present Illness:
Mrs [**Known lastname **] is a well known patient to us, being followed for
malacia of the Left main stem bronchus. She is a 39-year-old
woman with IgG deficiency who has had recurrent pneumonias since
childhood. She [**Known lastname 1834**] the placement of a Y stent on
[**2142-11-19**] which she tolerated very well and reported significant
improvement after. The Y stent was removed about 2 weeks later,
and since she reports some dypnea upon exertion, cough with
yellowish secretions, no fever but some low grade temperature.
Her voice is better, appetite is good. she still takes her
inhalers as before (advair, albuterol + mucomyst)
She thinks that she was better when she had the stent. She is [**Name8 (MD) **]
RN who has not come back to work yet.
Past Medical History:
Past Medical History:
1. Asthma.
2. IgG deficiency. Recurrent pneumonias, bronchitis, sinusitis,
otitis media, UTI, pyelonephritis.
3. Patent foramen ovale: discovered during w/u for SOB during
her first pregnancy. Per patient, this is a small defect that
has not needed surgical repair.
4. Sjogren's syndrome: Per the patient this is manifested by
dry eyes and mouth and has not required treatment.
5. Papillary thyroid cancer: The patient was treated with
thyroidectomy [**4-28**] and radioactive iodine [**6-28**]. At recent
outpatient endocrine visit: No evidence of persistent, recurrent
or metastatic disease.
6. Pulmonary nodules: Found incidentally on chest CT and
stable
from this period of [**2141-9-20**] to [**2142-3-21**].
7. Fibromyalgia
8. Depression
9. Mood disorder--?Cyclothymia
10. Post-nasal drip
11. ?SLE. Per patient, had positive [**Doctor First Name **] and malar rash, unclear
if Dx was ever made
Social History:
Works as a nurse at a methadone clinic and at a prison substance
abuse facility. Lives in [**Location 1475**] on the [**Hospital3 **] with her
husband and two daughters ages 5 and 10. No tobacco, 1 EtOH
drink per month, no other drug use. Exercises regularly-yoga,
running.
Family History:
Father with HTN and MI. Mother with EtOH abuse/dependence.
Physical Exam:
VS: T 98.6, HR 103, BP 124/79, RR 20, O2 sats 97% RA
Physical Exam:
Gen: pleasant, highly energized
Lungs: trace rales t/o
CV: RRR S1, S2, no MRG
Abd: soft, NT, ND
Ext: warm, no edema
right thoracotomy site without redness, purulence or drg
Pertinent Results:
[**2143-1-31**] 07:00AM BLOOD WBC-8.1 RBC-3.31* Hgb-9.9* Hct-30.1*
MCV-91 MCH-29.9 MCHC-32.9 RDW-14.5 Plt Ct-337
[**2143-1-30**] 06:25AM BLOOD K-4.2
[**2143-1-28**] 10:50AM BLOOD Glucose-104* UreaN-9 Creat-0.7 Na-138
K-4.2 Cl-102 HCO3-27 AnGap-13
[**2143-1-30**]
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: S/P tracheoplasty with new fevers.
Comparison is made with prior study performed a day earlier.
A small left pleural effusion is unchanged. Small-to-moderate
right pleural effusion loculated in the major fissure is
unchanged. New opacity projecting over the lingula could
represent a new atelectasis. Linear atelectases in the right
lower lobe are unchanged. No evidence of pneumonia.
cultures negative to date.
Brief Hospital Course:
Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a tracheoplasty on [**2143-1-25**] and was
admitted to the SICU post-operatively. She was extubated the
night of surgery in the SICU. Intially her chest tube was to
suction. She had no air leak and the chest tube was changed to
water seal on POD #1 and continued to have have no air leak.
Creatinine kinase levels were cycled to evaluated for
rhabdomyolysis and peaked at 2653 approximately 24 hours after
surgery, after which they trended downward. Her chest tube was
dc'd [**2143-1-28**] without PTX on CXR. The patient was aggressive with
her pulmonary toilet, ambulated and used her IS. She spiked a
101.7 fever POD 5, was pancultured which cultures all negative
to date, and placed on levaquin. Her fevers came down, and CXR
did not reveal any concerns. The antibiotics were stopped but
due to the patients low grade fever, and rales, and history of
pneumonia, she was placed on levaquin for 7 days on date of
discharge. She tolerated orals, had a bowel movement and
adequate pain control. An epidural was placed preoperatively and
was replaced on POD2 after it was found to be out. Additionally,
she received Neurotin 300 Q8hr for pain control. The epidural
was removed [**2143-1-28**] and the patient's pain was overall controlled
with dilaudid and neurontin 600mg po tid. Dr. [**Last Name (STitle) **] deemed
the patient safe to discharge home today.
Medications on Admission:
Albuterol, Albuterl neb, Astelin 2 sprays, Wellbutrin SR 300,
Celexa 10, Codeine-Guaifenesin prn, Advair Diskus 250/50, IgG,
Levothyroxine 188, Provigil 400, Nasonex 2 sprays, Singulair 10,
Oxcarbazepine 150, Benadryl prn
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
6. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
13. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
[**Hospital1 **]:*75 Tablet(s)* Refills:*0*
14. Azelastine Nasal
15. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times
a day: continue this and will defer discontinuation to your
primary care MD.
[**Last Name (Titles) **]:*90 Tablet(s)* Refills:*2*
16. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
[**Last Name (Titles) **]:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronchomalacia.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
-Do not drive while taking narcotics.
-Pain will persist over two weeks. Take your pain medications
and stool softeners to prevent constipation.
-You may shower.
-Walk around.
-Use your incentive spirometer.
-Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you experience fevers
>101.5, chills, shakes, chestpains, worsening cough, worsening
shortness of breath, or any other problems.
-Remember you just had major surgery and it will take a few
weeks to feel better. Don't be too hard on yourself. Do not work
until cleared by a physician.
[**Name10 (NameIs) **] if your thoractomy site becomes angry red, drains, or
opens.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks with chest xray.
Call Dr.[**Name (NI) 2347**] office for the appointment.
Completed by:[**2143-1-31**]
|
[
"279.03",
"311",
"301.13",
"338.18",
"710.2",
"518.0",
"493.90",
"745.5",
"518.89",
"V10.87",
"519.19",
"780.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"32.29",
"33.48",
"03.90",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
6954, 6960
|
3708, 5124
|
309, 565
|
7027, 7027
|
2953, 3685
|
7843, 8004
|
2616, 2677
|
5396, 6931
|
6981, 7006
|
5150, 5373
|
7172, 7820
|
2760, 2934
|
248, 271
|
593, 1354
|
7041, 7148
|
1398, 2308
|
2324, 2600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,530
| 153,451
|
51009
|
Discharge summary
|
report
|
Admission Date: [**2191-4-18**] Discharge Date: [**2191-4-29**]
Date of Birth: [**2131-3-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Amiodarone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Admitted for carotid stent prior to coronary revascularization
surgery
Major Surgical or Invasive Procedure:
[**2191-4-19**] Placement of Right Carotid Stent
[**2191-4-25**] Four Vessel Coronary Artery Bypass Grafting(left internal
mammary artery to left anterior descending with vein grafts to
diagonal, obtuse marginal, and posterior descending artery) with
Mitral Valve Repair(28mm Annuloplasty Band).
History of Present Illness:
Mr. [**Known lastname 105970**] is a 60 year old male who during preoperative
evaluation for coronary revascularization surgery was found to
have severe bilateral carotid stenosis. He recently underwent
successful left carotid artery stenting on [**4-12**] by Dr.
[**Last Name (STitle) **]. He was readmitted for right carotid artery
stenting on [**4-19**] followed by coronary revascularization
surgery by Dr. [**Last Name (STitle) **]. Given the history of past renal failure,
he was admitted one day prior for hydration, Bicarbonate and
Mucomyst.
From a cardiac standpoint, he admits to intermittent chest pain
for approximately nine months which has increased in frequency
and intensity. A recent stress test showed multiple reversible
defects and an abnormal blood pressure response to exercise.
Subsequent cardiac catheterization in [**2191-3-20**] revealed severe
three vessel coronary artery disease(right dominant)and normal
left ventricular function.
Past Medical History:
Coronary Artery Disease
Cerebrovascular Disease/Carotid Disease - s/p Left Carotid Stent
Hypertension
Hyperlipidemia
Diabetes Mellitus Type II
HIV Positive - on HAART
History of Hepatitis B
Primary Hyperparathyroidism
History of Renal Failure - treated with CVVH in past
History of Pancreatitis
History of Basal Cell Carcinoma - s/p removal Left Cheek
Social History:
Quit tobacco over 30 years ago. Admits to occasional ETOH.
Currently lives with his male partner. [**Name (NI) **] denies IVDA and
recreational drugs.
Family History:
Father underwent CABG at age 66
Physical Exam:
Vitals: T 97.4, BP 136/84, HR 66, RR 18, SAT 99 on room air
General: well developed male in no acute distress
HEENT: oropharynx benign, sclera anicteric
Neck: supple, no JVD, bilateral carotid bruits noted
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2191-4-18**] 08:00PM BLOOD WBC-4.9 RBC-3.33* Hgb-12.0* Hct-35.5*
MCV-107*# MCH-36.1* MCHC-33.9 RDW-19.5* Plt Ct-387
[**2191-4-18**] 08:00PM BLOOD PT-12.1 PTT-24.9 INR(PT)-1.0
[**2191-4-18**] 08:00PM BLOOD Glucose-84 UreaN-20 Creat-1.4* Na-140
K-4.7 Cl-106 HCO3-25 AnGap-14
[**2191-4-18**] 08:00PM BLOOD Calcium-10.6* Phos-3.9 Mg-2.4
[**2191-4-20**] 06:07PM BLOOD CK-MB-17* MB Indx-3.1 cTropnT-0.16*
[**2191-4-21**] 07:15AM BLOOD CK-MB-13* MB Indx-3.4 cTropnT-0.29*
[**2191-4-22**] 07:12AM BLOOD CK-MB-5 cTropnT-0.51*
[**2191-4-23**] 11:18AM BLOOD CK-MB-NotDone cTropnT-0.82*
[**2191-4-24**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.69*
[**2191-4-20**] 10:36AM BLOOD CK(CPK)-223*
[**2191-4-20**] 06:07PM BLOOD CK(CPK)-554*
[**2191-4-21**] 02:55AM BLOOD CK(CPK)-502*
[**2191-4-21**] 07:15AM BLOOD CK(CPK)-384*
[**2191-4-22**] TTE: The left atrium is mildly dilated. There is
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with basal inferior hypokinesis. Overall
left ventricular systolic function is mildly depressed. 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)
are mildly thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 105970**] was admitted for hydration, bicarbonate, and
Mucomyst. The following day, Dr. [**Last Name (STitle) **] performed
successfull stenting of his right carotid artery. Later that
evening, he experienced chest pain associated with EKG changes.
He ruled in for a NSTEMI and was subsequently started on
intravenous Heparin and Nitro. His chest pain improved with
intravenous therapy. Cardiology was consulted to assist with
medical managment. Over several days, medical therapy was
optimized, intravenous Nitro was weaned and his cardiac enzymes
improved. He required one unit of packed red blood cells to
maintain hematocrit over 30%. Additional cardiac workup included
an echocardiogram on [**4-22**] which showed an LVEF of 55% with
mild aortic insufficiency, mild mitral regurgitation and only
trivial tricuspid regurgitation. He otherwise remained pain free
and was eventually cleared for coronary revascularization
surgery. On [**4-25**], Dr. [**Last Name (STitle) **] performed coronary artery
bypass grafting surgery along with a mitral valve repair. For
surgical details, please see seperate dicatated operative note.
Following the operation, he was brought to the CSRU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated. He maintained stable hemodynamics and weaned from
inotropic support without difficulty. On postoperative day one,
he transferred to the SDU for further care and recovery. He was
restarted on plavix for his carotid stent. Chest tubes and
epicardial wires were removed. He was seen in consultation by
the physical therapy service. By post-operative day four he was
ready for discharge to home.
Medications on Admission:
Aspirin 325 qd, Plavix 75 qd, Pravastatin, Atenolol 100 qd,
Univasc 30 qd, Oxandrin, Zantac, Actos 30 qd, Norvir, Viread,
Reyataz, Combivir
Discharge Medications:
1. Aspirin 81 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO once a day.
6. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Pravachol 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
11. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease and Mitral Regurg - s/p CABG, MV repair
Cerebrovascular Disease/Carotid Disease - s/p Right Carotid
Stent
Non ST Elevation MI(after carotid stent but prior to CABG, MV
repair)
Hypertension
Hyperlipidemia
Diabetes Mellitus Type II
Anemia
HIV Positive with history of Hepatitis B
Primary Hyperparathyroidism
History of Renal Failure
History of Pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-24**] weeks, call for appt
Dr. [**Last Name (STitle) **] as directed, call for appt
Dr. [**Last Name (STitle) 171**] in [**1-22**] weeks, call for appt
Dr. [**Last Name (STitle) 2148**] in [**1-22**] weeks, call for appt
Completed by:[**2191-4-29**]
|
[
"285.9",
"401.9",
"252.01",
"V08",
"250.00",
"433.10",
"V10.83",
"593.9",
"V17.3",
"272.4",
"414.01",
"424.0",
"997.1",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"36.13",
"99.05",
"89.60",
"35.33",
"00.61",
"36.15",
"39.61",
"99.04",
"00.40",
"00.63",
"99.07",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
7133, 7216
|
4258, 5951
|
385, 683
|
7640, 7647
|
2710, 4235
|
7965, 8255
|
2235, 2268
|
6141, 7110
|
7237, 7619
|
5977, 6118
|
7671, 7942
|
2283, 2691
|
275, 347
|
711, 1674
|
1696, 2051
|
2067, 2219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,342
| 159,504
|
39918
|
Discharge summary
|
report
|
Admission Date: [**2178-9-18**] Discharge Date: [**2178-9-22**]
Date of Birth: [**2130-11-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Transfer for TIPS?
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy
paracentesis
History of Present Illness:
This is a 47 year old male with past medical history significant
for HTN, low back pain, and alcohol abuse who presents from
[**Hospital3 5365**] for further mangement of esophageal varices
after presenting there with a GI bleed. Mr. [**Known lastname **] has been
dealing with low back pain for the past few months and has been
seeing a specialist at [**Hospital 3278**] Medical Center for this problem.
[**Name (NI) **] has been taking ibuprofen regularly for the last two months
for this issue (800 mg [**1-7**]*/day for >1 month). He thinks this
has gotten a bit worse over the last few weeks. He acknowledges
it may be slightly different in quality over this time but was
not able to elaborate. (When asked specifically he endorses a
boring nature). Over the past week the patient has felt
particularly unwell and he had been unable to stand over the
past three days. The patient attributed this to his back
despite the fac that he had a sensation of the room moving when
he stood up and h im being EXTREMELY unsteady. When he was
unable to walk so as to go to a neurosurgery appointment
yesterday he went into the ED at [**Hospital1 392**]. In the ED he was pale
and hypotensive (SBP's in the 80's) and had a hematocrit of 10
with elevated transaminases and a coagulopathy. He denied any
chest pain, nausea, or vomiting. He initially denied abdominal
pain but then acknowleged that he may have had some "gas pains"
that made it difficult for him to sleep one night. He endorses
dark stools over the preceding few days. He was admitted to
the ICU after being started on octreotide and pantoprazole drips
and received a total of 6 units of pRBC's, 15mg of Vitamin K,
and 4 units of FFP. His vital signs have been stable after
fluid resuscitation. Today, he underwent upper endoscopy that
revealed two duodenal ulcers without active bleeding and grade
four esophageal varices. He is transferred here on the
recommendation of Dr [**Last Name (STitle) 87787**], the consulting gastroenterologist,
for TIPS evaluation as he did not feel comfortable intervening
on the varices. Vitals prior to transfer T 98.7, BP 134/74,P
60, O2 98% on 3 L NC He has not received any antibiotics. Of
note, the patient uses significant alcohol but reports having
minimal alcohol over the preceding week and decreased intake for
a few weeks prior to that. Last drink was probably "one" a few
days ago.
Currently, the patient reports low back pain but denies nausea,
vomiting, light headedness, or any other acute issues. He is
hungry.
Past Medical History:
-Hypertension
-Elevated liver enzymes: he reports elevated LFT's for years and
that he has had ultrasounds in the past (last perhaps 2 years
ago), he denies every being told he had cirrhosis
-History of alcohol withdrawal (not recently) but denies any
history of DT's or seizures
-Hyperlipidemia
Social History:
He is single and lives alone. He has previously worked as an
engineer and as an accountant. He smokes approximately 3
cigars/wk and was previously a cigarette smoker. Regarding
alcohol, he reports he drinks 3-4 drinks of hard liquor
approximately four nights a week. He reports a history of
withdrawal but no seizures or DT's. Denies ever using IVDU.
Family History:
Notable for bladder cancer in his mother. Denies cirrhosis.
Physical Exam:
Temp:99.3 BP: 141/76 HR: 63 RR: 24 O2sat 96% on 3L NC
GEN: slightly disheveled middle aged man in NAD
HEENT: PERRL, EOMI, anicteric, MMM, white/brown plaque on
tongue, likely leukoplakia, no jvd, no thyromegaly or thyroid
nodules
RESP: Clear to auscultation bilaterally over upper lung fields
without wheezes, rhonchi, or rales. Dramatically diminshed
breath sounds at the bases bilaterally.
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Soft, distended, +shifting dullness and fluid wave, no HSM
or masseds appreciated, nontender, +bowel sounds
EXT: Few ecchymoses, no C/C/E
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. No asterixis
Pertinent Results:
Admission labs:
[**2178-9-18**] 10:50PM BLOOD WBC-8.7 RBC-3.68* Hgb-10.3* Hct-30.8*
MCV-84 MCH-28.0 MCHC-33.5 RDW-17.3* Plt Ct-120*
[**2178-9-18**] 10:50PM BLOOD PT-16.7* PTT-24.5 INR(PT)-1.5*
[**2178-9-18**] 10:50PM BLOOD Glucose-112* UreaN-10 Creat-0.8 Na-141
K-3.6 Cl-108 HCO3-26 AnGap-11
[**2178-9-18**] 10:50PM BLOOD ALT-112* AST-122* LD(LDH)-351* CK(CPK)-48
AlkPhos-220* TotBili-3.1*
[**2178-9-18**] 10:50PM BLOOD CK-MB-4 cTropnT-0.05*
[**2178-9-19**] 05:38AM BLOOD CK-MB-4 cTropnT-0.05*
[**2178-9-19**] 04:15PM BLOOD cTropnT-0.03*
[**2178-9-18**] 10:50PM BLOOD Albumin-3.6 Calcium-8.1* Phos-2.1* Mg-2.1
[**2178-9-19**] 05:38AM BLOOD calTIBC-322 TRF-248
[**9-19**] CXR: Opacity at the left base may represent a combination
of collapse and/or consolidation and some pleural fluid. If
clinically indicated, lateral view may help for further
assessment.
[**9-19**] RUQ u/s:
1. Nodular heterogeneous liver suggestive of a cirrhotic liver
without focal masses.
2. Sludge within the gallbladder with minimal wall thickening,
which may
reflect hepatic dysfunction, but no evidence for cholecystitis.
3. Abdominal ascites.
4. Bilateral pleural effusions.
5. Splenomegaly
...
Ascites: [**2178-9-21**]
Chemistry Protein 1.2 LDH 82
Albumin: <1.0
Ascites
WBC 68
RBC 33
Poly 38
Lymph 19
Mono 43
.....
[**2178-9-21**] 9:11 am PERITONEAL FLUID
GRAM STAIN (Final [**2178-9-21**]):
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 [**2178-9-24**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2178-9-27**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2178-9-22**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Brief Hospital Course:
47 year old male with hypertension, chronic back pain, and
chronic alcohol abuse as well as recent history of significant
ibuprofen use presenting after GI bleed for management of
esophageal varices and likely alcoholic hepatitis vs cirrhosis.
1. Upper GI bleed: The patient presented with melena and a
dramatic Hct drop without marked abdominal pain or nausea.
Given size of varices it seems unlikely that these would bleed
for such a significant hematocrit drop without nausea, vomiting,
or abdominal pain. Most likely etiology, therefore is peptic
ulcers most likley related to NSAID use.
-PPI drip
-Given inability to exclude variceal bleed would continue
octreotide, start prophylactic abx with ceftriaxone 1gm Q24hr
-Hepatology consult in AM
-Active T and S, IV access, NPO pending GI eval
-will need f/u of biopsies from [**Hospital6 **]
-pt was advised to avoid NSAIDs
-liver team f/u in 1 week, repeat endoscopy in [**7-14**] wks
-H. pylori serologies pending on dc.
2. Varices/ Portal HTN/ Cirrhosis: Patient with large varices
c/w portal hypertension. This could be due to acute alcoholic
hepatitis vs chronic cirrhosis. Given fairly indolent course I
would tend to favor the latter. Most likely etiology of
cirrhosis in this gentleman would be alcohol. No indication for
TIPS at this time given bleeding under control and pt stability.
-RUQ U/S in AM to evaluate liver parenchyma and for presence of
cirrhosis
-pt appears to have ascites, would intend to do diagnostic tap
in AM to confirm transudative process
-Discuss TIPS with hepatology
3. Ascites: Transudative associated with portal hypertension. No
evidence of spontaneous bacterial peritonitis. Cultures
negative.
4. Hypoxia: Unclear etiology. Pt has minimal lower lung field
sounds and given recent decreased movement would be concerned
about atelectasis.
-CXR, supplementary O2 to keep sat >92%
5. Coagulopathy: Nearly resolved, likely an element of
nutritional deficiency in addition to liver disease.
-[**Name (NI) **] PT daily
Comm: [**Name (NI) **] [**Name (NI) 87788**] [**Telephone/Fax (1) 87789**]
Medications on Admission:
Medications at home:
-Atenolol 100 mg PO daily
-Simvastatin 20 mg PO daily
-Ibuprofen 800 mg PO [**1-7**]*/day
-Folate 1 mg PO daily
-Paroxetine 20 mg PO daily
-MVI
Meds on transfer:
-Morphine mg Q4 hrs PRN back pain
-Pantoprazole drip at 8 mg IV /hr
-Octreotide 50 mcg IV/hr
Discharge Medications:
1. Outpatient Physical Therapy
Please provide outpt physical therapy 2x/week for 3 weeks.
2. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a
day.
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Vitamin B-1 (mononitrate) 100 mg Tablet Oral
10. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**3-10**]
hours as needed for pain for 2 days: Please do not take this
medication prior to driving or operating heavy machinery as it
may cause drowsiness.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: gastrointestinal ulcers, esophageal varices, alcoholic
liver disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking care of you during your recent
hospitalization at [**Hospital1 18**]. As you know, you were admitted for
ulcers and a gastrointestinal bleed. You were admitted to the
ICU for treatment of this bleeding and you were seen by
gastroenterology. Your symptoms were thought to be due to
bleeding ulcers. Incidentally, we also found enlarged blood
vessels in your esophagus which are likely caused by your liver
disease. We started you on a medication to prevent bleeding
from these ulcers. The following changes were made to your
medications:
-START nadolol 40 mg daily
-STOP taking all non-steroidal anti-inflammatory medications,
such as ibuprofen. Instead, you may take oxycodone as needed
for treatment of your pain. This medication may cause
drowsiness and therefore you should avoid taking while driving
or operating heavy machinery.
-STOP taking atenolol. This medication may need to be restarted
after you stabilize on nadalol. Please discuss this with your
primary care doctor.
-START taking pantoprazole twice a day
.
It is very important that you follow up with your primary care
doctor and the liver doctor [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below. We also
recommend that you start physical therapy and follow up with
your spine surgeon.
Followup Instructions:
Name: [**Last Name (LF) 81899**],[**First Name3 (LF) 1955**] F.
Address: [**Location (un) 81904**], [**Hospital1 **],[**Numeric Identifier 81905**]
Phone: [**Telephone/Fax (1) 81894**]
Appointment: Friday, [**9-25**] at 10:30AM
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: Monday, [**9-28**] at 3:45PM
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2178-9-27**]
|
[
"286.9",
"532.40",
"285.9",
"411.89",
"722.10",
"276.69",
"799.02",
"305.1",
"272.4",
"401.9",
"531.90",
"303.90",
"571.2",
"511.9",
"276.50",
"789.59",
"E935.9",
"572.3",
"456.21",
"458.9",
"571.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9767, 9773
|
6346, 8439
|
335, 377
|
9895, 9895
|
4385, 4385
|
11404, 12012
|
3652, 3714
|
8766, 9744
|
9794, 9874
|
8465, 8465
|
10046, 11381
|
8486, 8631
|
3729, 4366
|
6323, 6323
|
6169, 6287
|
277, 297
|
405, 2945
|
4402, 6136
|
9910, 10022
|
2967, 3265
|
3281, 3636
|
8649, 8743
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,280
| 148,878
|
39737
|
Discharge summary
|
report
|
Admission Date: [**2113-1-26**] Discharge Date: [**2113-2-7**]
Date of Birth: [**2054-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right lower lobe lung cancer.
Major Surgical or Invasive Procedure:
[**2113-1-26**]: Right thoracoscopy, right thoracotomy and right lower
lobectomy with en bloc right upper lobe posterior segmentectomy,
mediastinal lymph node dissection, bronchoscopy with
bronchoalveolar lavage.
History of Present Illness:
Mr. [**Known lastname 35028**] is a 58-year-old gentleman who was found to have a
right lower lobe mass. This workup initially began in the summer
but he had a delay
before he had been referred here for thoracic surgical
evaluation. His mediastinoscopy was negative. He was admitted
following right video-assisted thoracotomy right lower lobectomy
Past Medical History:
Diabetes
Hypertension
Social History:
Lives in [**Location 2498**]. Married, and lives with family. Current 50 pk
yr hx of smoking. Drinks one beverage per night.
Family History:
no hx of cancer in family
Physical Exam:
VS: T97.1 HR: 97 SR BP: 108/60 Sats: 94% RA 92% RA
w/ambulation
General: 58 year-old male
HEENT: normocephalic, mucus membranes moist
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds on right otherwise clear, no
crackles or wheezes
GI: benign
Extr: warm no edema
Incsion: Right thoracotomy site with scab, no erythema
Neuro: awake, alert, makes needs known
Pertinent Results:
[**2113-2-5**] Hct-29.0*
[**2113-2-4**] WBC-10.1 RBC-3.28* Hgb-9.6* Hct-29.0 Plt Ct-589*
[**2113-1-26**] WBC-11.5* RBC-3.79* Hgb-11.3* Hct-33.3 Plt Ct-281
[**2113-2-2**] Neuts-69.6 Lymphs-20.4 Monos-4.4 Eos-4.9* Baso-0.8
[**2113-2-7**] PT-24.8* INR(PT)-2.4*
[**2113-2-6**] PT-23.5* PTT-32.4 INR(PT)-2.2*
[**2113-2-5**] PT-25.8* PTT-35.1* INR(PT)-2.5*
[**2113-2-4**] PT-27.9* PTT-60.0* INR(PT)-2.7*
[**2113-2-3**] PT-20.9* PTT-69.6* INR(PT)-1.9*
[**2113-2-6**] Glucose-107* UreaN-12 Creat-0.6 Na-134 K-4.5 Cl-100
HCO3-23
[**2113-1-26**] Glucose-115* UreaN-12 Creat-0.6 Na-138 K-3.7 Cl-106
HCO3-25
[**2113-2-6**] Calcium-8.8 Phos-3.3 Mg-1.9
CXR:
[**2113-2-5**]: As compared to the previous radiograph, there is no
relevant
change. Lung volumes have minimally decreased. The pre-existing
massive
bilateral parenchymal opacities, predominating at the right lung
base and the left lung apex are unchanged. Also unchanged is the
accompanying right basal pleural effusion. Traces of gas in the
right lateral soft tissues have completely resolved. There is no
evidence of newly occurred focal parenchymal opacities.
Unchanged borderline size of the cardiac silhouette.
[**2113-2-1**]: There is a subsequent increase in severity of the
pre-existing massive parenchymal opacities, predominating at the
left lung
apex and the right lung base. No opacities have newly appeared.
The size of the cardiac silhouette is unchanged. Slightly
decreasing is the large right lateral chest wall air inclusion.
Chest CT: [**2113-1-30**]
1. Status post right lower lobe lobectomy and right upper lobe
posterior
segmentectomy.
2. Acute pulmonary embolism originating at the ligated right
lower lobe
pulmonary artery extending into the right middle lobe pulmonary
artery.
3. Diffuse bilateral honeycombing which is new since [**12-6**].
4. Right hydropneumothorax and pneumothorax.
5. Right-sided subcutaneous edema.
Echo: [**2113-1-31**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to hypokinesis of the basal inferior
septum, akinesis of the basal inferior free wall, and dyskinesis
of the basal posterior wall. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 35028**] was taken to the operating room on [**2113-1-26**] by Dr.
[**Last Name (STitle) **] for right thoracoscopy, right thoracotomy and right
lower lobectomy with en bloc right upper lobe posterior
segmentectomy, mediastinal lymph node dissection, and
bronchoscopy with bronchoalveolar lavage, for a right upper lobe
mass. The patient recovered in the PACU, extubated, on nasal
cannula, with IV fluid and PCA dilaudid for pain, along with
foley catheter and right chest tube to water seal with
intermittent leak. He was transferred to [**Hospital Ward Name 121**] 9 in stable
condition.
Neuro: The patient was initially on dilaudid PCA for pain which
was transitioned to oral tylenol, dilaudid, tizanidine. He
required IV medicine for breakthrough, including toradol on POD
3. On POD 4, tizandine was increased but stopped secondary to
hypotension and dilaudid changed to oxycodone with good control.
Over the course of his stay his pain medication was titrated and
he was discharged on oxycodone and acetaminophen.
Pulmonary: Serial chest xrays were done. The chest tube was
discontinued POD3. Aggressive pulmonary toilet with nebulizers
and mucolytics along with lasix, were continued for lung
opacification which had appearance of infection vs.
inflammation. Despite optimum medical management on the floor
the patient became increasingly hypoxic and confused on
[**2113-1-30**]. He developed respiratory failure with oxygen
saturations of 70% 6L NC. A CTA revealed right middle lobe
pulmonary embolus. Heparin drip was started. He was transferred
to the ICU for further management and observation. On 60%
Hi-flow FM With aggressive pulmonary toilet,nebs, incentive
spirometer and good pain control he titrated off supplemental
oxygen with room air saturations of 92-94% with ambulation and
at rest.
Cardiovascular: Sinus tachycardia 100-120's and lopressor was
titrated. On [**2-1**] he had brief episode of atrial fibrillation
150's with hypotension. Unresponsive to diltiazem and lopressor.
With Amiodarone bolus and drip he converted to sinus rhythm 80,
hemodynamically stable. Lopressor was continued, amiodarone
stopped secondary pulmonary side effect. He remained in sinus
rhythm the lopressor was changed to Atenolol 50 mg daily. Blood
pressure stable 100-120's.
Renal: Foley removed [**2113-1-27**]. Failed to void, bladder scan for
540 foley re-inserted and flomax started. Foley removed [**1-30**] he
voided without difficulty. Renal function normal with good urine
output. Electrolytes repleted as needed
GI: He advanced to a diabetic diet. Bowel regime & PPI were
continued.
Endocrine: insulin sliding scale with blood sugars < 150.
ID: Emperic Vancomycin and Cefipime were started [**2113-1-31**] but
discontinued on [**2113-2-2**] since he had no fevers or leukocytosis.
Heme: he was started on Heparin bridge to Warfarin on [**2113-1-31**].
Initial dose 5 mg
x 2 days with INR of 2.7, held for 2 days and restarted [**2-6**]
with 4 mg. INR [**2-7**] was 2.4 he was discharged on 2 mg warfarin
daily. He will follow-up with his PCP [**Last Name (NamePattern4) **].[**Last Name (STitle) 87533**] on Thursday
for further warfarin instructions.
Disposition: he was seen by physical therapy who deemed him safe
for home with a walker and PT. He was discharged on [**2113-2-7**] to
home with his family.
Medications on Admission:
none
Discharge Medications:
1. warfarin 2 mg Tablet Sig: take as directed Tablet PO once a
day: INR Goal 2.0-3.0.
Disp:*100 Tablet(s)* Refills:*2*
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
6. Outpatient [**Name (NI) **] Work PT/INR 2-3 times a week PRN
Please fax or call results to PCP:
[**Name Initial (NameIs) 7274**]: [**Name Initial (NameIs) 87533**],JIRI Address: [**Location (un) 87534**], [**Location (un) **],[**Numeric Identifier 87535**]
Phone: [**Telephone/Fax (1) 87536**] Fax: [**Telephone/Fax (1) 87537**]
7. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-13**]
puff Inhalation four times a day. Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 24356**] VNA
Discharge Diagnosis:
Right lower lobe cancer
Diabetes Mellitus
Hypertension
Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-Shower daily. Wash incision with soap and water, rinse pat dry
-No driving while taking narcotics. Take stool softners with
narcotics
-Walk 4-5 times a day for 10-15 minutes increasing to a Goal of
30 minutes daily
Warfarin for pulmonary embolism: Follow-up with your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] for further Warfarin managment. INR Goal 2.0-3.0
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2113-2-21**]
1:00
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 87538**] to manage Warfarin dosing. Blood draw
Thursday at [**Hospital3 **] or with VNA.
Completed by:[**2113-2-8**]
|
[
"415.11",
"250.00",
"518.5",
"458.21",
"788.20",
"512.1",
"162.5",
"401.9",
"427.31",
"511.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.49",
"32.39",
"40.3",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8814, 8874
|
4243, 7604
|
340, 556
|
8992, 8992
|
1574, 4220
|
9739, 10182
|
1138, 1165
|
7659, 8791
|
8895, 8971
|
7630, 7636
|
9143, 9716
|
1180, 1555
|
270, 302
|
584, 935
|
9007, 9119
|
957, 980
|
996, 1122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,549
| 141,941
|
54591
|
Discharge summary
|
report
|
Admission Date: [**2103-5-25**] Discharge Date: [**2103-6-4**]
Date of Birth: [**2024-10-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2103-5-29**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Epic Porcine
Valve), Single Vessel Coronary Artery Bypass Graft(LIMA to LAD),
and Maze Procedure.
History of Present Illness:
Mrs. [**Known lastname 111659**] is a 78 year old female with PMHx of HTN,
COPD/Asthma, paroxysmal AF, PVD, s/p bilateral carotid
endarterectomies and aortic stenosis who was referred for right
and left heart cath in the setting of worsening SOB. She was
previously seen by Dr. [**Last Name (STitle) 1911**] after being hospitalized
with progressive PND, orthopnea, SOB and peripheral edema. Pt
presented to OSH repeatedly with RLQ pain and lower extremity
edema. Pt had some symptom relief with lasix and was discharged
on Lasix 40mg daily. Pt denies any chest discomfort, or
presyncope. She has some intermittent palpitations that she
associates with her Afib. Pt underwent an echo on [**2103-5-16**]-normal
LV size and function, mild mitral regurgitation and LVEF of 65%.
Aortic valve had three leaflets, was calcific with severe
stenosis. The peak gradient was 84 mmHg, the mean gradient was
60 mmHg and there was mild AI. There was left atrial
enlargement.
Past Medical History:
# Severe aortic stenosis
# Paroxysmal atrial fibrillation
# Hypertension
# s/p bilateral CEAs
# CRI, ?baseline 1.4-1.9, most recently 1.4 [**2103-5-14**]
# h/o TIA x3, last 20 years ago
# Scarlet fever as an infant
# Rheumatic fever in her teens
# S/P ulnar nerve removal from her left arm
# S/P left knee arthroscopy
# S/P bilateral cataract surgery
# Asthma
# S/P cyst removal bilateral breasts
# Spinal stenosis/ several ruptured discs
# h/o UTI
# h/o pneumonia
# Hearing impaired
# Depression
Social History:
She is a widow and lives alone. Retired administrative
assistant. She has four grown children. She does not smoke (quit
30 yrs ago, 4 ppdx20 yrs) but drinks a glass of wine nightly.
Family History:
Brother died of MI at age 36
Physical Exam:
VS: T-98.5 BP 140/53 HR 62 RR 18 Sats 95% RA
Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Carotid bruits bilaterally (radiating from precordium)
CV: Irreg/irreg with gr 3 harsh SEM radiating across
pre-cordium.
Chest: Resp were unlabored, no accessory muscle use. Bilateral
crackles apprec at bases, otherwise no wheezes, moving air well
Abd: Soft, NTND. No HSM or tenderness. Obese
Ext: No c/c/e. Right groin stable with no femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2103-5-29**] Intraop TEE:
PREBYPASS - No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened. There is severe
aortic valve stenosis (area <0.8cm2). Mild to moderate ([**12-20**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
POSTBYPASS - There is preserved biventricular systolic function.
There is a well seated, well functioning bioprosthesis in the
aortic position. (Biocor #21 Epic supranullar). No AI is
visualized. The study is otherwise unchanged from the prebypass
period.
[**2103-6-4**] 05:33AM BLOOD WBC-10.9 RBC-3.04* Hgb-9.4* Hct-26.9*
MCV-88 MCH-31.0 MCHC-35.1* RDW-16.0* Plt Ct-181
[**2103-6-3**] 06:50AM BLOOD WBC-9.2 RBC-3.01* Hgb-9.0* Hct-26.5*
MCV-88 MCH-30.0 MCHC-34.1 RDW-16.1* Plt Ct-144*
[**2103-6-4**] 05:33AM BLOOD PT-15.6* PTT-34.5 INR(PT)-1.4*
[**2103-6-3**] 06:50AM BLOOD PT-14.4* PTT-40.2* INR(PT)-1.3*
[**2103-6-4**] 05:33AM BLOOD Glucose-92 UreaN-34* Creat-1.5* Na-136
K-4.0 Cl-93* HCO3-37* AnGap-10
[**2103-6-3**] 06:50AM BLOOD UreaN-33* Creat-1.5* K-3.9
[**2103-6-2**] 07:05AM BLOOD UreaN-32* Creat-1.9* K-4.0
[**2103-6-1**] 05:15AM BLOOD Glucose-93 UreaN-27* Creat-1.8* Na-131*
K-3.7 Cl-96 HCO3-27 AnGap-12
CHEST (PA & LAT) [**2103-6-2**] 9:23 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman s/p AVR/CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
CLINICAL HISTORY: Status post AVR and CABG.
CHEST
There is evidence of previous CABG. Heart remains enlarged. A
left effusion is present. Extensive atelectasis and a possible
infiltrate in the right lower and left lower lobe is present.
Brief Hospital Course:
Mrs. [**Known lastname 111659**] was admitted to the cardiology service and
underwent cardiac catheterization which confirmed severe aortic
stenosis with a 60mmHg gradient and valve area of 0.6cm2.
Coronary angiography revealed a right dominant system and a 60%
lesion in the proximal left anterior descending artery. Cardiac
surgery was therefore consulted and further evaluation was
performed. Given her paroxysmal atrial fibrillation, she was
maintained on intravenous Heparin. Carotid ultrasound found only
mild to moderate disease of both internal carotid arteries.
Preoperative course was otherwise uneventful with mild
improvement in renal function. Prior to surgery, she was
transfused with PRBC for a hematocrit of 27%. On [**5-29**], Dr.
[**Last Name (STitle) **] performed an aortic valve replacement, single vessel
coronary artery bypass grafting and Maze procedure. For surgical
details, please see seperate dictated operative note. Following
the operation, she was brought to the CVICU for invasive
monitoring. Within 24 hours, she awoke neurologically intact and
was extubated without incident. Amiodarone and Warfarin were
resumed. She was given additional PRBC to maintain hematocrit
near 30%. She otherwise maintained stable hemodynamics and
transferred to the SDU on postoperative day two. She converted
back to a rate controlled atrial fibrillation. She was started
on lovenox while her INR was subtherapeutic. She was ready for
discharge to rehab on POD #6.
Medications on Admission:
Amio 200 qd, Norvasc 10 qd, HCTZ 25 qd, Lasix 40 qd, Tramadol
prn, Spiriva 18 mcg qd, Albuterol Diskus, Calium 600 [**Hospital1 **],
Flovent, Olmesartan 40 qd, Crestor 10 qd, Trazadone 50 qhs,
Warfarin, Citalopram 40 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): until INR > 2.0.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily):
check INR [**6-5**] and continue lovenox until INR > 2.0.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Chronic Diastolic Congestive Heart Failure
Aortic Stenosis
Coronary Artery Disease
Hypertension
Paroxsymal Atrial Fibrillation
Chronic Renal Insufficiency
Cerebrovascular Disease - history of TIA's
Depression
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.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-24**] weeks, call for appt
Dr. [**Last Name (STitle) 1911**] in [**1-21**] weeks, call for appt
Dr. [**Last Name (STitle) 1159**] in [**1-21**] weeks, call for appt
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 16827**]
Date/Time:[**2103-8-1**] 11:20
Completed by:[**2103-6-4**]
|
[
"424.1",
"443.9",
"584.9",
"428.0",
"311",
"724.2",
"427.31",
"428.32",
"414.01",
"403.90",
"585.9",
"496",
"244.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"37.23",
"35.21",
"39.61",
"37.33",
"36.15",
"88.56",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8011, 8088
|
4962, 6442
|
283, 464
|
8341, 8348
|
2908, 4574
|
8684, 9044
|
2191, 2221
|
6712, 7988
|
4611, 4642
|
8109, 8320
|
6468, 6689
|
8372, 8661
|
2236, 2889
|
236, 245
|
4671, 4939
|
492, 1455
|
1477, 1976
|
1992, 2175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,604
| 110,989
|
29200
|
Discharge summary
|
report
|
Admission Date: [**2103-1-24**] Discharge Date: [**2103-1-29**]
Date of Birth: [**2059-7-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mild shortness of breath
Major Surgical or Invasive Procedure:
[**2103-1-24**] Minimally Invasive Mitral Valve Repair utilizing a 38mm
Annuloplasty Band
History of Present Illness:
This is a 43 year old female with known heart murmur since age
25. She has been followed by serial echocardiograms which have
shown worsening mitral regurgitation with increasing left
ventricular dimensions. She therefore has been referred for
cardiac surgical intervention. Most recent ECHO from [**Month (only) **]
[**2102**] revealed severe MR, dilated LV, EF of 55% and only trace
TR. Subsequent cardiac catheterization confirmed 4+ MR. Coronary
angiography showed clean coronary arteries.
Past Medical History:
Mitral Regurgitation
Social History:
Denies tobacco history. Admits to only social ETOH. She lives
with her daughter. She is a high school teacher. Denies IVDA.
Family History:
Denies premature CAD. Father currently alive in his 70's,
suffers from heart failure and diabetes.
Physical Exam:
Vitals: BP 130-140/86-88, HR 84, RR 12
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 4/6 systolic murmur left lower
sternal border
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2103-1-29**] Chest x-ray: A small right apical pneumothorax is
unchanged in size, with visceral pleural line overlying the
right third posterior rib level. Subcutaneous emphysema is again
demonstrated in the right axilla. Multifocal areas of discoid
atelectasis in the left mid and both lower lung regions have
slightly improved, and a small left pleural effusion has not
changed.
[**2103-1-28**] 05:33AM BLOOD WBC-9.7 RBC-3.00*# Hgb-9.8*# Hct-26.8*#
MCV-90 MCH-32.8* MCHC-36.6* RDW-14.0 Plt Ct-198
[**2103-1-27**] 06:10AM BLOOD Glucose-135* UreaN-9 Creat-0.6 Na-135
K-4.3 Cl-103 HCO3-27 AnGap-9
[**2103-1-26**] 07:45AM BLOOD Mg-1.9
COMPARISON: [**2103-1-28**].
INDICATION: Pneumothorax.
A small right apical pneumothorax is unchanged in size, with
visceral pleural line overlying the right third posterior rib
level. Subcutaneous emphysema is again demonstrated in the right
axilla. Multifocal areas of discoid atelectasis in the left mid
and both lower lung regions have slightly improved, and a small
left pleural effusion has not changed.
IMPRESSION: No change in small right apical pneumothorax.
echo [**1-24**]
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.0 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 5.0 cm
Left Ventricle - Fractional Shortening: *0.18 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
INTERPRETATION:
Findings:
Pre-CPB study performed to rule out LSVC/ASD and severe aortic
atheroslcerosis.
Retrograde coronary sinus and Pulmonary artery vent cannulae
placed under TEE
guidance and postions conformed.
LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast
in the body
of the LA. Depressed LAA emptying velocity (<0.2m/s) All four
pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Moderately dilated LV cavity. Low normal LVEF.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque. Normal ascending aorta diameter. Normal
descending
aorta diameter. No thoracic aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe
MVP. Partial
mitral leaflet flail. Severe (4+) MR. Eccentric MR jet.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
PRE-BYPASS: The left atrium is markedly dilated. No spontaneous
echo contrast
is seen in the body of the left atrium. The left atrial
appendage emptying
velocity is depressed (<0.2m/s). No atrial septal defect is seen
by 2D or
color Doppler. The left ventricular cavity is moderately
dilated. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular
chamber size and free wall motion are normal. The ascending,
transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic
plaque. No thoracic aortic dissection is seen. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic
regurgitation. The mitral valve leaflets are myxomatous. There
is
moderate/severe mitral valve prolapse. There is partial mitral
leaflet flail.
Severe (4+) mitral regurgitation is seen. The mitral
regurgitation jet is
eccentric. There is no pericardial effusion.
POST CPB:
First Attempt: Severely hypokinetic LV inferiro and spetal walls
with
mioderately hyokinetic RV free wall and severe hypotension
requiring
re-institutuion of full CPB.
2nd Attempt:
Improved biventricular systolic function. EF = 55%
Annuloplasty ring in mitralposition, trace MR, and no
significant
transmitralor LVOT gradient.
After thorough de-airing of the LV and LA and with background
inotropic
support, the focal and global LV aand RV function gradually
improved allowing
separation from CPB.
Posterior annuloplasty ring in mitral positon, well seated and
mecahnically
stable. Trace MR and no sigfnificant gradient across the mitral
valve.
LV and RV function returned to baseline.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Patient was admitted and underwent a minimally invasive mitral
valve repair by Dr. [**Last Name (STitle) 1290**]. There were no complications and
following the operation, patient was brought to the CSRU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. Her CSRU course was
uneventful and she transferred to the SDU on postoperative day
one. Chest tube was left in for several days secondary to
persistent serosanginous drainage. Chest tube was eventually
removed with resultant small right apical pneumothorax which
remained stable by serial chest x-rays. Postoperatively, she
also required several units of packed red blood cells for
anemia. Following blood transfusions, her hematocrit improved
from 18 to 26%. Postoperatively, she remained in a normal sinus
rhythm. Some premature atrial beats were noted on telemetry for
which beta blockade was initiated and slowly advanced as
tolerated. No episodes of atrial fibrillation were noted. The
remainder of her hospital stay was uneventful and she was
medically cleared for discharge on postoperative day five.
Medications on Admission:
[**Female First Name (un) **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Mitral regurgitation - s/p mitral valve repair, Postop right
apical pneumothorax, Postop anemia
Discharge Condition:
Good
Discharge Instructions:
Activity as tolerated.
Monitor wounds for signs of infection.
Please call with any questions or concerns.
Leave Dressing on chest tube site until [**1-30**] pm then remove, can
cover with dry guaze if needed changing daily
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**4-26**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 23651**] in [**2-24**] weeks, call for appt
Dr. [**First Name (STitle) 1726**] in [**2-24**] weeks, call for appt [**Telephone/Fax (1) 36012**]
Completed by:[**2103-1-30**]
|
[
"424.0",
"997.3",
"E879.9",
"285.1",
"998.11",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"35.12",
"39.61",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9549, 9608
|
7193, 8315
|
346, 438
|
9748, 9755
|
1666, 6437
|
10026, 10325
|
1162, 1262
|
8395, 9526
|
9629, 9727
|
8341, 8372
|
9779, 10003
|
1277, 1647
|
282, 308
|
466, 961
|
7170, 7170
|
983, 1005
|
1021, 1146
|
6447, 7135
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,880
| 107,184
|
20815+57198
|
Discharge summary
|
report+addendum
|
Admission Date: [**2199-4-25**] Discharge Date: [**2199-4-29**]
Date of Birth: [**2123-7-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
75 y/o man with PMH significant for esophageal cancer, GI
bleeding, and hepatocellular carcinoma admitted to the MICU
through the ED for GI bleeding. In pertinent recent history, the
pt was admitted to [**Hospital1 18**] for a probable upper GI bleed from
[**3-14**] to [**3-21**]. His varices could not be banded at that time due
to an esophageal stricture. Pt reports that he had been doing
well at home. On Monday, he came to the hospital and had an
infusion of Procrit. Following this, he felt very tired and
continued to feel more and more fatigued on Tues and Wed. He
also notes that his stool became dark on Tuesday. Pt reports
that he had one soft block stool per day over the next two days.
No BRBPR or hematoemesis. Pt denies abdominal pain, nausea, and
vomiting. He does report that his appetite has been very poor
over the last three days. In further discussion, pt reports that
he has felt mildly lightheaded since Tuesday. No vertigo. He
denies CP and SOB. Had difficulty moving around at home for the
last two days because of his severe fatigue but not because of
SOB. He reports mild pain in his right hip which he attributes
to his arthritis. No LE pain or swelling. No dysuria or
hematuria.
In the ED, the pt's VS were 96.3 91 100/46 20 94% RA. Pt was
started on an octreotide drip. Blood is coming up for
transfusion. GI is planning to see the pt. He will be
transferred to the MICU for further care.
Past Medical History:
1. GI bleeding- Pt was recently admitted to [**Hospital1 18**] from
[**Date range (1) 55482**] with a bleed thought to be due to esophageal
varices. Pt could not be successfully banded due to a esophageal
stricture that limited the passage of the banding device. He
retired MICU observation and a total of 9 units of PRBC.
2. Esophageal cancer- Was diagnosed in 05/[**2197**]. Pt was treated
with radiation and cucurrent cisplatin and continuous 5-Fu. He
underwent treatment from [**2198-6-13**] to [**2198-7-20**].
3. Hepatocellular carcinoma- Was diagnosed in 02/[**2198**]. Pt is s/p
chemoembolization in 03/[**2198**]. Per recent notes from Dr. [**First Name (STitle) **],
it appears that the pt had a good local result but has
progressive pulmonary mets. These may be from his esophageal CA
but as his CEA is also rising it cannot be excluded that they
are from his HCC.
4. Arthritis
5. Seasonal allergies
6. HTN
Social History:
Pt is married and lives with his wife. [**Name (NI) **] is the retired owner
of a fish market. He drank a large amount of ETOH until [**2176**]
when he quit and was sober until [**2189**]. However, he resumed
drinking at that time until quiting again in 01/[**2198**]. Pt smoked
3 to 4 PPD from 30 years before quiting 35 years ago.
Family History:
Pt's grandfather died of an unknown cancer. He has a brother
with "heart disease" and a sister with breast cancer.
Physical Exam:
96.3 91 100/46 20 94% RA
Gen- Alert and oriented. NAD. Resting comfortably on the
strecher.
HEENT- NC AT. PERRL. Mildly dry mucous membranes.
Cardiac- RRR. No m,r,g.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Pulm- Diffuse crackles throughout lower half of lungs
bilaterally.
Extremities- No c/c/e. 2+ DP pulses bilaterally.
Pertinent Results:
[**2199-4-25**] 11:05AM BLOOD WBC-4.2 RBC-2.83* Hgb-8.4* Hct-25.6*
MCV-90 MCH-29.7 MCHC-32.8 RDW-18.1* Plt Ct-191
[**2199-4-25**] 06:49PM BLOOD Hct-29.4*
[**2199-4-25**] 10:36PM BLOOD Hct-28.9*
[**2199-4-25**] 11:05AM BLOOD Neuts-79.7* Lymphs-12.6* Monos-6.1
Eos-1.4 Baso-0.2
[**2199-4-25**] 11:05AM BLOOD Plt Ct-191
[**2199-4-25**] 11:05AM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2
[**2199-4-25**] 11:05AM BLOOD Glucose-127* UreaN-21* Creat-0.7 Na-140
K-4.0 Cl-106 HCO3-27 AnGap-11
[**2199-4-25**] 11:05AM BLOOD ALT-33 AST-71* AlkPhos-139* Amylase-45
TotBili-1.0
[**2199-4-25**] 11:05AM BLOOD Lipase-25
[**2199-4-25**] 11:05AM BLOOD Albumin-3.2* Calcium-12.2* Phos-3.3
Mg-1.6
CHEST (PORTABLE AP) [**2199-4-25**]:
FINDINGS: Central venous line remains in place. Cardiac and
mediastinal contours are unchanged. Note is made of faint
opacity in the right lower lobe, which may represent aspiration
or aspiration pneumonia. Note is made of multiple small nodular
opacities in bilateral lungs, probably representing metastatic
disease noted on the prior chest CT.
IMPRESSION: Faint opacity in right lower lobe, which may
represent aspiration versus aspiration pneumonia. Multiple
nodular opacities in bilateral lungs, probably representing
metastatic disease noted on prior chest CT in this patient with
HCC.
DISCHARGE LABS:
[**2199-4-29**] 10:00AM BLOOD WBC-3.8* RBC-3.57* Hgb-11.3* Hct-32.6*
MCV-91 MCH-31.6 MCHC-34.6 RDW-18.3* Plt Ct-147*
[**2199-4-29**] 10:00AM BLOOD Glucose-117* UreaN-9 Creat-0.5 Na-134
K-3.9 Cl-102 HCO3-24 AnGap-12
[**2199-4-29**] 10:00AM BLOOD Albumin-3.1* Calcium-10.0 Phos-2.3*
Mg-1.4*
[**2199-4-29**] 10:00AM BLOOD PTH-8*
Brief Hospital Course:
1. GI bleeding- Pt with melanotic stools and a Hct drop from 32
on [**4-22**] to 25.6 on arrival in the ED. Bleeding is most probably
from his know esophageal varices. However, this is very
difficult as they could not be banded in the past secondary to
esophageal strictures. GI was consulted and an EGD was
performed. Varicies in esophagus showed the "red [**Last Name (un) 23199**] sign"
(red streaks). No intervention was made but iv octreotide was
administered for four days and his hct remained stable.
2. Hepatocellular carcinoma- Pt is s/p chemoembolization. His
most recent CT scan from [**4-16**] showed tumor thrombus occluding
the portal vein and nodular implants along the hepatic capsule
along with mesenteric stranding consistent with peritoneal
carcinoma. Pt also has significant increase in size and number
of bilateral pulmonary nodules and a new lytic foci in the left
iliac bone and increased size of lytic foci in the right
sacroiliac joint and the thoracic spine. However, unclear if
these are due to the HCC or esophageal CA. Pt's AFP is
significantly increased at 6654. The last value was 1187 from
[**2199-3-14**].
3. Hypercalcemia- This is a new finding for the pt, it is likely
hypercalcemia of malignancy. The patient was given 3 days of
caclitonin IM. His PTH was low but PTHrp was not sent. The pt
also had hypomagnesemia which may be secondary to the
hypercalcemia. Starting a bisphosphonate may be considered as
an outpatient if his calcium remains elevated.
4. Esophageal carcinoma- Pt was treated for this in [**2197**]. [**Month (only) 116**] be
reason for the pulmonary and bone mets but these are most
probably due to the HCC.
5. HTN- antihypertensive medications were held in the setting of
the acute bleed. They were restarted on discharge.
6. FEN- the patient was initially kept NPO and diet was advanced
as tolerated once his hct stabilized.
7. Proph- Pneumoboots; PPI.
8. Code- Full. Discussed at length with the pt and his daughter
who is his health care proxy. [**Name (NI) **] would wish to be recussitated
but not maintained on life support long term with no meaniful
hope of recovery.
Medications on Admission:
1. Nadolol 40 mg [**Hospital1 **]
2. Thiamine 100 mg daily
3. Folic acid 1 mg daily
4. Albuterol MDI 1-2 puffs Q4-6H PRN wheezing
5. Spironolactone 25 mg daily
6. Isosorbide dinitrate 10 mg [**Hospital1 **]
7. Extra strength tylenol QID PRN
8. Lasix 40 mg daily
9. Ambien 5 mg QHS PRN
10. Protonix 40 mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Magnesium Oxide 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO
twice a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Nadolol 40 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GI Bleed
Discharge Condition:
Stable, afebrile, hct was stable for >3 days.
Discharge Instructions:
Please call 911 if you have any bloody vomiting or become
dizzy/lightheaded. Please seek medical attention for
fevers>101.4 or for anything else medically concerning.
Please take your medications as directed.
Followup Instructions:
Please see your oncologist in [**12-16**] weeks for follow-up.
1) Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2199-5-2**] 9:30 Provider: [**Name Initial (NameIs) 4426**] 16 Date/Time:[**2199-5-2**]
10:30
2) Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2199-5-2**] 10:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Name: [**Known lastname 10377**],[**Known firstname 133**] E Unit No: [**Numeric Identifier 10378**]
Admission Date: [**2199-4-25**] Discharge Date: [**2199-4-29**]
Date of Birth: [**2123-7-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1472**]
Addendum:
Mr. [**Known lastname **] [**Last Name (Titles) 10379**], diagnosed by biopsy, is secondary to his
extensive alcohol use. His varicies are due to alcoholic
[**Last Name (Titles) 10379**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**]
Completed by:[**2199-5-15**]
|
[
"401.9",
"530.85",
"571.2",
"V10.03",
"456.20",
"305.00",
"197.6",
"198.5",
"275.2",
"155.0",
"275.42",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10386, 10594
|
5247, 7392
|
322, 334
|
8840, 8887
|
3578, 4880
|
9146, 10363
|
3095, 3211
|
7763, 8707
|
8808, 8819
|
7418, 7740
|
8911, 9123
|
4897, 5224
|
3226, 3559
|
274, 284
|
362, 1788
|
1810, 2729
|
2745, 3079
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,094
| 104,829
|
35764
|
Discharge summary
|
report
|
Admission Date: [**2181-11-17**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2126-10-22**] Sex: M
Service: SURGERY
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 M hospitalized in [**2180**] for severe necrotizing pancreatitis.
He was eventually
discharged to rehab after multiple laparoscopic necrosectomies
as well as takedown of an EC fistula and SBR. He was in his
usual state of health until 3 days ago when he started having
gradual onset of epigastric pain. Pain consistently worsened
over the past 48 hours so he presented to [**Hospital3 **] where
he got a CT abdomen and then transferred to [**Hospital1 18**]. En route he
vomited 3
times. He denies fevers, chills, shortness of breath, or chest
pain. Today he has had zero bowel movements, when normally he
has 6 loose ones daily. He also reports that he resumed drinking
[**Hospital1 **] 3 months ago (approximately [**1-20**] pints per day). Despite
2mg IV morphine every 15 minutes, he complains of severe
abdominal pain.
Past Medical History:
PMH:
Hypertension, Ulcerative colitis s/p colectomy, J pouch, Removal
of nonmalignant brain tumor, [**Month/Day (2) **] abuse, Chronic Methadone
Maintenance
PSH:
Takedown EC fistula with small-bowel resection and primary
anastomosis, extended adhesiolysis, repair of enterotomy, G-tube
placement, and J-tube placement [**2180-5-25**]; resection non-malignant
brain tumor [**2161**]; colectomy [**2157**]
Social History:
Lives w/sister. History long-term smoking. Chronic [**Year (4 digits) **] use.
Denies IVDU.
Family History:
Not-contributory
Physical Exam:
On discharge:
The patient was afebrile with vital signs stable.
Gen: AAOx3. NAD.
Card: RRR. No r/g/m
Pulm: CTA b/l. No r/r/w/c
Abd: Soft. ND. NT. NO rebound tenderness or guarding noted on
exam.
Pertinent Results:
[**2181-11-17**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2181-11-17**] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2181-11-17**] 06:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2181-11-17**] 06:30PM URINE AMORPH-MOD
[**2181-11-17**] 04:09PM LACTATE-3.0*
[**2181-11-17**] 03:55PM GLUCOSE-152* UREA N-26* CREAT-1.6* SODIUM-139
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2181-11-17**] 03:55PM ALT(SGPT)-150* AST(SGOT)-160* ALK PHOS-655*
TOT BILI-2.2*
[**2181-11-17**] 03:55PM LIPASE-1334*
[**2181-11-17**] 03:55PM WBC-9.8 RBC-3.73* HGB-12.0* HCT-35.6* MCV-96
MCH-32.2* MCHC-33.7# RDW-13.2
[**2181-11-17**] 03:55PM NEUTS-91.6* LYMPHS-3.7* MONOS-4.4 EOS-0.1
BASOS-0.3
[**2181-11-17**] 03:55PM PLT COUNT-326
[**2181-11-17**] 03:55PM PT-12.3 PTT-21.0* INR(PT)-1.0
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. The patient arrived on the floor NPO,
on IV fluids, with a foley catheter, Dilaudid PCA for pain
control. The patient was hemodynamically stable.
Neuro: The patient received morphine IV in the mergency
department with minimal dimunition of pain as per patient. On
admission the patient was placed on a Dilaudid PCA.
CV: The patient was written for Hydralazine with holding
parameters for proper blood pressure control. Vital signs were
routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was made NPO with IV fluids. The patient
was placed on Protonix IV for GI prophylaxis, as well as Zofran
for nausea. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
On HD#2, the patient developed signs of delirium tremens and
acute [**Month/Day/Year **] withdrawal. The patient was transferred to the ICU
and was placed on Diazepam, Lorazepam, and Midazolam as needed
to control his delirium tremens. The patient was resuscitated
wih IVF which was increased from 150 to 200. The patient was
placed on Mechanical Ventilation with Assist control (Volume
Targeted). Tidal volume was 500 cc. Respiratory rate was 18.
PEEP was 5cm/h2o. FIO2 was maintained at 80%. The FiO2 was
weaned to 40 by the evening of the same day. The patient was
started on Ampicillin-Sulbactam.
HD#3: The patient was given a PICC line for total parenteral
nutrition. His Dilaudid PCA was switched to a PRN Dilaudid. The
patient was also started on methadone. The ampicillin sulbactam
was discontinued on the evening of that day.
HD#4: The patient's mechanical ventilation was changed to CPAP
(5 cm/h2o PEEP: 5 cm/h2o FIO2: 40 %) early in the morning. After
several hours tolerating this, the patient was extubated. The
patient was given a PICC line.
HD#5: The patient was started on sips, wich he tolerated. The
patient was transferred to the floor, with a Dilaudid IV PRN for
pain control, On IV fluids, on sips, and on telemetry. The
patient had a clonidine patch as well as Hydralazine with hold
parameters for blood pressure control.
HD#6: The patient was found to have a swollen upper extremity.
An UE U/S was obtained which revealed no DVT in the upper
extremity. The patient was started on clear liquids and HCTZ
which the patient tolerated. The Protonix was switched to PO
from IV. The patient was written for PO medications including
Mirtazapine and Citalopram.
HD#7: The patient's Diazepam was weaned from Diazepam 5 mg PO/NG
Q6H
to Q8H. The patient's telemtry was stopped. Diet was advanced to
full liquids. The patient was written fro tylenol and ibuprofen
for pain control.
HD#8: The patient's diet was advanced to regular which he
tolerated. At the time of discharge, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The PICC line was d/c'ed
prior to discharge.
Medications on Admission:
klonopin 1', remeron 15 QHS, HCTZ 12.5', ? other
anti-hypertensives but patient unsure
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic pancreatitis; [**Month/Day/Year **] withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Last Name (un) **] were seen in the hospital with acute on chronic
pancreatitis. Your hospital stay was complicated by withdrawal
and delirium tremens. You were given an appropriate course of
valium to treat this very dangerous condition. This medication
is being stopped before your discharge. Please return to the
hospital if you experience palpitations, vomiting, nausea,
excessive sweating, or fevers.
You have been diagnosed with chronic pancreatitis. Your pancreas
is inflamed and may be permanently scarred. The pancreas is an
organ that produces chemicals and hormones that help you digest
food and use sugar for energy. Gallstones are one of the most
common causes of pancreatitis. These hard stones form in the
gallbladder, which shares a passage with the pancreas into the
small intestine. If gallstones block this passage, fluid can't
escape the pancreas. The fluid backs up and causes inflammation
and pain. Chronic use of [**Last Name (un) **] is another cause of chronic
pancreatitis. Here's what you can do at home to help with your
condition.
Home Care
Ask someone to drive you to appointments until you know how the
illness has affected you.
Tell your doctor about any medications you are taking. Some
medications can cause pancreatitis.
Ask your doctor about over-the-counter medications for pain.
Work with your doctor to control blood sugar levels.
Learn to take your own pulse. Keep a record of your results.
Ask your doctor [**First Name (Titles) 6643**] [**Last Name (Titles) 21636**] mean that you need medical
attention.
Watch for symptoms that your pancreatitis is getting worse.
These symptoms include abdominal pain, nausea and vomiting, and
fever.
Diet Changes
Eat a low-fat diet. Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 81326**] and other diet
information.
Take vitamins A, D, and E, and add calcium to your diet.
Stop drinking, especially if your illness was caused by [**Last Name (Titles) **].
Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) **] abuse programs and support groups
such as Alcoholics Anonymous.
Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 16615**] medications that can help you
stop drinking.
When to Call Your Doctor
Call your doctor right away if you have any of the following:
Fever above 100??????F
Severe pain in your upper abdomen to your back
Nausea and vomiting
Abdominal swelling and tenderness
Dizziness or lightheadedness
Yellowing of your skin or eyes (jaundice)
Bruises on your abdomen or back
Rapid pulse
Shallow, fast breathing
Loss of weight without dieting
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2182-1-4**] 11:00 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]. You will have a
MRI prior your appointment with Dr. [**Last Name (STitle) **], please call Dr. [**Name (NI) 60612**] office to clarify the date and time of the MRI.
.
Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-20**] weeks after discharge
Completed by:[**2181-12-4**]
|
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76,597
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2946
|
Discharge summary
|
report
|
Admission Date: [**2102-1-15**] Discharge Date: [**2102-1-26**]
Date of Birth: [**2028-12-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine Sulfate / Benadryl
Attending:[**First Name3 (LF) 14145**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Thoracentesis
Transesophageal Echocardiogram
cardiac catheterization with balloon angioplasty of left
circumflex artery.
History of Present Illness:
Mr. [**Known lastname 14146**] is a 73 yo M with history of CAD s/p PCI, sick sinus
syndrome s/p PPM, chronic pericardial effusion presenting with
central chest pain for 2 days. The pain started Friday night
while he was sitting watching TV and was intermittent, burning
pain centered over his sternum without clear radiation. His pain
worsened after drinking cranberry juice and improved a little
with a heating pad. The discomfort later became a dull [**2102-2-2**]
pain, slightly worse with deep breathing but without associated
SOB, diaphoresis, nausea, radiation, lightheadedness,
palpitations. NTG did not relieve his pain. When this pain did
not resolve, he decided to come to the ED.
.
In the ED, initial vitals were T 95.8 HR 78 BP 125/99 RR 18 100%
on 2L NC. He was given a full dose aspirin and NTG by EMS on the
way in. In the ED, he received a GI cocktail without relief of
his pain. EKGs showed flattened lateral T waves. FAST bedside
ultrasound showed pericardial effusion. Echo was slightly worse,
diastolic invagination without overt tamponade. Trop 0.04. CXR
showed a left pleural effusion. He was admitted to [**Hospital1 1516**] for
further workup.
.
On the floor, he reports continued central chest dull pain
([**4-8**]) but denies any shortness of breath, nausea, vomiting,
diaphoresis.
.
On review of systems, he endorses constipation but denies
headaches, sore throat, abdominal pain, nausea, vomiting,
weakness, myalgias, joint pains, cough, hemoptysis, recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for dyspnea on exertion
that has been stable since [**2101-3-30**]. He denies paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
CAD s/p IMI age 32
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: Percutaneous coronary
intervention, in [**2094**] with stent to mid-LAD, in stent thrombosis
in [**2098**] with repeat stenting
-PACING/ICD: status post pacemaker implant on [**2101-11-17**]
secondary to sick sinus syndrome, atrial fibrillation,
tachybrady syndrome and syncope. [**Company 1543**] pacemaker, Sensia
SEDR01
3. OTHER PAST MEDICAL HISTORY:
s/p Pericardiocentesis [**4-7**]
SCLC, ltd stage s/p chemo XRT [**4-30**] and ppx cranial XRT, now in
remission
Type 2 Diabetes
Atrial fibrillation ([**5-31**]) had been on coumadin until recent
subdural hematoma(per neuro/Dr. [**Last Name (STitle) **]
HTN
Aortic sclerosis
Thalassemia minor
GERD
s/p TKR
Diverticulosis
Social History:
Retired police officer. Smoked 3 packs per day for nearly 50
years; quit in [**2093**]. Denies EtOH. Married; five children and ten
grandchildren.
Family History:
No family history of premature CAD. Mother died of liver CA;
father had CVA.
Physical Exam:
VS: T= 97 BP= 145/82 HR= 87 RR= 24 O2 sat= 98% RA
GENERAL: WDWN male in NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: No bruits or JVD noted.
CARDIAC: Irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasalar crackles with
decreased BS on the L.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs [**1-15**]:
WBC-6.3 RBC-4.98 Hgb-10.6* Hct-35.4* MCV-71* MCH-21.4*
MCHC-30.0* RDW-16.0* Plt Ct-335
PT-13.3 PTT-27.9 INR(PT)-1.1
Glucose-142* UreaN-31* Creat-1.1 Na-141 K-4.1 Cl-105 HCO3-26
AnGap-14
Mg-2.2
.
Thyroid studies:
TSH-21* T4-4.7
.
Cardiac enzymes:
[**2102-1-15**] 11:00AM CK(CPK)-67 CK-MB-NotDone cTropnT-0.04*
[**2102-1-15**] 08:00PM CK(CPK)-219 CK-MB-25* MB Indx-11.4*
cTropnT-0.13*
[**2102-1-16**] 05:30AM CK(CPK)-258 CK-MB-30* MB Indx-11.6*
cTropnT-0.37*
[**2102-1-16**] 03:45PM CK(CPK)-253 CK-MB-25* MB Indx-9.9*
cTropnT-0.37*
[**2102-1-17**] 05:30AM CK(CPK)-132 CK-MB-9 cTropnT-0.50*
[**2102-1-18**] 05:45AM CK(CPK)-64 CK-MB-NotDone cTropnT-0.58*
[**2102-1-19**] 06:45AM CK(CPK)-55 CK-MB-NotDone cTropnT-0.52*
.
Lipid panel:
Cholest-80 Triglyc-46 HDL-30 CHOL/HD-2.7 LDLcalc-41
.
Iron studies:
Iron-39* calTIBC-244* Ferritn-214 TRF-188*
.
Discharge labs:
WBC 6.5, Hct 32.7, Platelet 390
PT 14.0, PTT 28.1, INR 1.2
Na 139, K 4.7, Cl 105, HCO3 24, BUN 30, Cr 1.3, Glucose 151
Ca 8.3, Mg 2.2, Phos 3.4
.
STUDIES:
.
[**1-15**] TTE: There is a moderate sized, circumferential pericardial
effusion. There is slightly right ventricular diastolic
invagination, consistent with impaired filling/ possible early
tamponade physiology.
Compared with the prior study (images reviewed) of [**2101-11-8**],
the pericardial effusion has slightly increased in size, and
there is slightly more pronounced diastolic collapse of the
right ventricle. The resting heart rate is faster.
.
[**1-15**] CXR: New moderate to large left pleural effusion. There is
likely compressive atelectasis. Consolidation in this region
cannot be excluded. Moderate-to-severe cardiomegaly, unchanged.
.
[**1-15**] CT Chest:
1. New large simple left pleural effusion. There is volume loss
within the left upper and lower lungs with compressive
atelectasis.
2. Increased size of pericardial effusion. Pericardial effusion
also appears simple.
.
[**1-18**] TTE: Following pericardiocentesis, there is a small
pericardial effusion. There are no echocardiographic signs of
tamponade. Following balloon pericardiotomy, the pericardial
effusion is now smaller. There is a minimal rim anteriorly
although there is still a small collection posteriorly.
.
[**1-18**] Cardiac cath (prelim):
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.11 m2
HEMOGLOBIN: 9.8 gms %
PRE-TAP POST-TAP
**PRESSURES
LEFT VENTRICLE {s/ed} 130/30
AORTA {s/d/m} 130/80/97
PERICARDIUM {m} 30 10
**CARDIAC OUTPUT
HEART RATE {beats/min} 94 94
RHYTHM SINUS SINUS
O2 CONS. IND {ml/min/m2} 125
**PTCA RESULTS
PERICARDOTOMY
PTCA COMMENTS:
Preprocedure transthoracic echocardiography revealed a moderate
sized, circumferential pericardial effusion with evidence of
tamponade. We planned to perform a pericardiocentesis
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 15 minutes.
Arterial time = 1 hour 15 minutes.
Fluoro time = 12.7 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 150
ml, Indications - Renal
Premedications:
Midazolam 1 mg IV
Fentanyl 150 mcg IV
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 0 units IV
Other medication:
Vancomycin 1 mg iv
Cardiac Cath Supplies Used:
20MM B. [**Doctor Last Name 14147**], TYSHAK II 5CM
- [**Company **], PERICARDIOSENTISIS SET
12MM EV3, ADMIRAL 40MM
14MM [**Company **], XXL VASCULAR 4CM
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
- [**Company **], RIGHT HEART KIT
4FR CORDIS, MULTIPACK
- [**Doctor Last Name **], PRIORITY PACK 20/30
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed single vessel obstructive coronary artery disease. The
LMCA was normal. The LAD had a patent prior stent proximally,
and 40% stenosis just distal to the stent. The LCX was occluded
in the AV groove, which filled distally by right to left
collaterals. The RCA had serial 50% stenoses.
2. Limited resting hemodynamics demonstrated a pulsus of 25m Hg
on the systemic arterial waveform. Pericardiocentesis was
performed with needle entry from the subxiphoid position. The
opening pericardial pressure was 30 mm Hg. 812 cc of
serosanguinous fluid was removed, with subsequent reduction of
pericardial pressures to 10mm Hg.
FINAL DIAGNOSIS:
1. Single vessel obstructive coronary artery disease with
occluded AV groove LCX.
2. Pericardial effusion s/p percardiocentesis of 812cc of
serosanguinous fluid.
3. Succesful balloon pericardiotomy and placement of pericardial
drain.
.
[**1-18**] TTE:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is a moderate sized
pericardial effusion although there is <1 cm diastolic clearance
anterior to the right ventricle in subcostal views. There is
borderline right ventricular diastolic collapse in some views,
consistent with impaired fillling/early tamponade physiology.
Compared with the prior study (images reviewed) of [**2102-1-15**],
findings are similar.
.
[**1-19**] TTE:
Right ventricular chamber size is normal with mild global free
wall hypokinesis. There is abnormal septal motion, consistent
with but not diagnostic of pericardial constriction. There is a
small circumferential, echodense pericardial effusion. The
pericardium may be thickened.
IMPRESSION: Minimal pericardial fluid reaccumulation with
indirect evidence of effusive-constrictive physiology.
Compared with the prior study (images reviewed) of [**2102-1-18**],
amount of pericardial fluid has slightly increased. RV systolic
function appears borderline on both studies.
Brief Hospital Course:
Mr. [**Known lastname 14146**] is a 73 yo M with history of CAD s/p PCI, sick sinus
syndrome s/p PPM here with L sided chest pain x 2 days.
.
# CAD/NSTEMI: He ruled in for NSTEMI on [**1-16**]. Coronary
angiography on [**1-18**] revealed a patent LAD stent but an occluded
circumflex, which was not intervened on due to desire to avoid
need for further anticoagulation in the setting of recent
drainage of hemorrhagic effusion. Following drainage of the
pericardial effusion, the patient underwent cardiac
catheterization on [**1-23**] in which a left circumflex lesion was
ballooned with resulting slow distal flow, but no stent was
placed. He was chest pain free and without dyspnea after
catheterization and was maintained on ASA, Plavix, Metoprolol,
and a high dose statin throughout his stay. He is scheduled for
close Cardiology follow up.
.
# PERICARDIAL EFFUSION: Patient with known pericardial effusion
s/p 2 prior pericardiocenteses, most recent in [**4-7**]. Cytology
is negative x2 for malignant cells. An echocardiogram on
admission demonstrated an EF>60% with interval enlargement of
the effusion with more pronounced diastolic collapse of the
right ventricle but no overt tamponade and no alternans on EKG.
Pulsus <10. He underwent balloon assisted pericardial drain
placement on [**1-18**] that drained ~800cc of serosanguinous fluid.
Interval TTE demonstrated resolution of the effusion after
placement and cytology was negative for malignant cells.
Pericardial drain was maintained per protocol and pulled on
[**1-19**]. Repeat TTE on [**1-19**] showed showed minimal pericardial fluid
reaccumulation. To further evaluate the etiology of the
effusion, his pacemaker was evaluated to r/o wire-induced
microperforation in the ventricle, but the pacemaker
interogation showed the pacer is working well. Rheumatologic
studies to r/o collagen vascular disease were also sent that
demonstrated an elevated ESR and CRP (of limited use given known
pericardial inflammation) and a negative [**Doctor First Name **]. Given all the
negative workup mentioned above, and his symptom onset after XRT
for small cell lung cancer, this pericarditis is most likely
related to over-radiation. He had some chest discomfort, worse
with inspiration, following drainage of the effusion that was
owed to pericardial inflammation and treated with Indomethacin &
Colchicine. TTE on [**1-21**] showed a thickened pericardium with a
small pericardial effusion and interval improvement in the
effusion compared to prior echocardiograms.
.
# RHYTHM: Patient with a history of atrial fibrillation, not on
Coumadin secondary to a SDH in [**2097**]. He was monitored on
telemetry with several episodes of atrial fibrillation with RVR
in the CCU that were improved with IV Metoprolol. EP evaluated
his pacemaker and found episodes of AF, but no other arrythmia.
His pacemaker settings were changed as an inpatient to prevent
over-pacing of the ventricle when the patient is in AF.
Otherwise, he remained well rate-controlled on PO Metoprolol and
Diltiazem as an inpatient.
.
# PLEURAL EFFUSION: Patient w/ history of SCLC s/p chemotherapy
and radiation in [**2094**], currently in remission. He was admitted
with a left-sided pleural effusion noted on CXR and enlarged
simple effusion seen on CT. He has h/o loculated L pleural
effusion noted on chest CT [**9-7**]. In the CCU, the patient
underwent thoracentesis removing nearly 2L of fluid from his
left pleural space. Cultures and labs were sent revealing a
transudative process. Final cultures were negative. Cytology
showed no malignant cells.
.
# PUMP: Patient with EF >60% from admission TTE. While he
demonstrated a significant pleural effusion on the left, he did
not have e/o of right-sided congestion or other e/o fluid
overload by clinical exam. Patient had signs of early diastolic
invagination but no tamponade physiology and no hemodynamic
disruption on preprocedure echocardiograms. Repeat TTE on [**1-19**]
showed minimal pericardial fluid reaccumulation with indirect
evidence of effusive-constrictive physiology. He was continued
on a beta-blocker and his home Diltiazem.
.
# DM: Patient's home oral regimen was held and he was treate
with an insulin sliding scale during this hospitalization.
.
# ANEMIA: Patient with known anemia from thallesmia minor. Iron
studies demonstrated a microcytic anemia and simultaneous anemia
of chronic disease, but with increased RDW concerning for iron
deficiency in addition to thallesmia. Patient was advised to
pursue colonoscopy as an outpatient.
.
# HYPERTENSION: Patient continued on beta-blocker and home dose
Diltiazem. Because of orthostatic hypotension, Imdur and
lisinopril were held. He was discharged home with Toprol 25mg
daily and Dilt ER 120mg daily. Imdur and lisinopril were
discontinued.
.
# HYPERTHYROIDISM: TSH elevated to 21 but normal total T4. After
consultation with his endocrinologist during this
hospitalization, his Methimazole was decreased from 5mg to 2.5mg
daily.
.
# CODE: Patient remained DNR/DNI throughout this hospitalization
with temporary reversal for procedures.
Medications on Admission:
MEDICATIONS AT HOME:
1) Lisinopril 5 mg daily
2) Clopidogrel 75 mg daily
3) Methimazole 10 mg [**Hospital1 **]
4) Diltiazem HCl 120 mg Sustained Release daily
5) Isosorbide Mononitrate 30 mg daily
6) Polyethylene Glycol 3350 17 gram/dose daily
7) Glipizide 10 mg daily
8) Metformin 500 mg [**Hospital1 **]
9) Calcium Citrate-Vitamin D3 315-200 mg-unit Tablet daily
MEDICATIONS ON TRANSFER:
1) Insulin SS
2) Acetaminophen 650 mg PO/NG Q6H:PRN
3) Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4) Aspirin 325 mg PO/NG DAILY
5) Lisinopril 5 mg PO/NG DAILY
6) Atorvastatin 80 mg PO/NG DAILY
7) Metoprolol Tartrate 25 mg PO/NG Q 8H
8) Methimazole 2.5 mg PO/NG DAILY
9) Bisacodyl 10 mg PO DAILY
10) Polyethylene Glycol 17 g PO/NG DAILY
11) Calcium Carbonate 500 mg PO/NG DAILY
12) Senna 1 TAB PO/NG [**Hospital1 **]
13) Clopidogrel 75 mg PO/NG DAILY
14) Diltiazem Extended-Release 120 mg PO DAILY
15) Vitamin D 400 UNIT PO/NG DAILY Order date: [**1-18**] @ 1835
16) Docusate Sodium 100 mg PO BID Order date: [**1-18**] @ 1835
Discharge Medications:
1. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
3. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Methimazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may take for chest pain every 5 mintues up to 3 tablets, if you
still have chest pain, call 911.
Disp:*25 Tablet, Sublingual(s)* Refills:*0*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO three
times a day.
Disp:*90 Capsule(s)* Refills:*2*
14. DILT-CD 120 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Pericardial effusion
Pleural effusion
Coronary artery disease
Secondary:
GERD
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital for chest pain, and your
cardiac enzymes were slightly elevated indicating a recent heart
attack. You had some fluid accumulation around your heart and
lungs. The fluid around your heart was drained and should not
reaccumulate. You are on indomethecin and colchicine to treat
the pain of irritation from the tubes and drain. You missed a
scheduled CAT scan today, please talk to Dr. [**Last Name (STitle) 3274**] about
rescheduling this before your appt next week. Your chest x-ray
showed that the pleural effusions were better today. You also
had a cardiac catheterization and a blockage in your coronary
artery was opened using a balloon. You are on aspirin and Plavix
to keep this blockage open.
.
Medication changes:
1. stop taking Atenolol, start long acting Metoprolol instead
2. Start aspirin 325 mg daily to prevent another heart attack
3. Increase Atorvastatin (Lipitor) to 80 mg daily. This will
lower your cholesterol and prevent further blockages in your
heart arteries.
4. Start Colchicine and Indomethecin to treat the chest pain
from the fluid collection around your heart.
5. Keep nitroglycerin at home to take for chest pain that is
different from the soreness in your chest. You can take up to 3
pills only for pain. Sit down when you take the nitroglycerin
and call 911 if you still have chest pain after 3 tablets.
6. Stop taking Imdur and Lisinopril
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] S. Phone: [**Telephone/Fax (1) 14148**] Date/time: Please keep any
scheduled appts.
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 14149**] Date/Time: Friday [**1-27**] at 2:00pm.
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2102-1-24**] 11:45
Oncology:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2102-1-31**] 1:00
Electrophysiology:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2102-5-24**]
10:00
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|
3150, 3299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
984
| 152,912
|
7881
|
Discharge summary
|
report
|
Admission Date: [**2143-1-29**] Discharge Date: [**2143-2-19**]
Date of Birth: [**2074-4-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Edema, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 68 yo M with a h/o hemochromatosis and DM2 recently
admitted to this hospital with a MSSA bacteremia, PNA, ARF with
creat 3.4, hyperK 6.0 and lactic acidosis with AG of 25. Pt had
fallen and was taking large amounts of Motrin prior to that
admission. On that admission, EKG showed right heart strain and
possible lateral ischemic changes. Pulmonary embolism was
considered; V/Q scan was read as low probability. He was
admitted to the MICU for hypotension and a PNA and then sent to
the floor, finished course Oxacillin for bacteremia while in
house. Other issues during that hospitalization included:
-CTA [**1-16**] showed an enlarged left-sided pleural effusion (fluid
density) and a R-sided pleural effusion that was determined to
be solid on thorocentesis (Path result is pending)
-HIV, [**Doctor First Name **] and RF were sent and found to be negative; scleroderma
ab neg
-[**1-8**] TTE was obtained and showed a dilated RV with severe
global free wall hypokinesis and abnormal septal movement;
moderate-severe pulmonary artery systolic hypertension
consistent with a primary pulmonary process. LVEF was >55%.
-Seen on CTA [**2143-1-16**]:
1. 3mm pulmonary nodule in the right middle lobe.
2. hypodense oval lesion approx 8mm at the liver dome.
Recommend follow-up CT in 1 year.
.
Pt returned to [**Location **] [**2143-1-29**] with c/o increased fatigue and marked
increase in peripheral edema. On home O2 since discharge home.
States compliant with meds. Denies CP/worsened SOB/abd
pain/HA/F/C. Admits cough with small amt white sputum
occasionally.
.
CCU Course: Pt was started on Viagra for Primary Pulmonary HTN,
and aggressively diuresed with Lasix gtt and diuril for several
days with net [**Location 10226**]7.4L with symptomatic improvement in SOB on
5LNC, also started on anticoagulation with Lovenox for several
days however switched to Hep gtt and will transition to
coumadin. Thoracentesis on [**2-7**] removed ~800 cc serosanguinous
fluid which was negative for malignant cells. He was also
started on steroids for COPD. His O2 Sats were stable on 5LNC.
On [**2-12**] pt's sats stable while working with physical therapy. Pt
also noted to go in and out of AF/Flutter, was started on
Digoxin, dosed by levels. His CRI was followed closely and Cr
stable at 1.9 in setting of aggressive diuresis. Pt was also
started on Dilt for better HR control in setting of AF/Flutter.
Pt was called out of MICU to floor in stable condition.
Past Medical History:
PMH:
* Hemochromatosis with monthly phlebotomy; dx 15 yrs ago
* Cardiac involvement from hemochromatosis
* DM
* hx of colon polyps
* gallstones (asx)
* Hypothyroidism
* ARF in setting of NSAID use 13 years ago, requiring 5 months
of HD.
Social History:
Widowed, occ alcohol, no cigarettes, usually very active, plays
golf, no TOB use, can do all ADLs
Family History:
Parents died in their 50s, unknown cause, no fam hx of CAD, DM,
hemochromotosis, malignancy, hypercoaguable state
Physical Exam:
Gen: Elderly male, NAD, full sentences
VS: 97.6 98 152/80 16 89 RA 95% 5L NC
HEENT: PERRL, EOMI, nl sclera, MMM
Neck: Supple, no JVD
Cor: s1s2 RRR
Lungs: Decreased BS bilat, scattered exp wheeze, ? crackles at L
base
Abd: Soft, NT/ND; eccymoses (fading) from previous heparin subQ
injections
Ext: 3+ pitting edema to knees bilat, +sacral edema
Neuro: A&Ox3, CN intact, strength 5/5 prox & distal, no pronator
drift, no asterixis
Skin: bronze color
.
.
Pertinent Results:
[**2143-1-29**] 05:41PM GLUCOSE-327* UREA N-23* CREAT-1.3*
SODIUM-131* POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-27 ANION GAP-13
[**2143-1-29**] 05:41PM WBC-7.5 RBC-3.79* HGB-11.0* HCT-33.9* MCV-89
MCH-29.1 MCHC-32.5 RDW-18.7*
[**2143-1-29**] 05:41PM NEUTS-79* BANDS-1 LYMPHS-7* MONOS-9 EOS-3
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2143-1-29**] 05:41PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ TARGET-1+ BURR-2+
[**2143-1-29**] 05:41PM PT-13.6* PTT-30.6 INR(PT)-1.2*
[**2143-1-29**] 05:41PM PLT SMR-LOW PLT COUNT-80*
.
CXR [**2142-1-29**]: CHEST, PA AND LATERAL: Comparison is made to
[**2143-1-17**]. The lung volumes are low. The PICC line has
been removed. Allowing for low lung volumes, the cardiac and
mediastinal contours are unchanged. There is a persistent right
lower lobe opacity, probably some atelectasis in addition to
effusion. There is also a left-sided effusion with parenchymal
opacity obscuring the medial hemidiaphragm, which may represent
atelectasis. Right apical thickening is unchanged since a prior
study from [**2138**]. IMPRESSION: Moderate bibasilar effusions and
opacities, which are likely to represent atelectasis. Underlying
pneumonia cannot be excluded however.
.
CXR [**2143-1-30**]: PRELIMINARY READ
PA and lateral chest. There are bilateral moderate-sized pleural
effusions with possible partial posterior loculation. The
cardiac silhouette is enlarged. I doubt the presence of vascular
congestion although appearances suggest possible underlying
chronic lung disease with stranding in the right lung. Since
exam one day previous the equivocal interstitial edema appears
improved or resolved. The effusions are associated with
bibasilar subsegmental atelectasis. IMPRESSION: Short interval
probable improvement/resolution of CHF. No change in effusions.
.
[**2143-2-1**] R-Sided Cardiac Cath:
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.95 m2
HEMOGLOBIN: 11 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 13/13/11
RIGHT VENTRICLE {s/ed} 82/21
PULMONARY ARTERY {s/d/m} 82/43/63
PULMONARY WEDGE {a/v/m} 13/13/11
**CARDIAC OUTPUT
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 56
CARD. OP/IND FICK {l/mn/m2} 4.4/2.2
**RESISTANCES
PULMONARY VASC. RESISTANCE 946
**% SATURATION DATA (NL)
SVC LOW 57
PA MAIN 54
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 21
.
COMMENTS: 1. Vasodilator challenge in this patient with
pulmonary
hypertension revealed baseline severe pulmonary hypertension
with
pressures of 82/43. The RA pressure was slightly elevated at
mean of
14mmHG with a relatively normal left sided filling pressure with
PCWP of
11mmHG. The cardiac index was preserved at 2.2.
2. With 100% oxygen and then nitric oxide there was no decrease
in
pulmonary pressures. With oxygen PA was measured at 83/38 mean
57 and
PCWP of 13mmHG. With nitric oxygen pressure was 91/39 wit mean
of 60.
The cardiac index did improve on oxygen to 2.7 and on nitric
oxide to
3.2
FINAL DIAGNOSIS:
1. Severe pulmonary hypertension with normal left sided filling
pressures, not responsive to vasodilators.
.
[**2143-2-4**] ECHO Bubble Study:
Conclusions:
No definite right-to-left passage of microbubbles identified at
rest or with maneuvers (cough, post-Valsalva). The right
ventricle is dilated with prominent free wall hypokinesis.
.
[**2143-2-4**] CXR:
INDICATION: CHF versus developing pneumonia.
A right subclavian vascular catheter remains in place,
terminating at the junction of the superior vena cava and right
atrium. The cardiac silhouette is enlarged but stable. There is
upper zone vascular redistribution and perihilar haziness, not
significantly changed. There is partial atelectasis of the right
lower lobe with inferomedial displacement of the right major
fissure. An area of increased opacity is noted within the left
retrocardiac region, with interval improvement since the recent
study. This is probably due to a combination of effusion and
atelectasis.
.
[**2143-2-6**] CHEST CT:
Bilateral pleural effusion, moderate and low density on the
left, and small with high density contents and perimeter
enhancement is unchanged in both hemithoraces. Bibasilar
consolidation is more pronounced in comparison to the previous
studies and may represent pneumonia or secondary atelectasis.
Prominence of the interlobular septa as well as some engorgement
of the pulmonary vasculature represent congestive heart failure.
Imaged part of the upper abdomen demonstrate several gallstones
in othewise normal gallbladder, calcified liver granuloma and
nodularity of the liver margin (the patient has a known history
of cirrhosis ). The spleen, adrenals, kidneys and pancreas are
unremarkable except for left renal cortical atrophy.
No suspicious lytic or blastic lesions within the bones were
shown. Prominent gynecomastia is due to cirrhosis.
IMPRESSION: 1) Increased, moderate left pleural effusion.
Smaller high density right pleural fluid collection is
unchanged.
2) Increased bibasilar pulmonary consolidations, which may
represent secondary atelectasis or pneumonia.
3) Mild congestive heart failure. Prominent coronary artery
calcifications and cardiomegaly are unchanged.
4) Gallstones without evidence of acute cholecystitis.
.
[**2143-2-7**] Thoracentesis fluid:
NEGATIVE FOR MALIGNANT CELLS.
-Mesothelial cells and lymphocytes.
.
[**2143-2-8**] ECHO TTE:
Conclusions:
There is moderate symmetric left ventricular hypertrophy. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
markedly dilated. Right ventricular systolic function appears
depressed. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. The mitral valve leaflets are mildly thickened. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
No vegetations seen (but cannot definitively exclude).
.
[**2143-2-16**] Portable KUB:
IMPRESSION: Nonspecific bowel gas pattern. If clinically
indicated, CT scan may be useful to further characterize this
finding. This was discussed with Dr. [**First Name (STitle) 4223**] at approximately
3:30 a.m., [**2143-2-16**].
.
[**2143-2-17**] ABD U/S w/Doppler:
IMPRESSION:
.
1. No evidence of perihepatic ascites.
2. Stable appearance of hepatofugal portal venous flow.
3. Limited examination secondary to cirrhotic heterogeneously
echogenic liver. Although no focal liver lesions are identified,
given the technical difficulties of this ultrasound
surveillance, CT or MRI surveillance for lesions could be
performed for future examinations.
.
[**2143-2-17**] CXR:
FINDINGS: There has been interval removal of the left IJ line.
NG tube is in the stomach. There is hazy bilateral increased
vasculature and increased bilateral pleural effusion suggesting
CHF.
IMPRESSION: Worsening CHF.
.
[**2143-2-17**] ECG:
Sinus rhythm with first degree A-V block. Since the previous
tracing
of [**2143-2-10**] the rhythm has reverted from atrial fibrillation to
no significant change and the rate has slowed. Diffuse
non-specific ST-T wave abnormalities persist.
.
LABS:
-last set
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2143-2-18**] 10:11AM 13.1* 2.64* 7.6* 22.6* 86 28.7 33.5 19.1*
147
.
PT PTT Plt Smr Plt Ct INR(PT)
[**2143-2-18**] 10:11AM 147*
[**2143-2-18**] 10:00AM 18.7*1 33.6 1.8*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2143-2-18**] 04:16AM 68* 87* 2.4* 141 3.4 97 34* 13
---
COAGS:
Fibrino D-Dimer
[**2143-2-17**] 08:19AM 159
[**2143-2-17**] 01:58AM 176#
[**2143-2-6**] 03:49AM [**Telephone/Fax (1) 28368**]*
[**2143-2-5**] 05:45AM 293
[**2143-2-4**] 09:50AM 332
.
HEMOLYTIC W/U:
Ret Aut
[**2143-2-16**] 03:19AM 6.5*
[**2143-2-14**] 06:17AM 6.7*
[**2143-2-6**] 04:35PM 3.5
.
HIT AB TEST=NEG:
HEPARIN DEPENDENT ANTIBODIES
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES negative
COMMENT: NEGATIVE FOR HEPARIN PF4 ANTIBODY BY [**Doctor First Name **]
Complete report on file in the laboratory.
.
.
calTIBC VitB12 Folate Hapto Ferritn TRF
[**2143-2-17**] 08:19AM <20*
[**2143-2-16**] 03:19AM <20*
[**2143-2-13**] 03:49AM 169* 1695* GREATER TH1 69 130*
ADDED CHEM [**2143-2-13**] 11:50AM
1 GREATER THAN 20 NG/ML
[**2143-2-5**] 05:45AM 39
[**2143-2-4**] 09:50AM <20
.
--
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
[**2143-2-18**] 04:16AM 27 37 402* 103 125* 1.1
ADDED OSMO [**2143-2-18**] 8:24AM
[**2143-2-17**] 08:19AM 26 39 441* 103 1.3 0.9* 0.4
[**2143-2-16**] 03:19AM 401* 1.2
[**2143-2-11**] 05:27AM 17 28 80 0.7
Source: Line-mlc
[**2143-2-6**] 03:49AM 21 38 346* 92 0.9
[**2143-2-5**] 05:45AM 353*
[**2143-2-4**] 09:50AM 466* 0.7 0.3 0.4
[**2143-1-30**] 05:44AM 21 36 429* 122* 0.8
.
HBsAg HBsAb HBcAb
[**2143-2-1**] 06:55PM NEGATIVE NEGATIVE NEGATIVE
IMMUNOLOGY dsDNA
[**2143-2-1**] 06:55PM NEGATIVE
PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
[**2143-2-1**] 06:55PM NO SPECIFI1 1054 557* 166 NO MONOCLO2
.
HCV Ab
[**2143-2-1**] 06:55PM NEGATIVE
.
.
C3 C4
[**2143-2-1**] 06:55PM 83* 17
.
---
MICRO:
Brief Hospital Course:
The patient was admitted to the Medical ICU in critical
condition in setting of severe pulmonary HTN. His course was
complicated by hemolytic anemia, GIB, in setting of
anticoagulation for his pulmonary HTN. Also c/b hepatic
encephalopathy. Per family and HCP-daughter [**Name (NI) 3608**] [**Name (NI) 28369**], pt
was made [**Name (NI) 3225**] on [**2-18**] and expired on [**2-19**]. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] provided
support to family towards the end of his complicated course of
illness.
.
.
Medications on Admission:
Spironolactone 25mg daily
Furosemide 20mg daily
Synthroid 0.1mg daily
Folic Acid 1mg daily
Diltiazem 30mg daily
Mirtazapine 15mg at bedtime
Aspirin 81mg daily
Combivent 103-18 mcg/Actuation Aerosol 1 puff QID
Oxygen 2-3L via nasal cannula to keep O2 sat>94%
insulin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
-Hemochromatosis, ESLD
-pulmonary hypertension
-Expired
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2143-2-20**]
|
[
"570",
"041.11",
"416.8",
"790.7",
"583.81",
"572.3",
"535.01",
"244.9",
"275.0",
"584.9",
"427.31",
"428.0",
"V58.67",
"286.7",
"273.8",
"571.5",
"280.0",
"250.40",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"99.07",
"88.72",
"45.13",
"99.04",
"34.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14132, 14141
|
13238, 13786
|
329, 335
|
14240, 14250
|
3818, 6776
|
14303, 14468
|
3215, 3330
|
14103, 14109
|
14162, 14219
|
13812, 14080
|
6793, 13215
|
14274, 14280
|
3345, 3799
|
275, 291
|
363, 2823
|
2845, 3084
|
3100, 3199
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,490
| 139,300
|
5976
|
Discharge summary
|
report
|
Admission Date: [**2184-7-4**] Discharge Date: [**2184-7-11**]
Date of Birth: [**2126-8-4**] Sex: M
Service: NSU
ADMISSION DIAGNOSES: grade V subarachnoid hemorrhage.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 57 year-old man
who was found face down in his garden at home at
approximately 6:00 p.m. on [**2184-7-4**]. The patient works
as an electrician at the [**Hospital1 69**]
and had worked prior in the day and was last seen
approximately a half an hour before being found prone in his
garden. On EMT arrival the patient was found awake with his
eyes closed and he was not following commands. At this time
his pupils were 2 mm reactive bilaterally and he was moving
all extremities. Electrocardiogram revealed a rhythm of
atrial fibrillation at a rate of 140. In route to the
Emergency Department at approximately 6:15 p.m. the patient
exhibited 20 seconds of seizure activity. He began to
demonstrate decerebrate posturing and he was therefore
intubated for airway protection.
Per the Emergency Room physician the patient was started on
Propofol on arrival and had 2 mm reactive pupils and was seen
moving all extremities. He was transported expediently to
the CT scanner, which showed a large left temporal bleed with
blood extending to the cisterns and a left frontal
intraparenchymal contusion without any evidence of skull
fracture. He was also seen to demonstrate decerebrate posturing
on the left upper extremity and had only minimal inward rotation
on the right upper extremity without any movement in his lower
extremities. Significant admission laboratory values
revealed stable hematocrit and coagulation panel and based on
the CT findings, which were significant for a massive left
temporal lobe intraparenchymal hemorrhage with diffuse
subarachnoid hemorrhage and early demonstration of a shift
from left to right of his septum [**Last Name (LF) 23543**], [**First Name3 (LF) **] emergent
ventricular drain was placed by the neurosurgical resident in
the Emergency Room. The patient was then transported to the
neuro SICU for close monitoring.
PHYSICAL EXAMINATION ON ADMISSION: Temperature afebrile,
heart rate 80 with a rate of atrial fibrillation, pressure
189/110, ventilator 99 percent on 100 percent oxygen. The
patient was intubated and sedated. He was not following
commands. Left pupil was 5 mm nonreactive, right pupil was
3.5 mm minimally reactive, with minimal corneal reflexes on
the right and no corneal reflexes of his left eye. The left
upper extremity demonstrated decerebrate posturing, and the
right upper extremity demonstrated minimal inward rotation.
Bilateral lower extremities demonstrated no movement to
painful stimuli. Babinski was positive bilaterally. There
was no evidence of clonus. Reflexes were normal in the
bilateral biceps and bilateral patella.
HOSPITAL COURSE: On [**7-4**] after placement of ventricular
drain the patient was transported to the neuro CICU. CT of
the C spine was read as negative without any evidence of
fracture dislocation. He was transported for a CTA of the
head four hours after his first CT, which demonstrated
interval increase with mass effect and subthalassin
herniation. The drainage catheter was in good place. CTA
was significant for a 5 mm aneurysm at the bifurcation of the
left MCA. On [**7-5**] in the early morning the patient was
taken to angio by Dr. [**Last Name (STitle) 1132**], which was significant for a
ruptured pedunculated left middle cerebral artery, which was
then coiled. His postop check revealed stable disconjugate
gaze with his left pupil being down and out. At this time
both pupils were 2 mm trace reactive and he did have a
bilateral weak corneal reflex. The patient was localizing to
the bilateral upper extremities and had only slight withdraw
to his lower extremities. He was continued on Ancef for his
ventricular drain and goal pressures were under systolics of
130s with PCO2s of 35 to 40. His drain was kept at 15 cm and
he was continued on Mannitol, Nimodipine, and Dilantin.
On [**7-6**] the patient was found to have ICPs ranging from 12
to 16 and therefore his drain was decreased to 10 cm while
the Mannitol was continued. His examination had not changed
from the day before where he continued to localize his
bilateral upper extremities and had slow slight withdraw to
the bilateral lower extremities. Due to the patient's
continued high intracranial pressures in the high teens and
low 20s on Mannitol the decision was made by the
neurosurgical team to take the patient to the Operating Room
for a decompressive craniectomy. The procedure involved a
large left craniectomy with intraabdominal placement of bone
flap and it went well without any complications. For further
details please see the operative note dictated on this day.
He was transferred back to the neuro CICU at this time where
he was continued on Mannitol 25 q four hours and was started
on Lasix 10 mg for ICPs greater then 25 and CVPs greater then
10. On [**7-7**] the patient was found to have a fever to
101.2. He was pan cultured with results being negative and
he was maintained on his Mannitol and Lasix with frequent
serum osmol checks. His drain was dropped to 0 for his
intracranial pressures in the high teens and low 20s. He was
also transfused 2 units of red blood cells for a low
hematocrit. On [**7-8**] the patient continued to have fevers
to 101.1 and his examination on Propofol revealed only trace
movement of the bilateral upper extremities with very little
movement of the lower extremities. A CT of the head was done
and revealed stable ventricles and trans central herniation,
however, it also was significant for new infarct of the
occipital lobe in the left frontal parietal region. The
large subarachnoid hemorrhage and left temporal lobe
intraparenchymal hemorrhage appeared stable on this scan.
Cultures were resent including cerebral spinal fluid and came
back negative. The patient's examination did not change
during this time. He continued to be unresponsive and had
minimal movement to stimulation.
On [**7-9**] the patient went down for another CT scan
revealing no change in the trans central herniation and
stable progression of his new infarct in the occipital lobe
and left frontal parietal region. His surgical drain was
discontinued at this time. He was ruled out for an
myocardial infarction with cardiac enzymes times three and he
was transfused a unit of packed red blood cells for a low
hematocrit of 26.6. In addition, he was bolused to establish
a therapeutic Dilantin level. The patient continued to have
fevers overnight to 102.2 and on [**7-10**] an x-ray was
performed showing a right lower lobe opacity as well as some
fluid overload, therefore the patient was aggressively
diuresed and started on Levofloxacin in addition to the
Kefzol for his ventricular drain. Family meetings were held
with discussion with the neuro Intensive Care Unit team and
the neurosurgical team and discussion was held regarding the
patient's likely poor prognosis given his very limited
examination, large bleed with herniation of the brain and new
infarcts. On [**7-11**] the patient's extended family arrived
and a discussion was held with the SICU staff and the patient
where the decision was made to make the patient CMO on [**2184-7-12**] with subsequent organ donation at this time. The
organ bank was contact[**Name (NI) **].
DISCHARGE DIAGNOSES: Left middle cerebral aneurysm and
subarachnoid hemorrhage.
DISCHARGE STATUS: Expired.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 23544**]
MEDQUIST36
D: [**2184-7-12**] 10:55:03
T: [**2184-7-12**] 12:26:52
Job#: [**Job Number 23545**]
|
[
"430",
"518.5",
"780.6",
"427.31",
"285.9",
"434.91",
"331.4",
"344.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.24",
"96.72",
"39.72",
"86.09",
"99.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7466, 7819
|
2876, 7444
|
156, 190
|
219, 2134
|
2149, 2858
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,757
| 133,902
|
2538
|
Discharge summary
|
report
|
Admission Date: [**2179-4-21**] Discharge Date: [**2179-5-1**]
Service: MEDICINE
Allergies:
Diovan
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
severe abdominal pain and back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87F c/o of sever back and abdominal pain with sudden onset. Pt
related a similar occurence 3 months ago. She denied an
episodes of nausea/vomitting. Pt is known to have AAA. Pain
radiated from the mid abdomen to the back. PT denied SOB, leg
pain, buttock pain, other associated symptoms. Pt was found to
elevated BP in ED, admitted for hypertensive crisis [**2179-4-21**], was
started on Esmolol drip.
Past Medical History:
TAA 3.8 cm
AAA 4.0 cm
HTN
hypercholesterolemia
AS (valve area 1.0)
PVD with intermittent claudication
s/p arterectomy L PFA [**2-15**]
s/p R SFA angioplasty [**3-15**] ([**Doctor Last Name **])
s/p Wharthin gland excision
h/o R popliteal artery aneurysm
neurocystercircosis s/p VP shunt x14y for ?hydrocephalus
Social History:
Lives with husband and daughter. denies tobacco, etoh, other
drugs.
Family History:
noncontributory
Physical Exam:
Vitals: T 98.9 BP 150/80 HR 80 RR 16 O2 98% RA
Gen: NAD, pleasant
HEENT: PERRL
Cardio: irregular, [**3-16**] sys murmur @ RUSB
Resp: CTAB
Abd: soft, nt, nd, +BS. No rebound/guarding.
Ext: no c/c/e. Warm.
Pertinent Results:
[**4-27**] CT TORSO.
INDICATION: 87-year-old woman with known abdominal aneurysm,
presenting with abdominal and back pain, evaluate for change in
aneurysm and mesenteric ischemia.
CT OF THE CHEST, ABDOMEN AND PELVIS WITH AND WITHOUT IV
CONTRAST.
TECHNIQUE: Multidetector scanning is performed from the thoracic
inlet through the symphysis during dynamic injection of 100 cc
of Optiray. Non- contrast-enhanced images of the chest are
obtained. Comparison is made to prior examination of [**2179-4-23**].
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is mild
dilatation of the ascending aorta measuring up to 3.8 cm. This
is unchanged in comparison to a prior examination of the chest
of [**2178-5-9**]. There is no axillary, mediastinal or hilar
lymphadenopathy. No pleural effusions are noted. There are no
filling defects in the pulmonary arteries. There are small
calcified plaques in the pleura. There is a 4-mm nodule in the
right middle lobe. This is stable in appearance. A 3-mm
non-calcified nodule is seen in the left lower lobe. This was
not definitely identified on the prior examination, likely due
to the small size of the nodule. There is a calcified nodule in
the left lower lobe.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver is without focal
lesions. The gallbladder, spleen, pancreas and adrenal glands
are unremarkable. Subcentimeter hypodense lesions are seen in
the kidneys bilaterally and are stable. The aorta is stable in
size measuring 4.0 x 3.9 cm (previously 3.9 x 3.8 cm). There is
no retroperitoneal hematoma. No fat stranding is identified.
Contrast is identified in the celiac axis and its branches as
well as the SMA and its branches. The small bowel is normal,
demonstrating no wall thickening. There is no mesenteric fluid.
CT OF THE PELVIS WITH IV CONTRAST: A small amount of fluid is
seen in the pelvis. This measures 21 Hounsfield units and is
unchanged in amount to the prior studies. There is a Foley
catheter in the bladder as well as air. There are extensive
diverticula along the colon. No inflammatory changes are seen.
There is no pelvic lymphadenopathy.
On bone windows, there are degenerative changes in the lumbar
spine.
IMPRESSION:
1. No change in comparison to the prior study of [**2179-4-23**].
Abdominal aortic aneurysm unchanged in size. No evidence for
rupture. No evidence for mesenteric ischemia.
2. Diverticulosis without evidence for diverticulitis.
3. Bilateral renal lesions about that are too small to
characterize but stable and most consistent with cysts.
4. Calcified granuloma in the left lower lobe. Two additional
lung nodules, one of which measures 4 mm and is stable for over
one year. The second measures 3 mm, not identified on the prior
study likely due to the small size of the nodule
U/S [**2179-4-23**]:
RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is unremarkable
without evidence of stones or wall edema. The common bile duct
is not dilated. The liver is normal in echotexture without focal
lesions. Limited views of the pancreas are unremarkable.
IMPRESSION:
1. No cholelithiasis or cholecystitis.
.
LABS (admission):
.
[**2179-4-21**] 08:55PM GLUCOSE-156* UREA N-15 CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
[**2179-4-21**] 08:55PM CALCIUM-9.5 PHOSPHATE-4.8* MAGNESIUM-2.2
[**2179-4-21**] 08:55PM WBC-9.6 RBC-3.73* HGB-11.1* HCT-32.3* MCV-87
MCH-29.9 MCHC-34.5 RDW-14.2
[**2179-4-21**] 08:55PM PLT COUNT-181
[**2179-4-21**] 05:06PM GLUCOSE-93 UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
[**2179-4-21**] 05:06PM estGFR-Using this
[**2179-4-21**] 05:06PM CK(CPK)-229*
[**2179-4-21**] 05:06PM cTropnT-<0.01
[**2179-4-21**] 05:06PM CK-MB-5
[**2179-4-21**] 05:06PM PT-12.1 PTT-24.6 INR(PT)-1.0
[**2179-4-21**] 05:06PM SED RATE-10
Brief Hospital Course:
Pt was admitted [**4-21**] from ED for hypertensive crisis and w/u of
T/AAA. On Ct scans the AAA and TAA were found to be stable. A
finding of a [**Doctor Last Name 6261**] hernia was also made. Pt was ruled out
for mesenteric ischemia with serial CT scans, AAA and TAA
remained stable in size. Elevated amylase and lipase shifted
the focus to probable pancreatitis which was treated with IVF
and keeping the pt NPO. Her HCTZ was then held. Her diet was
advanced and she states that she was better.
Pt was in the unit on HD [**1-13**], and was then transferred to the
VICU for monitoring. In the unit she was on an esmolol drip and
nipride. Initially an endovascular repair approach was planned
for the 3.9 cm AAA, but there is very low risk for rupture, so a
decision was made to follow and monitor. Pt also experienced
unexplained ?tetany in left leg that repsonded to ativan.
Pancreatic enzymes were elevated on HD2 and continued to rise
but eventually trend toward normal. During this time period a
working dx of pancreatitis was made and the patient was made NPO
with IVF. Pt was transitioned back to food on [**4-27**]. The pts
hypertensive meds were adjusted as needed to allow good BP
control (eventually only on metoprolol). Her HCTZ was held
during the admission and on discharge due to pancreatitis.
On HD 10, the patient was transferred to the Cardiology service
for management. Pt tolerated regular diet, but amylase/lipase
remained mildly elevated. Her abdominal pain had resovled, and
she was discharged home.
Medications on Admission:
ASA 81', HCTZ 25', metoprolol 25", lescol 80', protonix 40',
cholestyramine
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lescol XL 80 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Preliminary diagnoses:
AAA
pancreatitis
hypertensive crisis
Secondary diagnoses:
HTN
PVD
Discharge Condition:
Stable. Tolerating PO. No abdominal pain.
Discharge Instructions:
Please seek medical attention immediately if you experience
chest pain, shortness of breath, abdominal pain, nausea,
vomiting, headache, blood in your stools, dizziness, or any
other concerning symptoms.
Please attend all follow-up appointments.
Please take all medications as prescribed. You should not take
hydrochlorothiazide until you have been seen by your PCP.
Followup Instructions:
Pleease follow-up with your PCP [**Last Name (NamePattern4) **] [**5-17**] days.
Please follow-up with Dr. [**First Name (STitle) **] within 7 days. His phone
number is [**Telephone/Fax (1) 920**]. Please call to make an appointment -
tell them that you may be seen by [**Last Name (NamePattern5) 7224**], NP.
You need to see Dr. [**Last Name (STitle) **] within the next 2 weeks; please call
her office at [**Telephone/Fax (1) 2395**] to make an appointment. Don't forget
to inform them that you also need to have a CT angiogram prior
to this appointment - they will help to set you up with this.
You also have the following appointments scheduled:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12898**], DPM Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2179-5-4**]
2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2179-8-14**] 9:00
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2179-10-14**]
2:00
Completed by:[**2179-5-2**]
|
[
"272.0",
"458.9",
"441.4",
"424.1",
"577.0",
"443.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7399, 7485
|
5232, 6772
|
249, 256
|
7619, 7663
|
1387, 5209
|
8080, 9199
|
1130, 1147
|
6899, 7376
|
7506, 7567
|
6798, 6876
|
7687, 8057
|
1162, 1368
|
7588, 7598
|
174, 211
|
284, 693
|
715, 1028
|
1044, 1114
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,013
| 184,013
|
17585
|
Discharge summary
|
report
|
Admission Date: [**2201-3-3**] Discharge Date: [**2201-3-6**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old
male with no known cardiac history who presents to [**Hospital1 1444**] for biopsy and
catheterization evaluation to evaluate cardiomyopathy of
unknown etiology, recent onset. The patient had an abnormal
electrocardiogram at primary care physician's office and left
bundle branch block and was denied life insurance.
He was referred to cardiologist Dr. [**Last Name (STitle) **] who did an
echocardiogram and found the patient to have cardiomyopathy
and an ejection fraction of approximately 20 to 25%. The
patient was without symptoms. No chest pain, syncope,
dyspnea. The patient had a Holter monitor without
ventricular tachycardia. He was admitted to the [**Hospital Unit Name 196**] Service
for elective catheterization and biopsy.
He had clean coronary arteries, but the biopsy procedure was
complicated by bleeding, cardiac tamponade, decreased blood
pressure and PEA arrest. He transiently required pressors;
total time without pulses approximately 2 to 5 minutes. A
pericardial drain was placed and his blood pressure
increased. He received 2 units of packed red blood cells and
20 of intravenous Lasix. He was intubated and transferred to
the Coronary Care Unit for further management.
Repeat echocardiogram initially in the Coronary Care Unit
showed a small collection of fluid. The patient had
presented with ventilator settings of AC570 by 12 and a
ventilation of 10.4, PEEP of 5, 60%. He was on a Propofol
drip.
PHYSICAL EXAMINATION: Heart rate 80, blood pressure 107/62,
SPO2 100% and afebrile. He was intubated and sedated and
anicteric. Pupils are equal, round, and reactive to light
and accommodation. JVD unable to assess given positive
pressure of ventilation. Regular rate and rhythm. S1 and
S2. Distant heart sounds. No distention. Abdomen was soft
with no clubbing, cyanosis or edema. 2 out of 2 dorsalis
pedis pulses. Babinski sign was negative. Sedated.
ALLERGIES: Erythromycin.
MEDICATIONS AS AN OUTPATIENT:
1. Coreg 3.25 b.i.d.
2. Aspirin 81 q.d.
3. Vitamin 400 units IU.
4. Multivitamins.
5. Ginseng q.d.
6. Calcium.
7. Zinc.
8. Vitamin C.
PAST MEDICAL HISTORY: He has no known prior coronary artery
disease. His cardiomyopathy was noted at the beginning of
[**2201-2-24**].
SOCIAL HISTORY: He works in real estate, he is a lawyer. [**Name (NI) **]
has a high pressure job. He has no history of hypertension,
hypercholesterolemia, cigarette use, diabetes.
FAMILY HISTORY: No family history of coronary artery
disease.
LABORATORIES ON PRESENTATION TO THE CORONARY CARE UNIT:
White blood cell count 4.8, hematocrit 34.7 and was 44 on
admission. Platelets 167. Sodium 135, potassium 3.7,
chloride 103, bicarb 28, anion gap 4, BUN 16, creatinine 1.1.
CK 123, MB index 6.5, MB 10. Magnesium 1.6, calcium 7.7,
phosphorus 1.8.
HOSPITAL COURSE: The patient is a 50 year-old male with new
onset unknown etiology cardiomyopathy who presents to [**Hospital1 1444**] for elective catheterization
and biopsy. Status post a catheterization a clean coronary
arteries, status post perforation secondary to biopsy
complicated by tamponade. Pulseless electrical activity
arrest status post tamponade drain, transient use of
pressors, status post 2 units of packed red blood cells,
status post intubation and had an echocardiogram in the
Coronary Care Unit with only a small amount of residual
fluid.
1. Cardiology: Hemodynamics, cardiac tamponade status post
pericardial drain. The patient was off pressors when he
arrived in the unit. He had repeat echocardiogram, two more
on the 8th and three on the 9th. The final one after the
pericardial drain was pulled on 9th showed trivial
physiological pericardial effusion. Serial hematocrits:
Final hematocrit was 32 at the day of discharge, stable
throughout his stay following initial traumatic tamponode.
Regarding his cardiomyopathy initially and remained
tachycardic during any motion. His heart rate would be in
the 70s to 80s at rest and when the patient ate or moved
around in bed his heart would shoot up to the 110s, 120s. He
was started on Coreg after he became hemodynamically stable.
The Coreg was titrated up from 3.25 which was his outpatient
dose, to 25 mg po b.i.d. p.o. For the patient's
cardiomyopathy he was started on a low dose of an ACE
inhibitor, initially started on Captopril. He was discharged
on 5 mg of Zestril.
2. Coronary artery disease: The patient had clean coronary
arteries. The patient had aspirin held given the recent
bleed.
3. Pulmonary: The patient was extubated overnight on the
8th and had no respiratory distress afterwards. He has no
history of lung disease.
4. Neurological: The patient was neurologically intact
following extubation. He had trouble recalling events around
the time of the code, but otherwise had no focality on
neurological examination. Alert and oriented times three.
Cranial nerves II through XII were intact. Normal gait.
Normal strength upper and lower extremities. Normal finger
to nose.
He did have injected conjunctivae prompting ophthalmology
consult. Impression was subconjunctival hemorrhage likely
secondary to the time of anticoagulation at the
catheterization with the code and some possible refractory
error in the left eye. The patient is to follow up with Dr.
[**Last Name (STitle) **] as an outpatient in ophthalmological clinic.
5. Prophylaxis: The patient received a PPI, Pneumoboots and
ambulation.
7. ID: The patient received three days of Cefazolin status
post a pericardial drain placement.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Cardiomyopathy.
2. Coronary tamponade.
3. Hemopericardium.
4. Pulseless electrical activity arrest.
RECOMMENDED FOLLOW UP:
1. Dr. [**Last Name (STitle) **] on [**2201-3-10**] 3:30 p.m.; the patient has an
appointment.
2. He is instructed to follow up with ophthalmologist in
approximately two to four weeks. The patient is to call for
this appointment.
SURGICAL PROCEDURES:
1. Cardiac catheterization.
2. Status post myocardial biopsy.
3. Status post pericardial drain placement.
4. Status post intubation.
MEDICATIONS AT DISCHARGE:
1. Carvedilol 25 mg po b.i.d.
2. Zestril 5 mg po q.d.
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern1) 1731**], M.D. [**MD Number(1) 1732**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2201-5-8**] 10:31
T: [**2201-5-13**] 14:00
JOB#: [**Job Number 49024**]
|
[
"423.9",
"425.4",
"E878.8",
"998.2",
"997.1",
"372.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"37.0",
"37.25",
"96.71",
"88.53",
"99.60",
"96.04",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
5724, 5731
|
2624, 2977
|
5752, 5872
|
2995, 5702
|
5883, 6288
|
1642, 2284
|
6302, 6639
|
149, 1619
|
2307, 2422
|
2439, 2607
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,181
| 159,632
|
7524
|
Discharge summary
|
report
|
Admission Date: [**2186-10-12**] Discharge Date: [**2186-10-21**]
Date of Birth: [**2114-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Nitroglycerin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Abnormal ETT
Major Surgical or Invasive Procedure:
CABG X 4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA on [**2186-10-12**]
History of Present Illness:
Pt with known CAD had + ETT, followed by cath which revealed
3vCAD. Then seen by CT surgery and scheduled for CABG. Pt same
day admit for CABG
Past Medical History:
1. Coronary artery disease s/p cardiac catheterization [**2180**]
without intervention
2. Hypertension
3. Hyperlipidemia
4. Congestive heart failure with EF 50% per OSH echocardiogram
[**7-23**]
5. Diabetes mellitus times 12 years with retinopathy and
neuropathy
6. Sleep apnea on CPAP
7. Hypercholesterolemia
8. Chronic renal insufficiency, baseline creatinine 1.4
9. Ventral hernia
10. Gout
Social History:
Owns a liquor store. Lives alone. Never smoked. [**1-20**] alcoholic
drinks per day.
Family History:
Mother with "heart trouble", unknown age of onset. Father
"healthy." Brother with diabetes.
Physical Exam:
ht 72 in wt 112kg
98 hr 55 bp 139/55 rr 18 sat 96%
Gen NAD
Pulm CTA
CV RRR
Abdm soft/NT/ND/NABS
Ext warm
Discharge
VS T 99.3 hr 73 bp 110/60 rr 18 sat 93%RA
Gen NAD
Pulm CTA-bilat
CV RRR, sternum stable incision CDI
Abdm soft NT/ND/NABS
Ext warm, left LE phlebitis(improved)
Pertinent Results:
[**2186-10-20**] 05:55AM BLOOD Hct-26.1*
[**2186-10-19**] 05:40AM BLOOD WBC-14.7* RBC-2.76* Hgb-8.5* Hct-25.4*
MCV-92 MCH-30.8 MCHC-33.6 RDW-15.1 Plt Ct-349
[**2186-10-15**] 01:16AM BLOOD PT-16.0* PTT-25.6 INR(PT)-1.5*
[**2186-10-19**] 05:40AM BLOOD Glucose-119* UreaN-20 Creat-1.0 Na-146*
K-4.0 Cl-109* HCO3-27 AnGap-14
CHEST (PA & LAT) [**2186-10-19**] 1:07 PM
Reason: eval post op, effusions, [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
72 year old man s.p Cabg
REASON FOR THIS EXAMINATION:
eval post op, effusions, atel
CLINICAL HISTORY: Status post CABG.
Cardiac size is somewhat enlarged and widening of the aorta is
present. Atelectasis of the left base is seen. Costophrenic
angles appear sharp.
There is no failure or evidence of pneumonia.
IMPRESSION: Atelectasis. Cardiomegaly.
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease. Shortness of breath.
Intraoperative TEE for CABG procedure.
Height: (in) 72
Weight (lb): 246
BSA (m2): 2.33 m2
BP (mm Hg): 148/54
HR (bpm): 64
Status: Inpatient
Date/Time: [**2186-10-12**] at 10:07
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *5.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: 0.44 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aorta - Arch: 2.4 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 2.1 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.50
Mitral Valve - E Wave Deceleration Time: 190 msec
TR Gradient (+ RA = PASP): >= 19 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
Patient's last name spelt as Brrry in the prebypass study .
Changed for Post
Bypass study
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Normal LV wall thickness. Normal regional LV
systolic function.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal
aortic arch diameter. Simple atheroma in aortic arch. Normal
descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR.
TRICUSPID VALVE: Physiologic 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. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
PRE-BYPASS:
1. The left atrium is normal in size. No atrial septal defect is
seen by 2D or
color Doppler. Left ventricular wall thickness, cavity size, and
systolic
function are normal (LVEF>55%). Left ventricular wall
thicknesses are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
2. Right ventricular chamber size and free wall motion are
normal.
3. There are simple atheroma in the aortic arch. There are
simple atheroma in
the descending thoracic aorta.
4.The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve
stenosis. Trace aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6.There is no pericardial effusion.
Post Bypass
1. The patient is being AV paced.
2. Biventricular systolic function is unchanged.
3. Mild Mitral regurgitation persists.
4. Aorta intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2186-10-13**]
19:41.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr [**Known lastname 3646**] is a same day admit for CABG. Pt had cardiac
catheterization [**10-6**] and was then referred for CABG. Pt seen
and evaluated at that time. now readmitted for CABG on [**10-12**],
please see operating room report for full details. In summary pt
had CABGx4 with LIMA-LAD,SVG-Diag,SVG-OM, SVG-PDA, her bypass
time was 86 minutes with crossclamp time of 77 min. Tolerated
operation well, transferred to CT ICU on Neo and Propofol in
Sinus rhythm with mean arterial pressure 102.
Pt did well in immediate post-op period, and was sucessfully
extubated the day of surgery. His pulmonary status remained
tenuous and he remained in the ICU for pulmonary toilet and
monitoring for several days. On POD3 the patients chest tubes
and temporary pacing wires were removed. The patient was noted
to have some confusion most pronounced at night, all narcotics
and benzo's were discontinued. By POD6 the confusion had
resolved and he was transferred to the floors for continued
post-op care and cardiac rehabilitation. Over the next several
days the patients activity level was advanced and on POD 9 the
patient was transferred to reabilitation at [**Hospital3 27503**]-[**Location (un) **]
Medications on Admission:
ASA 325', Allopurinol 300', Crestor 10', Lisinopril 5', Cardizem
CD 120', Toprol XL 50', Metolazone 5', Lasix 80',
Insulin-Glargine 54 QAM, Insulin-NPH 34 QPM, RISS
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
10. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
CAD
HTN
hypercholesterolemia
DM
Sleep apnea
Gout
Chronic renal insufficiency
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving for 1 month
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) 12982**] in [**1-20**] weeks
Dr. [**Last Name (STitle) **] in [**1-20**] weeks
with Dr. [**Last Name (STitle) **] in [**3-22**] weeks
Pt to call for all appointments
Completed by:[**2186-10-23**]
|
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"250.60",
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icd9cm
|
[
[
[]
]
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[
"39.61",
"36.15",
"36.13"
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icd9pcs
|
[
[
[]
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|
6063, 7268
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304, 372
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8813, 8820
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1494, 1908
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7483, 8598
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1945, 1970
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8713, 8792
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252, 266
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1999, 2295
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566, 961
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977, 1064
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,348
| 123,562
|
48091
|
Discharge summary
|
report
|
Admission Date: [**2164-9-5**] Discharge Date: [**2164-10-5**]
Date of Birth: [**2106-2-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
Central line placement
Arterial line placement
Intubation
tPA treatment for pulmonary embolus
History of Present Illness:
This is a 58 year old male with a history of polysubstance abuse
(ETOH, heroine, crack and cocaine) and hepatitis C who presents
for alcohol detoxification. Pt reports that he had been drinking
~2 pints of whiskey per day for the past 18 mo and that two days
ago he decided to "sober up" and hasn't had a drink since.
Yesterday morning started to feel "the shakes" and while walking
down the street his R leg suddenly started to shake
uncontrolably and he fell down. He does not recall the episode
very well but does recall that he never had LOC and denies loss
of bowel or bladder control during the episode. He has gone
through withdrawal in the past but denies ever having seizures
or DT's. Denies CP, palpitations, SOB, HA, diarrhea or abdominal
pain.
.
In the [**Hospital1 18**] ED, initial vs were: T 97.9 P88 BP150/100 R16 O2
sat 95%. In the ED he was noted to be intermittently agitated
and tremoulous. He was given 40mg valium. He was also noted to
be intermittently in atrial fibrillation with RVR to 170s and
was given diltiazem 20 mg IV x 1 then diltiazem 40 mg PO. He was
also given folate, thiamine, MVI and 2L NS. He had a head CT
that was negative for an acute process.
.
In the ICU he noted feeling shaky and requested that he be
detoxed during this hospitalization.
Past Medical History:
Polysubstance abuse (heroin, cocaine, ETOH). Detoxed following
admission to an inpatient facility about 3 years ago. Currently
in [**Hospital1 **] suboxone program.
Hepatitis C
Depression
Social History:
Lives in [**Location **] alone. Had been homeless earlier in the year.
Drinks 2 pints of Whiskey per day. Distant heroin/cocaine abuse.
Family History:
Father died of lung cancer in mid 70s, alcohol abuse,
hypertension. Mother died of lung cancer in mid 70s. Three
siblings; two brothers, one sister, all in good health.
Physical Exam:
On admission to ICU:
Vitals: T: 99.5 BP: 139/86 P: 105 R:28 O2: 94% pon 50% face tent
General: somnolent and minimally arousable, able to follow
simple commands and yes/no. Pt with + gag and poor cough.
tachypneic with shallow breathes
HEENT: Pupils 1mm but reactive to light, sclera anicteric, MMM
Neck: Supple, JVP not elevated, no LAD
Lungs: Rhonchi at the right base, no wheeze
CV: Irregularly irregular and tachy to 100's, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no ascites
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No spider angioma
Pertinent Results:
On admission [**2164-9-5**]:
[**2164-9-7**] 03:50AM BLOOD WBC-8.0 RBC-4.11* Hgb-14.5 Hct-41.2
MCV-100* MCH-35.3* MCHC-35.2* RDW-13.7 Plt Ct-119*
[**2164-9-8**] 04:15AM BLOOD WBC-7.4 RBC-4.19* Hgb-14.5 Hct-41.8
MCV-100* MCH-34.5* MCHC-34.6 RDW-13.7 Plt Ct-145*
[**2164-9-8**] 04:15AM BLOOD PT-13.8* PTT-24.3 INR(PT)-1.2*
[**2164-9-5**] 08:00PM BLOOD PT-14.3* PTT-23.1 INR(PT)-1.2*
[**2164-9-8**] 04:15AM BLOOD Glucose-102 UreaN-11 Creat-0.8 Na-133
K-5.0 Cl-101 HCO3-19* AnGap-18
[**2164-9-7**] 03:50AM BLOOD Glucose-95 UreaN-9 Creat-0.9 Na-135 K-4.0
Cl-99 HCO3-23 AnGap-17
[**2164-9-8**] 04:15AM BLOOD ALT-69* AST-144* LD(LDH)-818* AlkPhos-87
TotBili-2.8*
[**2164-9-7**] 03:50AM BLOOD ALT-79* AST-151* AlkPhos-88 TotBili-3.3*
[**2164-9-6**] 03:42AM BLOOD ALT-106* AST-230* LD(LDH)-899* AlkPhos-88
TotBili-2.5*
[**2164-9-8**] 04:15AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.9 Iron-86
[**2164-9-7**] 03:50AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0
[**2164-9-8**] 04:15AM BLOOD calTIBC-252* Ferritn-1079* TRF-194*
[**2164-9-5**] 08:00PM BLOOD TSH-1.2
[**2164-9-5**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-9-5**] 10:13PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2164-9-5**] 10:13PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG
[**2164-9-5**] 10:13PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
CTA chest ([**9-17**])
1. Extensive bilateral pulmonary emboli, extending to all lobar
arteries.
2. Peripheral tree-in-[**Male First Name (un) 239**] and ground-glass opacities, suggesting
possible
infection.
3. IVC reflux, hepatic vein reflux-findings indicate an element
of right heart failure.
.
Bilateral Lower Extremity Ultrasound ([**9-17**]): Bilateral
non-occlusive thrombus within the peroneal vein extending into
the distal popliteal veins.
.
Echocardiography TTE ([**9-17**])
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. 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 moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2164-9-6**],
left ventricular systolic function is improved and the right
ventricular cavity is now dilated and severely hypokinetic (c/w
pulmonary embolism). Moderate pulmonary artery systolic
hypertension is now present.
Echocardiography TTE ([**9-24**])
The left atrium is normal in size. The left ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is moderately dilated with severe
global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. There is a
small pericardial effusion. Echocardiographic signs of tamponade
may be absent in the presence of elevated right sided pressures.
There is significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
Compared with the prior study (images reviewed) of [**2164-9-17**], a
small pericardial effusion is now seen. This is located anterior
to the right ventricle. There is respiratory variation in the
mitral inflow, suggesting impaired LV filling. However, this
could be due to the dilated, hypokinetic RV. There is no
evidence of RA or RV collapse, however echo signs of tamponade
may be absent when the RA and RV pressures are elevated.
.
ECHO TTE [**2164-9-28**]: Compared with the findings of the [**2164-9-24**], the right ventricle is no longer dilated, and contractile
function is markedly improved. The pericardial effusion is
smaller.
.
MRI [**2164-10-3**]: 1. No finding to specifically suggest vertebral
osteomyelitis, discitis, or paraspinal or epidural abscess.
2. Thoracolumbar scoliosis with asymmetric degenerative changes,
as described above. These findings are most marked at the L3-4
and L4-L5 levels, where there is subarticular zone stenosis,
bilaterally, without definite neural impingement.
3. Diffusely and relatively uniformly hypointense signal in
vertebral bone
marrow, without focal abnormality (other than discogenic
endplate changes). This appearance may reflect red marrow
re-conversion in response to underlying anemia, or even diffuse
osteopenia, but an infiltrative process cannot be completely
excluded - clinical correlation recommended.
Brief Hospital Course:
# Alcohol detoxification/Benzodiazepime Intoxication: Patient
has a long history of ETOH abuse. On admission he was in clear
withdrawal w/ tachycardia (HR up to 160s), hypertension (up to
150s/110s), tremolousness, diaphoresis and aggitation. He was
requiering high doses of benzos everyday and frequent CIWA
monitoring (up to Q30min). On [**9-8**] he was transitioned to
strictly PO Valium. On [**9-9**] he had received >500mg of Valium (IV
+ PO) and signs of withdrawal had started to decrease. His HR
was under much better control (HR 87-104), BP ranging from
106/87-144/109, his tremolousness and other signs of withdrawal
had decreased dramatically. His CIWA interval was increased to
Q4H. He never had any signs of seizure activity or of DT's. The
patient received over 400 mg of Valium in the ICU for EtOH
withdrawal; he then developed benzodiazepime intoxication,
with somnulance, lethargy, slurred speech. Addictions and
social work were consulted. His mental status slowly improved
however on [**2164-9-14**] he had an aspiration event, respiratory
distress and his mental status declined again. On [**9-15**] he was
transferred back to the ICU due to inability to manage his
secretions and somnulance.
.
In the ICU pt was initially easily arousable without the need
for much flumazenil. Urine and serum toxiciology continued to
show positive benzos though pt has not had any benzos since [**9-10**].
Patient continued to have thick secretions, developed
respiratory distress, and found to have an absent gag reflex,
and so was intubated on [**9-17**]. Benzos were avoided for means of
sedation while intubated. Patient subsequently received
tracheostomy.
.
# Aspiration PNA: The patient had an aspiration event on
[**2164-9-11**]; head CT at that time also showed sinusitis. He
developed a 2L O2 requirement. He was afebrile and had no
leukocytosis, however, due to cough and nasal secretions was
started on Unasyn for aspiration PNA and sinusitis. His mental
status improved and following swallow eval he was started on a
ground/thickened diet. On [**2164-9-14**] the patient then developed
respiratory distress and was thought to have suffered another
aspiration event. He spiked to 102 and his mental status
deteriorated again. He had copious secretions requiring
frequent suctioning. His antibiotics were broadened to Zosyn.
On [**9-15**] the patient was noted to have increasing thick secretions
requiring high level nursing care and therefore he was
transferred back to the ICU.
.
In the ICU, patient continued to have very thick secretions that
could not be cleared by suctioning. He was found to be in
respiratory distress, which was later found to be due to
bilateral pulmonary embolus, and without a gag reflex, so was
intubated on [**9-17**]. Pt completed course of empiric antibiotics
for aspiration pneumonia.
.
# Fever/Endocarditis - Patient was found to be febrile during
second ICU admission. Patient was found to have coag negative
staph growing from A-line catheter tip and central line cultures
as well as Klebsiella, MRSA and GNRs (most likely diptheria)
growing from sputum for which he is currently being treated with
vancomycin and ceftriaxone. Pt c/o back pain and MRI spine was
negative for osteomyelitis. Echocardiography performed on [**10-4**]
showed tricuspid vegetations. Patient had PICC line placed and
will be treated with 6 weeks of IV vancomycin, started on [**9-26**],
to be completed on [**2164-11-7**].
.
# Respiratory Failure/Pulmonary Emboli: patient was found to be
severely tachypneic and without a gag reflex on [**9-17**] for which
he was intubated. CTA showed bilateral PEs. LENIs showed
bilateral DVTs. Because of the extent of the clots, patient was
given tPa and then subsequently put on heparin drip. During tPa
treatment, patient developed bleeding from the left middle
turbinate area due to trauma from previous suctioning. ENT
packed the site of bleed without any other intervention. While
on heparin, patient continued to have slow oozing from the
oropharynx and exhibited some hematuria (likely trauma from
foley placement, UA was negative for red cell casts which would
suggest renal emboli) which progressively resolved. Hematocrit
was stable despite the bleeding. Pt remains on heparin drip
currently, being bridged to coumadin. Nasal bleeding has
resolved.
.
Patient had received a bronchoscopy shortly after intubation
which showed normal airways with the exception of thick mucus in
the mainstem bronchus.
.
Attempts to wean patient off ventilator was challenging.
Patient did well on AC and was changed to CPAP/PS. He showed
signs of distress on CPAP/PS and was tachypneic to the 40s-50s
regardless of PEEP setting, likely because of diaphragmatic
weakness. Patient will be maintained on AC with intermittent
trials of CPAP/PS to strengthen diaphragm. Patient underwent
tracheostomy on [**2164-9-28**] in anticipation of a more prolonged
course on the ventilator. Patient is currently doing well on
trach mask and speaking valve. Speech and swallow has cleared
patient to take food and drink by mouth so PEG tube placement
was deferred.
.
# Atrial fibrillation: Patient was found to have new onset
atrial fibrillation of uncertain duration on admission. This
was thought to be secondary to his EtOH abuse but less likely
etiologies including hyperthyroidism, hypertension and PE were
also pursued. He was started on diltiazem PO given his history
of cocaine abuse. His TSH was within the normal range. He also
required metoprolol for rate control. He was started on aspirin.
Anticoagulation was contraindicated given low CHADS2 score and
active polysubstance abuse/lack of regular medical follow up. He
will require outpatient follow up.
.
In the ICU patient was continued on PO diltizam 90mg 4x/day and
metoprolol 12.5mg TID with good rate control. ASA was held for
bleeding. Metoprolol was subsequently discontinued as patient
was well controlled on the PO diltiazem alone. Patient was
anticoagulated with heparin drip and is currently being bridged
to coumadin.
.
# Cardiomyopathy: Patient was found to have new cardiomyopathy
seen on Echo with EF 40-45%. This was thought to be most likely
due to a combination of prolonged tachyarrhythmia (A-fib) and
EtOH use; however, the differential also includes HIV, virus,
hemochromatosis or idiopathic. HIV testing was deferred during
the active withdrawal phase and should be re-addressed when
patient is felt to be able to consent for the test. Iron
studies were not consistent w/ hemochromatosis. He was started
on an ACE-I. He will require outpatient follow up for further
workup.
.
After discovery of bilateral PE on CTA, echocardiography showed
that patient had RV hypokinesis and wall strain likely due to
bilateral PEs. Repeat Echo was performed [**2164-9-28**] which
demonstrated improved RV function.
.
# Alcoholic Hepatitis: Patient had elevated LFT's on admission
which were thought to related to ETOH abuse/hepatitis and
confounded by Hep C. No stigmata of chronic liver disease were
seen on physical examination. His discriminant function was 6
so there was no indication to start steroids. RUQ U/S showed
fatty infiltration of the liver and biliary sludging.
Cholecystitis was not suspected as he had no signs or symptoms
consistent with it. LFT's trended down steadily over his
hospitalization.
.
# Anion gap: Pt had an AG of 16 on admission. It was suspected
that this was likely related to alcoholic ketoacidosis. He
denied any other ingestions. His Osm gap was calculated to be 3
and his gap closed on HD2.
.
# C. diff - patient was found to have loose stools. Stool tests
showed that he was positive for C.diff and was started on oral
vancomycin. PO vancomycin will be continued until [**2164-10-18**].
Medications on Admission:
Omeprazole 20
Flomax 0.4
Suboxone
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day/Year **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**7-16**]
Puffs Inhalation Q4H (every 4 hours) as needed for when on vent.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (3) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Senna 8.8 mg/5 mL Syrup [**Month/Day (3) **]: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (3) **]: One Hundred (100) mg
PO BID (2 times a day).
9. Acetaminophen 325 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for Fever, pain.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day) as needed for Agitation.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
13. Diltiazem HCl 90 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day): please hold for SBP<100 or HR<60.
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: 1000
(1000) mg Intravenous Q 12H (Every 12 Hours) for 6 weeks: please
complete 6 week course. started [**9-26**], to be completed on [**11-7**].
15. Morphine 2 mg/mL Syringe [**Month/Year (2) **]: 2-4 mg Injection every six (6)
hours as needed for pain.
16. Diazepam 5 mg/mL Syringe [**Month/Year (2) **]: Five (5) mg Injection [**Hospital1 **] (2
times a day) as needed for agitation.
17. Heparin Drip
As per hospital heparin drip flowsheet. Please discontinue
heparin drip when patient is therapeutic on coumadin (INR goal
of [**3-13**])
18. Vancomycin 250 mg Capsule [**Date Range **]: One (1) Capsule PO Q6H (every
6 hours) for 14 days: last dose [**2164-10-18**].
19. Warfarin 5 mg Tablet [**Month/Day/Year **]: Five (5) mg PO Once Daily at 4 PM:
please titrate based on INR, goal INR of [**3-13**].
20. Outpatient Lab Work
Please check PT, PTT, INR everyday and titrate coumadin dosage
for goal INR of [**3-13**]. Once therapeutic on coumadin, labs can be
checked on a weekly basis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
Pulmonary Emboli, bilateral
Deep vein thrombosis, bilateral
Alcohol withdrawal
Benzodiazepine intoxication
Atrial fibrillation with rapid ventricular rate
Secondary Diagnosis:
Hepatitis C
Depression
Discharge Condition:
Good, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
management of alcohol withdrawal. During your admission you
developed pulmonary emboli and were intubated. In anticipation
of a more prolonged course on the ventilator you received a
tracheostomy. Echocardiogram of your heart showed evidence of
bacterial infection of your heart valves, for which you will
require a longer course of antibiotics. You were also found to
have clostridium difficile colitis for which you will need to
take oral vancomycin for 14 days. You were also started on
coumadin for anticoagulation because of your pulmonary emboli
and deep vein thrombosis.
If you experience chest pain, shortness of breath, or any other
worrisome symptoms, please return to the emergency room.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 4 weeks
Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2164-10-29**] 2:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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|
1967, 2105
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76,134
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10985
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Discharge summary
|
report
|
Admission Date: [**2202-1-8**] Discharge Date: [**2202-2-1**]
Date of Birth: [**2163-9-18**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Orencia / Remicade
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
L leg pain and erythema
Major Surgical or Invasive Procedure:
IR guided fluid drainage
Incision and drainage
Muscle biopsy
History of Present Illness:
Mr. [**Known lastname 17385**] is a 38 y.o. male with a history of psoriatic
arthritis on immunosuppresive therapy, HTN, HL, DM, cervicogenic
headaches who was recently discharged on [**1-8**] for left leg pain.
Pt reprots that he presented to the ED on [**2202-1-3**] for L heel pain
radiating to knees. He was initially treated with vanc and cipro
for question of septic left knee; the aspirate showed [**Numeric Identifier **] WBC
and 94% PMN but neg gram stain and culture and no crystals so
abx discontinued. LENI was negative for DVT or [**Hospital Ward Name **] cyst. No
fx on x-ray. This was thought to be a psoriatic arthritis flare,
so his prednisone was increased from his home dose of 30mg to
60mg daily with improvement in his inflammation. His pain
subsequently reutrned and repeat LENI was negative. Pt was
started on gabapentin for presumed fibromyalgia and discharged
yesterday on a stable pain regimen of MS contin with prn
dilaudid. He saw Rheum today who referred him to Derm for
evaluation of a superficial erythematous plaque, questioned
erythema nodosum. Derm did not think this was consistent but was
concerned about compartment syndrome so referred pt to ED.
.
In the ER, vitals were: T 98.2, P 79, BP 145/77, RR 17, O2sat
98. LENI neg for DVT but pt was noted to have an extensive left
posterior calf subcutaneous complex fluid collection. Ortho did
not see evidence of compartment syndrome and recommended
vascular c/s to rule out necrotizing fasciitis given the fluid
collection. Vascular did not think this was consistent with
necrotizing fasciitis. An MRI of the LE was done per Rads recs,
and this showed small fluid collections concerning for abscess
in his gastrocnemius that were too small to be drained with no
evidence of osteomyelitis. He was given vancomycin, zosyn, and
clindaycin. He also received his home meds of gabapentin, MS
contin, and po dilaudid. He was admitted to medicine with VS on
transfer: T 98.5, P 76, BP 136/68, RR 15, O2sat 98RA.
.
On evaluation on the floor, patient complains of persistent LE
pain and tenderness which is controlled on his pain regimen. His
LLE knee effusion has improved markedly since his recent
admission. He denies any fevers, chills, or night sweats.
.
ROS: Mild constipation d/t pain meds. Review of systems
otherwise negative.
.
Past Medical History:
-Psoriatic arthritis: Dx in early [**2198**] when pt presented with a
few lesions of psoriasis and symmetric polyarticular swelling of
MCPs, PIPs, MTPs, and dactylitis. Has failed trials of enbrel
and methotrexate due to lack of response. Failed Arava due to
Arava-induced polyneuropathy. Failed remicade and orencia due to
infusion reactions. Imuran was re-initiated in [**2201-2-25**].
Started Simponi in [**2201-8-27**].
-Morbid obesity
-OSA on CPAP
-IBD vs IBS: never diagnosed as UC or Crohns
-HTN: prednisone-induced
-DM2: prednisone-induced, followed by the [**Last Name (un) **]
-Hyperlipidemia
-Peripheral neuropathy
-NAFLD, felt to be secondary to methotrexate
-Cervicogenic migraine/dystonic muscle spasm/occipital
neuralgia:
Followed by pain clinic. s/p intermittent trigger point
injections, greater occipital and auriculotemporal nerve blocks
combined with Botox chemodenervation therapy
-Keratoconus s/p bilateral corneal transplant: 1st in 95, 2nd in
99
-s/p 4 anal fistulotomies
-s/p tonsillectomy x2 and adenoidectomy
-DJD s/p L4/L5 diskectomy
-Patello-femoral syndrome s/p arthroscopic surgery for both
knees
x 3 each
.
Social History:
Patient has never smoked. Admits to 1 beer per month. Admits to
1 x use of LSD in college. Patient is married with 4 children.
Only recent travel to [**Location (un) 6408**]and [**Last Name (un) 3625**] World. Has only
ever been sexually active with wife.
Family History:
Mother has [**Name2 (NI) **], HTN, hypercholesterolemia and bipolar disorder.
Father has non-smoking induced COPD and hypertension. Brother
has dermatologic psoriasis and UC. Sister with HTN and
hypercholesterolemia. Paternal Aunt with Crohn's and
sarcoidosis.
Physical Exam:
Vitals: T 98.5, BP 135/87, P 78, RR 17, O2sat 99RA, Height 6'1",
Weight 153 kg
General: Well-appearing, pleasant, obese man in NAD
HEENT: NCAT, oropharynx clear
Neck: Supple, no LAD
Pulm: CTA b/l
CV: RRR, S1-S nl
Abd: BS+, soft, obese, NT, ND
Extrem: Left knee perhaps mildly larger than right; erythema,
warmth, and tenderness over medial left calf, excoriations over
anteriolateral left calf. Pitting edema b/l. DP/PT pulses 2+
b/l.
Neuro: AAOx3, strength 5/5 in LE.
Pertinent Results:
rtPCR RNA study NEG
URINE culture NGTD
Wound culture NGTD
Blood culture NGTD after [**1-8**]
[**1-8**] BLOOD CULTURE GRAM POSITIVE COCCUS(COCCI) IN CLUSTERS -
pan-sensitive
[**2202-1-9**] JOINT FLUID: Stain NEG; BACT/FUNGAL/ACID FAST CULTURE
NEG
[**2202-1-8**] LYME SEROLOGY NEG
[**2202-1-11**] HBsAg: NEG HBs-Ab: NEG HAV-Ab: NEG HCV-Ab: NEG
[**2202-1-11**] ABSCESS Fluid - Fungal/GS NEG
.
Imaging:
[**2202-1-20**] US: No significant change in size of fluid collection
in the left popliteal fossa extending into the left posterior
calf, which contains small foci of gas.
.
[**2202-1-16**] US: 1. No evidence of left lower extremity DVT between
the left popliteal and common femoral veins. 2. Left popliteal
fossa collection extending into the calf, again seen.
.
[**2202-1-12**] CT of LLE - 1. Redemonstration of two loculated fluid
collections in the left calf. Slightly increased inferior extent
of the collection along the anteromedial edge of the medial head
of the gastrocnemius muscle. Otherwise no significant change. 2.
Subcutaneous edema along the anterior left leg, in keeping with
cellulitis, unchanged. 3. Small loculates of air within the
lower collection is attributed to recent aspiration procedure.
No other evidence of soft tissue emphysema identified.
.
[**2202-1-12**] TTE - The right atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. No mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No obvious
echocardiographic evidence of endocarditis. Mild symmetric left
ventricular hypertrophy with preserved global LV systolic
function. Mild pulmonary hypertension.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
[**2202-1-22**]
MRI calf
1. Persisted popliteus muscle collection and collection at the
anteromedial aspect of the medial head of the gastrocnemius
muscle.
2. Post-surgical findings following incision and drainage is a
new collection posterior to the medial head of the gastrocnemius
muscle, contiguous with the medial open skin defect and contains
low signal intensity foci, which may be due to air or possibly
packing.
3. Muscle edema in the medial head of the gastrocnemius muscle
and vastus
medialis obliquus muscle, likely postoperative.
4. A small knee joint effusion and mild synovitis without
definite findings of septic arthritis. As previously noted, the
popliteus tendon sheath can communicate with the knee joint.
Cartilage thinning and subchondral cysts along patella may be
degenerative. Clinical correlation is requested.
.
[**2202-1-12**] Radiology UNILAT LOWER EXT VEINS -1. Large complex
fluid collection tracking from the left popliteal fossa along
the medial left calf to the proximal mid calf region. Since it
is difficult to fully assess the extent and geography of this
collection on ultrasound, an MRI is suggested for further
characterization. 2. Smaller fluid collection at the left
anterior knee measuring 3.5 cm. 3. No evidence of deep vein
thrombosis in the left leg.
.
[**1-8**] LENIS: No left lower extremity DVT. Extensive left
posterior calf subcutaneous complex fluid collection.
.
[**1-8**] MRI calf: 1. Two loculated fluid collections concerning
for abcess collections, one in the substance of the popliteus
muscle, and the other along the anteromedial edge of the medial
gastrocnemius muscle.
2. Subcutaneous edema likely represents cellulitis in this
setting.
3. No evidence of osteomyelitis.
4. Limited assessment of knee joint -- please see comment (No
obvious direct communication between these collections and the
knee joint effusion is identified, but the popliteus abscess
does extend along the popliteus tendon, which can communicate
with the knee in some patients. Full assessment of the
relationship between the knee joint and popliteus is limited on
these views.)
Labs on admission:
[**2202-1-8**] 01:35PM GLUCOSE-152* UREA N-28* CREAT-1.2 SODIUM-136
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17
[**2202-1-8**] 01:35PM WBC-13.7* RBC-4.37* HGB-12.2* HCT-37.4*
MCV-86 MCH-27.9 MCHC-32.5 RDW-13.4
[**2202-1-8**] 01:35PM NEUTS-87.6* LYMPHS-8.4* MONOS-3.8 EOS-0.1
BASOS-0.1
[**2202-1-8**] 01:35PM PLT COUNT-354
[**2202-1-8**] 01:35PM PT-14.3* PTT-21.7* INR(PT)-1.2*
Brief Hospital Course:
38 years old male with psoriatic arthritis on immunosuppression,
DM, HTN, HL p/w LLE erythema, swelling and pain, found to have
gastrocnemius abscesses and overlying cellulitis.
.
# Acute renal failure: Patient noted to have acutely elevated
creatinine after I&D by surgery. All urine lytes testing
indicated pre-renal etiology. Resolved after fluid challenge. He
again had acute renal failure on [**2202-1-27**] in the setting of having
received increased doses of pain medications and resultant
hypoperfusion. His peak creatinine was 3.0, and resolved to his
baseline of 0.8-0.9 by the time of discharge.
.
# Left calf fluid collection with overlying cellulitis: No DVT
or [**Hospital Ward Name 4675**] cyst on multiple imaging studies. No compartment
syndrome per Orthopedic evaluation. No osteomyelitis on MRI and
not consistent with necrotizing fascitis per Vascular surgery.
It was noted on imaging that he had gastroceminis fluid
collection and overlying cellulitis. No signs of septic joint
from evaluation of knee aspiration. He had one positive blood
culture with pan-sensitive staph. He was placed on zosyn, later
narrowed to nafcillin. All other microbiology data were
negative. IR and vascular surgery helped drained the fluid
collection. Leg incision is to heal via secondary intention.
He developed a body rash that was determined to be folliculitis.
He completed the 2 week course IV antibiotics in house. His
major issue remained to be pain management. He required a large
amount of narcotics to control his pain, but after overdose (see
below) he was switched to a very conservative regimen. It was
determined that the swelling/fluid collection is from psoriatic
arthritis versus idiopathic spondylarthropathy. He was
discharged in stable condition. Muscle biospy showed necrotic
muscle with granulation tissue.
.
# Medication overdose: On [**2202-1-26**], on recommendation from the
pain service, patient's MS Contin dose was increased to 160 mg
TID from 130 mg TID, in addition to being ordered for PRN
Dilaudid. Later that night, Pt fell while ambulating. He had a
CT scan which was negative for acute intracranial pathologu.
Morning after the fall, Pt was noted to be somnolent and
hypotensive. He was given Naloxone 0.4 mg X3 and would arouse
briefly after each dose. He continued to be hypotensive after a
bolus of 1L of NS. He was transferred to the MICU for further
monitoring. In the MICU he was monitored closely and his
hypotension and mental status gradually improved. He was called
out back to the floor on [**2202-1-28**]. He never required intubation.
After being called out, he was normotensive and alert and
oriented X 3. It was believed his hypotension and altered mental
status were caused by medication overdose in the setting of
acute kidney injury. He was discharged on oxycodone 5mg Q4
hours, which he did well on for the 3 days prior to his
discharge. He will follow up with the pain clinic as an
outpatient.
.
# Psoriatic arthritis: On Golimumab every month, azathioprine,
prednisone. Rheumatology was consulted and suggested to decrease
prednison level to 20mg from 30 mg. He continued on PCP [**Name9 (PRE) **]
with Bactrim. Indomethacin was held due to renal failure but
restarted on discharge. He will continue to follow with
rhematology as an outpatient.
.
# DM: Continued on Lantus 8u qAM, 10u qPM with sliding scale
dictated by patient based on carbohydrate counting. [**Last Name (un) **] was
consulted and followed.
.
# HTN: Continued on HCTZ 25mg, lisinopril 40mg, metoprolol
succinate 100mg [**Hospital1 **]. Held HCTZ and lisinopril due to
ARF/hypotension and was restarted afterwards.
.
# Anemia: Patient found to be iron deficient and started on
supplementation. Patient informed he will need oupatient
evaluation to determine cause of this by his PCP. (PCP informed
by letter).
# HL: Continued pravastatin
.
# OSA: Continued CPAP qhs
.
# GERD: Continued Donnatal prn
.
Code: FULL
Comm: With pt. HCP is wife [**Name (NI) 5321**] [**Name (NI) 17385**] ([**Telephone/Fax (1) 35617**] H,
[**Telephone/Fax (1) 35618**] C)
Medications on Admission:
Prednisone 60mg PO daily
Golimumab (Simponi) 50mg SQ monthly
Azathioprine 150mg PO qAM, 100mg PO qPM
Indomethacin 50mg PO TID
MS contin 60mg [**Hospital1 **]
Gabapentin 300mg tid
Dilaudid 4-8mg q8h prn pain
Donnatal 16.2mg 1-2 tabs PO QID prn for dyspepsia
Alendronate 35mg PO qSunday
Calcium 500mg daily
Vitamin D2 50,000 unit capsule PO 3x per week (T/Th/F)
Bactrim DS 1 tab 3x per week (M/W/F)
Clobetasol 0.05% to scalp [**Hospital1 **] on weekends
Levemir 8u qAM, 10u qPM
Aspart based on carb counting
ASA 81mg PO daily
HCTZ 25mg PO daily
Lisinopril 40mg PO daily
Metoprolol succinate 100mg PO BID
Pravastatin 80mg PO daily
Montelukast 4mg PO daily
Discharge Medications:
1. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
2. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
3. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Golimumab 50 mg/0.5 mL Pen Injector Sig: Fifty (50) mg
Subcutaneous once a month.
6. Phenobarb-Hyoscy-Atropine-Scop 16.2-0.1037 -0.0194 mg Tablet
Sig: 1-2 Tablets PO every six (6) hours as needed for heartburn.
7. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QSUN (every
Sunday).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. INSULIN
Please resume as you were taking before hospitalization:
Levemir 8u qAM, 10u qPM
Aspart based on carb counting
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QTUTHFRI ().
14. Clobetasol 0.05 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): on weekends.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain: Never drink alcohol, drive, or operate
heavy machinery with this medicine.
Disp:*30 Tablet(s)* Refills:*0*
16. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Montelukast 4 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
18. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours: Do not exceed 4 grams in 24 hours.
20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for loose stools.
Disp:*60 Capsule(s)* Refills:*0*
22. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itchiness: Can apply to back
of calf or other regions of itchy skin. Avoid open wound -
please cover wound before application. .
Disp:*1 tube* Refills:*0*
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
Disp:*60 Tablet(s)* Refills:*0*
24. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
25. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*0*
26. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Idiopathic spondylarthropathy
Cellulitis
Hypotension in the setting of narcotic overdose
Psoriatic arthritis
Acute renal failure
GERD
OSA
DM
HTN
HL
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].
You were admitted because your left knee was swollen, red and
painful and you also had a pain on your left leg and foot. The
rheumatology team evaluated and took fluid from your knee. You
were initially treated with antibiotic for possible infection
and pain medications. The fluid was cultured for infection but
this was negative. You did have a blood culture that was
positive and we provided you with a two week course of
antibiotics. We also had interventional radiology and vascular
surgery to help drain the fluids from your leg. This helped
your swelling. You required a lot of pain medications to
control the pain, and at one point went to the ICU because your
system did not clear the medicines adequately. You are now on a
much more conservative pain regimen. You will follow up with
pain doctors as [**Name5 (PTitle) **] outpatient. We determined that the fluid
collection is not due to infection, and more likely a
rheumatological problem. [**Name (NI) **] will follow up with the
rheumatologists as an outpatient.
Please note we made the following changes to your medications.
1. Decrease prednisone from 60mg to 20mg
2. Stop MSContin
3. Stop gabapentin
4. Stop dilaudid
5. Start oxycodone every four hours for pain control. Never
drink alcohol, drive, or operate heavy machinery with this
medication.
6. Start iron supplementation
7. Start Sarna lotion and mupirocin cream for your rash and
follow up with your PCP for resolution
8. Start tylenol 1 gram every six hours as needed for pain. Do
not exceed 4 grams in one day.
9. Start omeprazole daily to protect your stomach lining while
you are taking prednisone and indomethacin (which can cause
irritation)
10. Start colace and senna to ensure you have having bowel
movements while on oxycodone and iron supplementation. Don't
take these medicines when you are having loose stools.
Follow up with your PCP and Dr. [**Last Name (STitle) **] for the results from your
muscle biopsy, which are still pending.
A visiting nurse will be coming to your home to help with your
wound vac. Follow up with Dr. [**Last Name (STitle) **] (vascular) as listed
below.
Followup Instructions:
You have the following appointments in place.
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2202-2-1**]
8:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2202-2-11**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2202-3-29**] 9:40
Department: INFECTIOUS DISEASE
When: TUESDAY [**2202-2-2**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -Primary Care
Address: [**Location (un) 35619**], [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**Telephone/Fax (1) 35614**]
Appt: [**2-8**] at 2pm
Department: PAIN MANAGEMENT CENTER
When: WEDNESDAY [**2202-2-17**] at 10:20 AM
With: [**Name6 (MD) 8673**] [**Last Name (NamePattern4) 8674**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
You have been placed on an urgent patient cancellation list and
they will call you if there is an earlier appointment as well.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,403
| 140,747
|
24873
|
Discharge summary
|
report
|
Admission Date: [**2198-10-29**] Discharge Date: [**2198-12-5**]
Date of Birth: [**2146-2-9**] Sex: M
Service: SURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
acute pancreatitis
Major Surgical or Invasive Procedure:
Central Venous Line placement
Arterial-line placement
Percutaeous tracheostomy
Endotracheal intubation
bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 52 year old male, PMH significant for ETOH abuse,
who originally presented to an OSH with severe abdominal pain --
workup revealed severe pancreatitis. His hospital course was
notable for significant fluid resuscitation precipitating
respiratory failure, which lead to intubation. He was
transferred to [**Hospital1 18**] for further care.
Past Medical History:
ETOH abuse
HTN
hypercholesterolemia
plantar fasciitis
gastric ulcer c/b upper GI bleed s/p EGD and cautery
Social History:
ETOH abuse: 3 beers/day, 12packs/weekend
married
works at [**Company 378**]
quit smoking 12 years ago
Physical Exam:
PHYSICAL EXAM ON DISCHARGE
Genl: NAD, alert + oriented x3
HEENT: no scleral icterus, EOMI, PERRLA,
Neck: tracheostomy in place
CV: RRR, no mrg
Resp: coarse bs bilaterally, decreased breath sounds on the left
Abd: obese, soft, nontender, nondistended
Extr: no c/c/e
Skin: no rashes
Pertinent Results:
MICROBIOLOGY SUMMARY:
[**11-26**] MRSA=P, Cdiff=neg, BCx=P, UCx=P,
[**11-25**] SputCx=GNR,
[**11-20**] Cdiff=neg,
[**11-19**] MRSA/VRE=neg, BAL=Pseudomonas, Enterobacter ([**Last Name (un) 36**]-gent,
imip, [**Last Name (un) 2830**]), [**11-18**] SpCx=GNR/Pseudomonas, IV Tip Cx>15 colonies
coag neg Staph;
[**11-17**] BCx=neg, UCx=neg;
[**11-15**] Cdiff=neg,
[**11-14**] BCx=neg,
[**11-12**] RIJ Tip=mult col (klebs, pseudo, entero), VRE=neg,
[**11-6**] UCx=neg, BCx=neg;
[**11-5**] BCx=neg, SpCx=Pseudomonas [**Last Name (un) 36**] to Cipro/Zosyn, UCx=neg,
MRSA/VRE=neg, [**11-4**] BAL=2+PMN/Pseudomonas,
[**11-3**] BCx=neg, SpCx=4+GPC staph coag +, Tip Cx=Staph coag neg,
[**11-1**] BCx=staph coag neg, SputCx=4+GNR/2+GPC, UCx=neg,
[**10-31**] SputCx=pseudomonas [**Last Name (un) 36**] to Zosyn,
[**10-30**] BCx=1 bottle coag neg staph,
[**10-29**] UCx=neg, BCx=coag neg staph.
RADIOLOGY SUMMARY:
[**11-26**] CXR=no sig change,
[**11-24**] CXR=mod L-pleur effus, CHF unchanged,
[**11-23**] IR placed Dobhoff;
[**11-19**] CT abd/pelvis w/peripanc colln's, inflamm, pleural eff,
[**11-18**] CXRx2=atelectasis & L-sided pleur effus no change, no PTX;
[**11-15**] CXR=increase in L pleur effus, stable vasc congestion;
[**11-12**] CXR=incr LLL opacity->poss effus, no infiltrate, congested
pulm vasc, no PTX;
[**11-9**] CXR=R-atelectasis;
[**11-6**] CXR=stable R basilar opacity;
[**11-5**] CXR=consolid/eff of RLL; [**11-5**] RUQ U/S=sludge, no portal
vein thrombosis, [**11-5**] BLE doppler neg,
[**11-4**] CXR=R pleural eff, atelect;
[**11-3**] CXR=unchgd,
[**11-2**] CXR w/patchy RLL opacity,
[**11-1**] CTA no PE, bilat pleural effusions and atelectasis/collapse
of adjacent lower lobes. mutifocal opacities of right lung
-?pneum. severe pancreatitis-?necrosis of tail and head.
[**10-31**] CXR w/patchy atelectasis, mod bilat effusions,
[**10-30**] CXR w/mild pulm edema,
[**10-28**] CXR bilat lower lobe effusions(mod size) w/recent increase
and bilat lower lobe infiltrate,
[**10-27**] CT Abd acute pancreatitis w/lack of enhancement in neck and
body of pancreas compared to head and tail.
Brief Hospital Course:
1. Neuro: Mr. [**Known lastname **] was periodically agitated, requiring
significant amounts of sedation. By the time of discharge, Mr.
[**Known lastname 62569**] agitation status was much improved.
2. Cardiovascular: Mr. [**Known lastname **] remained relatively hemodynamically
stable. He did have intermittent bouts of atrial
fibrillation/flutter that required a Diltiazem drip. He was
successfully transition to PO Diltiazem and Lopressor, and near
the time of discharge, Lisinopril.
3. Respiratory: Initially, there was a question of ARDS vs.
pneumonia, and had a PEEP requirement as high as 22. On [**11-4**] and
[**11-5**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a bronchoscopy and BAL, with sputum
cultures growing Pseudomonas. His pneumonia was covered by
Ciprofloxacin and Zosyn (for pseudomonal double-coverage). He
was slow to wean from his vent, however, soon only had PEEP and
PS requirements of 5 and 5. On [**11-21**] he [**Month/Year (2) 1834**] a bedside
tracheostomy, which he tolerated well. Soon thereafter, Mr.
[**Known lastname **] was able to tolerate a trach collar.
4. GI: He came to [**Hospital1 18**] on TPN until [**11-9**]. On [**11-5**] a DHT was
placed and tube feeds were gradually advanced to goal. On [**11-29**]
he [**Month/Year (2) 1834**] a video swallow evaluation in which he had some
initial aspiration. Speech and swallow recommendations were for
thin liquids and ground solids, which he tolerated well. On
[**12-1**], he [**Month/Year (2) 1834**] a repeat CT scan that showed that only the
head of the uncinate process of the pancreas was viable, but
otherwise improved. Speech and nutrition recommend that the
patient have re-evaluation with a video swallow to determine if
he can tolerate regular texture.
5. GU: He was placed on a Lasix drip to help achieve diuresis.
By [**11-26**] his Lasix requirement was down to Lasix 20 mg PO BID
and he was euvolemic. The diuresis was stopped on [**12-1**].
6. ID: Mr. [**Known lastname **] was placed on Imipenem for empiric coverage of
necrotizing pancreatitis, which was stopped on [**10-31**]. Mr. [**Known lastname **]
had a high-grade MRSA bacteremia from CVL sepsis, with last
positive blood cultures on [**9-23**]. He suffered from
Pseudomonas VAP, with a [**11-4**] BAL/sputum grew pseudomonas and
MRSA, respectively. He was treated with Vanc/Zosyn/and Cipro.
A [**11-14**] TEE was negative for vegetations. He received a 2-week
course of Vancomycin for MRSA coverage and a 3-week course of
Zosyn and Cipro for pseudomonal coverage. While on
broad-spectrum antibiotics, he was also placed empirically on
Fluconazole, which was completed on [**11-28**]. His WBC count
continued to decline and he became afebrile. His progress was
facilitated by the Infectious Disease team. The patient is
currently on no antibiotics.
7. Endocrine: Blood sugar control was aggressively managed with
an insulin drip and sliding scale as needed. The patient's
sugars have been well controlled with sliding scale.
Medications on Admission:
Lipitor 40mg PO daily
Prilosec 20mg PO daily
Lisinopril 40mg PO daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-11**]
Drops Ophthalmic PRN (as needed).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
16. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed.
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous three times a day as needed for blood sugar
control.
Disp:*10 units/ml* Refills:*5*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
acute pancreatitis
respiratory failure requiring intubation
ventilatory associated pneumonia
bacteremia
atrial fibrillation
CVL infection
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Name (NI) 2829**] office if you fever (>101.5), chills,
abdominal pain, persistent nausea/vomiting, early fullness when
you eat, difficulty breathing or any significant change in your
medical condition.
Followup Instructions:
[**Hospital Ward Name 23**] [**Location (un) **] 9am CT scan abd, NPO 3hrs prior to scan.
Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 62570**] appointment is on [**12-28**] at
11am.
Also follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 61040**] for
an appointment.
|
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32,666
| 117,557
|
62
|
Discharge summary
|
report
|
Admission Date: [**2160-4-10**] Discharge Date: [**2160-4-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
Colonoscopy
Esophagogastroduodenoscopy
History of Present Illness:
87 yo F with h/o CAD, A fib on coumadin, HTN, hyperchol,
hypothyroidism p/w melena. Pt notes that for the past 2.5 weeks
she has been "run down with the flu," principally with symptoms
of malaise and poor appetite. Two days ago the pt noted the new
onset of black stools, described as "clots", passed with large
amounts of flatus. She was concerned that this was blood and
went to her PCP's office today. He did a rectal exam and in turn
referred her to the ED. Other than the melena, she denies any
frank blood. She had one episode of NB/NB vomitous one week but
no hematemesis. She denies CP/SOB/f/c/urinary sxs. Of note, pt
has had recent changes in her coumadin dose over the past 2
weeks though is unsure of doses.
.
In the ED, vitals: 97.6, hr 77, 181/64, rr 18, 95% ra. Hct 32
(baseline 38). wbc 16.9. INR 7.2. lactate 1.3. Lytes nml. U/A
6-10 wbcs. ekg: nsr@77bpm, LAD, no ishcemic changes. Pt given
vit K 10 mg po x 1, zosyn 4.5 grams iv, flagyl 500 grams iv. Pt
transferred to MICU for further management.
.
In the MICU, the patient received 2units FFP, HCTs remained
stable. GI evaluated and felt that an EGD was non-urgent and
will be done on Monday.
Past Medical History:
CAD: stress MIBI '[**56**]: IMPRESSION: At the level of exercise
achieved, there is a mild, partially reversible inferior wall
defect. MIBI in [**3-21**] without evidence of ischemia.
hypothyroidism
HTN
hypercholesterolemia
A fib
Social History:
widow, no tob, etoh, illicits, lives alone
Family History:
Three sisters with CAD after age 65 but all still living (ages
95, 81, 77). Mother had h/o CAD.
Physical Exam:
Temp 98.8
BP 136/63
Pulse 75
Resp 18
O2 sat 95 % ra
Gen - comfortbale, alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nmildly distended, with normoactive bowel
sounds
Extr - No edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3,
Skin - No rash
rectal: guaiac pos in the ED
Pertinent Results:
[**2160-4-10**] 10:07PM BLOOD Hct-27.1*
[**2160-4-11**] 03:01PM BLOOD Hct-28.6*
[**2160-4-13**] 03:00PM BLOOD Hct-30.3*
[**2160-4-15**] 05:15AM BLOOD WBC-11.0 RBC-3.15* Hgb-9.2* Hct-28.2*
MCV-90 MCH-29.3 MCHC-32.7 RDW-14.0 Plt Ct-390
[**2160-4-16**] 05:28AM BLOOD WBC-11.1* RBC-3.09* Hgb-9.0* Hct-27.8*
MCV-90 MCH-29.1 MCHC-32.4 RDW-13.7 Plt Ct-355
[**2160-4-10**] 01:18PM BLOOD PT-60.6* PTT-58.5* INR(PT)-7.2*
[**2160-4-11**] 04:47AM BLOOD PT-20.1* PTT-34.1 INR(PT)-1.9*
[**2160-4-16**] 05:28AM BLOOD PT-15.0* PTT-27.7 INR(PT)-1.3*
[**2160-4-16**] 05:28AM BLOOD Glucose-111* UreaN-7 Creat-0.8 Na-141
K-4.0 Cl-106 HCO3-24 AnGap-15
[**2160-4-10**] 01:18PM BLOOD Glucose-96 UreaN-12 Creat-1.0 Na-142
K-3.5 Cl-105 HCO3-28 AnGap-13
[**2160-4-10**] 01:18PM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
[**2160-4-10**] 05:56PM BLOOD Lactate-1.3
[**2160-4-10**] 06:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2160-4-10**] 06:00PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-TR
[**2160-4-10**] 06:00PM URINE RBC-0-2 WBC-[**6-24**]* Bacteri-OCC Yeast-NONE
Epi-0-2
CXR:
The heart size is normal. The aorta is tortuous and there is
calcification within the aortic knob. Ill-defined densities
noted within the right lung base. Questinable nodular densities
are scattered through out both lungs. The left retrocardiac
density corresponds to the hiatal hernia and appears unchanged
compared to the prior study. No pleural effusion or pneumothorax
is detected. The soft tissue and osseous structures are
unremarkable.
IMPRESSION:
Right basilar infiltrate is suggestive of peumonia.
Equivocal densities scattered through out both lungs need
further evaluation by nonurgent chest CT.
CT Abd/Pelvis:
Innumerable nodules measuring up to 13 mm in diameter are seen
in the imaged portion of the lung bases. The imaged portion of
the heart and pericardium appear unremarkable. Several enlarged
lymph nodes, some with hypodense centers, are seen in the
pericardial fat measuring up to 15 mm in diameter. Several
peripherally located heterogeneously hypodense lesions are seen
about the right and left lobes of the liver in subserosal
location consistent with metastases. The largest of these, in
the right lobe (2:14), measures 2.6 cm in diameter. Numerous
additional nodular and irregular foci involve the peripheral
aspects of segments V, VI, IVb and [**Doctor First Name 690**].
At the gastric fundus, a heterogeneous mass measures 3.4 x 2.6
cm and protrudes into the lumen (2:18).
Numerous enlarged lymph nodes and mesenteric masses are seen
throughout the entire abdomen. Two confluent omental masses
anteriorly (2:44) measure up to 6.1 cm in diameter. Numerous
additional mesenteric lymph nodes as well as retroperitoneal
nodes along the celiac axis and in aortocaval and paraaortic
location have hypodense centers consistent with central
necrosis. These are located in the omentum anteriorly (2:27), in
the lesser sac (2:27), adjacent to the spleen and along the left
lateral peritoneum (2:27, 21), and throughout the mesenteric
root (2:45). The pancreatic duct is nondilated and no definite
pancreatic masses are identified. The adrenal glands are mildly
nodular appearing although no definite masses are identified.
Bilateral hypodense renal lesions are too small to characterize.
There is no hydronephrosis. The aorta is normal in caliber with
mural calcification consistent with atheromatous disease. A
serosal mass involving the descending colon (2:60) measures 3.5
x 3.3 cm. The colon is displaced in multiple other locations by
multiple omental and serosal masses. There is no evidence of
bowel obstruction.
CT PELVIS WITH INTRAVENOUS CONTRAST: A heterogeneous centrally
hypodense mass spans the width of the lower abdomen and pelvis,
tethering the terminal ileum and cecum as well as the sigmoid
colon, and is contiguous with the uterus and adnexa. Overall,
this mass measures up to 14 cm in greatest transaxial dimension.
The sigmoid colon is extensively encased. The bladder contains
gas, and the dome of the bladder just touches the confluent
pelvic mass. Additional nodular implants are seen in the
rectovaginal cul-de-sac (2:78).
BONE WINDOWS: No definite lesions worrisome for osseous
metastatic disease are identified. There is lumbar scoliosis and
degenerative change.
IMPRESSION:
1. Innumerable omental and peritoneal masses throughout the
abdomen and pelvis, with the largest confluent mass in the deep
pelvis.
2. 3.4 x 2.6 cm gastric fundal mass.
3. Pulmonary metastases.
4. Serosal hepatic metastases.
5. Encasement of the uterus and sigmoid colon, and questionable
involvement of the bladder, by the conglomerate pelvic mass. No
evidence of bowel obstruction.
6. Air within the bladder. Please correlate with any possible
history of recent Foley catheterization.
Possible etiologies for the extensive metastatic disease could
include gastric cancer with metastases, versus other
gastrointestinal primary with metastases, or ovarian cancer.
Clinical correlation is recommended.
COLON BIOPSIES:
Proximal sigmoid colon mass, biopsy:
Colonic mucosa with chronic active inflammation.
No neoplasm seen.
Multiple levels have been examined.
Note: Possible causes include compression from an external
lesion or an intrinsic chronic colitis.
EGD:
Normal mucosa within the esophagus, stomach and duoenum. No sign
of gastric mass.
Colonoscopy:
Partially obstructing mass noted in the proximal sigmoid colon
(40cm) covered by normal appearing mucosa. Unable to pass scope
further.
Brief Hospital Course:
GI bleed: The patient intitially presented with a GI bleed.
Based on the presentation of more maroon stool than melena, it
was felt to be consitent with a lower GI bleed. Her INR was
significantly elevated at presentation, which was felt to be
contributing significantly to her bleeding. Her INR was reversed
with 2 units of FFP and 10mg of Vitamin K. She was initially
monitored in the ICU but remained hemodynamically stable and
required no blood transfusions with a stable hematocrit after
INR reversal. She was transferred to the floor and underwent a
colonoscopy after an uneventful prep. The colonoscopy found a
partially obstructing mass in the proximal sigmoid colon with
normal appearing mucosa. It was unclear if this was an
instrinsic vs. an extrinsic colonic mass pressing in so she
underwent a CT of her abd/pelvis. This found what is likely
diffuse metastatic disease, further discussed below. Her
coumadin has been stopped secondary to her increased bleeding
risk with her abdominal malignancy and for improved quality of
life. Her hematocrit remained stable througout her admission
with no further bleeding
Abdominal malignancy: As noted above, the patient was found to
have what appears to be diffuse metastatic disease throughout
her abdomen and lower lungs. The spread was consistent with a
gastric primary. Initial biopsies from the colonoscopy returned
as normal tissue, not surprising given the mass was only
extrinsically compressing the colon. An EGD was performed which
was entirely normal, indicating that the gastric mass seen on CT
was likely extraluminal. In discussion with the patient, she did
not desire any further work up including any other biopsies. She
does not desire any surgery or chemotherapy. A palliative care
consult was called and discussed hopsice options with the
patient. Fortunately, the patient was asymptomatic in regards to
her cancer. She was without pain, N/V, able to eat normally and
have normal bowel movement. Home hospice was set up and she was
discharged with close follow up with her PCP. [**Name10 (NameIs) **] was also set
up with an appointment with Dr. [**Last Name (STitle) **] in GI oncology to allow her
to ask further questions or discuss further options. She was
discharged with a prescription for stool softeners.
Pneumonia/UTI: The patient initially had a leukocytosis and a
positive U/A for a UTI. She also have a RLL infiltrate seen on
CXR. These were both treated with IV ceftriaxone and
transitioned to PO cefpodoxime, to finish a brief course at
home.
HTN: Initially her HTN meds were held in the setting of the GI
bleed. After she stabilized, they were restarted at lower doses
with good effect. She will be discharged on these lower doses
and follow up with her PCP.
A.fib: The patient remain rate controlled on her beta-blocker.
Her coumadin was stopped as above. She was continued on her low
dose aspirin.
Hypothyroidism: Continued on her home dose of Synthroid with
good effect.
Code status: DNR/DNI
Medications on Admission:
cozaar 100 mg daily
asa 81 mg daily
new thyroid medication X 2.5 weeks
coumadin (changed multiple times recently, pt unsure of dose)
toprol dose unknown
lipitor 10 mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Hospital3 **]
Discharge Diagnosis:
Likely metastatic abdominal cancer, primary unknown
Lower gastrointestinal bleed
HTN
Atrial fibrillation
Coronary Artery Disease
Discharge Condition:
All vital signs stable, pain free, tolerating POs.
Discharge Instructions:
You were admitted with a GI bleed, likely from your lower
abdominal tract. This was likely caused by your elevated
coumadin level. During the work up for this, it was discovered
that you likely have metastatic cancer throughout your abdomen,
including pushing on your lower colon. As we discussed with you
and your family, we will not pursue any aggressive diagnosis,
including further biopsies. We will also not pursue chemotherapy
or surgery at this time. You will follow up with Dr. [**Last Name (STitle) **] and
we will set up a follow up appointment with one of our abdominal
cancer doctors to discuss [**Name5 (PTitle) 691**] further questions you may have.
We have stopped your coumadin as the risk from bleeding is
greater due to your cancer than the risk of stroke. We have also
decreased your blood pressure medications slightly as you did
not require as much while you were in hospital.
You were also diagnosed with a mild case of pneumonia and a
urinary tract infection while here. You were initially treated
with an IV antibiotic to treat both. This was changed to an oral
antibiotic that you will finish taking at home.
In discussion with you and your family, we have arranged for you
to go home with hospice assistance for further care.
Please call your doctor or the hospice nurses if you experience
abdominal pain, bleeding, nausea/vomitting, constipation,
difficulty urinating or any other symptoms that concern you.
Followup Instructions:
Please call Dr.[**Name (NI) 692**] office at [**Telephone/Fax (1) 693**] to schedule a
follow up appointment in the next 2-4 weeks.
You have an appointment with Dr. [**Last Name (STitle) **] (abdominal cancer doctor)
on [**5-2**] at 2pm. Please call ([**Telephone/Fax (1) 694**] to reschedule.
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] |
icd9pcs
|
[
[
[]
]
] |
12321, 12383
|
8061, 11053
|
277, 318
|
12556, 12609
|
2473, 8038
|
14096, 14394
|
1841, 1938
|
11277, 12298
|
12404, 12535
|
11079, 11254
|
12633, 14073
|
1953, 2454
|
222, 239
|
346, 1511
|
1533, 1765
|
1781, 1825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,949
| 186,874
|
31749
|
Discharge summary
|
report
|
Admission Date: [**2197-10-15**] Discharge Date: [**2197-11-3**]
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Reason for admission: Hypertensive emergency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 74557**] is an 83yo male with PMH significant for HTN and
recently discharged from [**Hospital1 18**] s/p mechanical fall which
resulted in SAH and subdural hematoma. He now presents with
elevated blood pressures ~200's at rehab facility. Per records
[**Hospital 74558**] rehab, he has had 2 episodes of elevated BPs that have
been difficult to control with oral regimen. BP early this AM
was 226/90 and did not come down with Labetolol 200mg x1,
Nitropaste, and Hydralazine. Given this he was transferred to
[**Hospital1 18**] for further work-up. Patient denies any vision changes,
headaches, or abdominal pain.
.
In the ED his initial vitals were T 97.8 BP 162/75 AR 70 RR 14
O2 sat 96% RA. He received Hydralazine 10mg IV, Labetolol 10mg
x2, Labetolol 20mg IV, and was then started on Nipride gtt.
.
Of note, patient recently discharged from [**Hospital1 18**] on [**10-11**] s/p
mechanical fall which resulted in SDH and subdural hematoma. No
surgical intervention was done at the time as the bleed was
cnsidered stable and no urgent intervention was warranted.
Past Medical History:
1)Type 2 DM
2)SAH, subdural hematoma, and R temporal fracture secondary to
mechanical fall on [**2197-10-5**], recently discharged on [**2197-10-11**] (no
neurosurgery intervention; only placed on dilantin for seizure
prophylaxis)
3)Hypertension
4)BPH
Social History:
Prior to fall very active and worked 3d/week designing medical
equipment. No history of tobacco, alcohol, or IVDA.
Family History:
noncontributory
Physical Exam:
Admission PE:
vitals T 97.2 BP 185/82 AR 89 RR 12 O2 sat 98% on 2L
Gen: Patient sleeping but arousable, appears lethargic
HEENT: dry MM
Heart: RRR, II/VI SEM loudest at RUSB + LUSB
Lungs: CTAB, no crackles
Abdomen: soft, slightly distended, NT, +BS
Extremities: No edema, 2+ DP/PT pulses bilaterally
Neuro: arousable by voice; oriented to person and time, not
place; follows simple commands of hand squeezing and leg raises.
Pertinent Results:
ADMISSION LABS:
[**2197-10-15**] 01:48PM GLUCOSE-183* UREA N-23* CREAT-0.9 SODIUM-127*
POTASSIUM-3.6 CHLORIDE-89* TOTAL CO2-29.
[**2197-10-15**] 01:48PM CALCIUM-8.0* PHOSPHATE-3.0 MAGNESIUM-1.7.
[**2197-10-15**] 05:10AM WBC-10.7 RBC-4.27* HGB-14.1 HCT-38.6* MCV-90
MCH-32.9* MCHC-36.4* RDW-12.7
[**2197-10-15**] 05:10AM NEUTS-86.6* LYMPHS-7.1* MONOS-5.5 EOS-0.8
BASOS-0
[**2197-10-15**] 05:10AM PLT COUNT-247
[**2197-10-15**] 05:10AM PT-11.4 PTT-26.6 INR(PT)-1.0
.
DISCHARGE LABS:
[**2197-11-3**] 07:15AM BLOOD WBC-10.4 RBC-3.34* Hgb-10.7* Hct-32.3*
MCV-97 MCH-32.1* MCHC-33.2 RDW-13.5 Plt Ct-353
[**2197-11-1**] 07:25AM BLOOD Neuts-87.2* Lymphs-5.8* Monos-2.5
Eos-4.5* Baso-0.1
[**2197-11-3**] 07:15AM BLOOD Plt Ct-353
[**2197-11-3**] 07:15AM BLOOD Glucose-150* UreaN-28* Creat-2.0* Na-142
K-3.6 Cl-103 HCO3-29 AnGap-14
[**2197-11-3**] 07:15AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
.
IMAGING:
[**10-15**] CT Head:
Overall unchanged appearance of hemorrhagic contusions in
bilateral frontal lobes, with subdural, subarachnoid and
intraventricular hemorrhage which has been slightly decreased.
Redemonstration of opacified right mastoid air cells, likely
inflammatory in origin. Small high density area within the left
subdural collection can represent residual hemorrhage
versus recurrent hemorrhage since eight days ago.
.
[**10-18**] CXR:
Dual-obscuration of the left diaphragmatic pleural surface may
represent
either obliteration by consolidation in the adjacent left lower
lobe or
small-to-moderate left pleural effusion. Small right pleural
effusion is new. Upper lungs are clear. Heart size normal.
.
[**10-30**] CXR:
1. Persistent left lower lobe consolidation.
2. New right basilar atelectasis.
.
[**11-2**] CXR:
Progressive decrease in opacification at the right base
consistent with clearing of the previously noted pneumonia.
.
[**10-27**] Renal US:
Mildly elevated resistive indices and tardus parvus
configuration
bilaterally, but no evidence of hemodynamically significant
renal artery
stenosis in right or left kidneys
.
[**10-23**] Echo:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function
are normal (LVEF >55%) Right ventricular chamber size and free
wall motion are normal. The aortic root is moderately dilated
at the sinus level. The ascending aorta and aortic arch are
mildly dilated. The aortic valve leaflets are mildly thickened.
No masses or vegetations are seen on the aortic valve. There is
no aortic valve stenosis. An eccentric jet of mild to moderate
([**2-14**]+) aortic regurgitation is seen directed toward the
anterior mitral leaflet. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2197-10-7**], the findings are similar.
.
MICROBIOLOGY:
[**2197-10-19**] 11:27 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2197-10-22**]**
AEROBIC BOTTLE (Final [**2197-10-22**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
SULFA X TRIMETH SENSITIVITIES PERFORMED BY [**Doctor Last Name **]-[**Doctor Last Name **].
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ 0.25 R
TRIMETHOPRIM/SULFA---- S
ANAEROBIC BOTTLE (Final [**2197-10-22**]):
[**2197-10-20**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 6:05 AM.
STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.
.
[**10-31**] Blood Cx x 2: NGTD
.
[**2197-11-2**] 9:54 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2197-11-3**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2197-11-3**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Brief Hospital Course:
#) HYPERTENSION:
-- On the day of admission, the patient found to have elevated
SBPs~200's at rehab facility. He has history of difficult to
control BPs per recent discharge summary. No signs or symptoms
of end organ ischemia/damage were noted on admission. Patient
was initially started on Nitroprusside gtt in ED and responded
appropriately with better control of his BPs. When he arrived
to the ICU, the Nitroprusside drip was stopped and he was
transitioned to oral medications. He was restarted on
hydralazine 25mg PO q 6hr, his Labetolol was increased to 600mg
PO TID and his was restarted on Amlodipine 5 mg. His blood
pressures were noted to be lower than goal. Labetalol was
decreased to 400TID and hydralazine was stopped.
-- While on the floor, his regimen was optimized and his
pressures were well controlled. He is now on labetolol 600 mg
Q8 hours and amlodipine Q12 hours. He has not needed any IV
medications in over four days, and he his pressures have been
runnng 120 - 150's.
-- Goal BP is 120 - 160. Due to his recent head bleeds, he
becomes encephalopathic at lower pressures and at pressures >
200.
.
#) MENTAL STATUS + SDH/SAH:
-- Repeat head CT on admission showed no change in the SAH/SDH
from the end of [**Month (only) 216**].
-- He has had waxing and [**Doctor Last Name 688**] MS throughout the hospital
course, considered to be multifactorial in etiology (old brain
bleed + hyponatremia + bacteremia + ? keppra + uncontrolled BP).
The hyponatremia has resolved, and his bacteremia was treated
and cleared. Antiseizure PPX was discontinued, as, per
neurosurgery recs, he was had no seizure activity and is at low
risk for future seizures.
-- He was admitted on dilantin for antiseizure PPX; this was
started on his last admisison in [**Month (only) 216**]. It was noted that he
had a diffuse macular-papular rash, thought to be [**3-17**] the
dilantin. After the dilantin was discontinued, the rash
cleared. He was then placed on Keppra antiseizure PPX, but this
was eventually discontinued as it was felt the Keppra could be
contributing to his delirium and that he no longer needed
antiseizure PPX.
-- Overall, his MS is much improved from admission, although he
continues to have bouts of delirium, which, per neurology, is to
be expected with his brain bleeds.
.
#) MSSA BACTEREMIA:
-- cultures from [**10-19**] grew out 3/4 bottles with S. aureus,
oxacillin sensitive. He was started on vanco 1 g IV Q12 +
ceftriaxone 2 mg IV Q24, but switched to nafcillin when
sensitivities returned. He was eventually switched back to
vanco when he developed ARF, as there was cocnern the nafcillin
may have contributed to this.
-- The source of the bacteremia remained uncertain. His urine
cultures were negative, and while there was a LLL opacity on
CXR, his osycgen saturations were in the high 90's and he did
not have a cough suggesting a PNA that would lead to MSSSa
bacteremia. TTE was negative for vegetations.
-- Surveillance cultures were followed and negative. he
completed a full two week course of IV antibiotics on the
-- At the end of the hospital course, he did develop a cough.
CXR was repeated twice (once on [**10-31**] and once on [**11-2**]), and
there was no evidence of worsening or new PNA.
-- Although no source was ever clearly identified, it was
reassuring that he was clinically improving in terms of his
delirium and his vital signs were stable.
.
#) ACUTE RENAL FAILURE:
-- His baseline Cr was 0.8 and had bumped to 2.5 on [**10-25**]. he
had multiple risk factors for ARF including prerenal (has been
fluid restricted for SIADH tx; ~1 L per day); renal (nafcillin
use; lisinopril use); and postrenal (was temporarily off BPH
meds in the setting of delirium and had high bladder volumes on
PVR).
-- Lisinopril for HTN was discontinued and other medicines were
adjusted.
-- Nafcillin was discontinued and he was put back onto
vanocmycin for the bacteremia.
-- US was negative for renal artery stenosis.
-- As Na had normalized, fluid restrictions were lifted and he
was volume resuscitated.
-- Ultimatley, it was thought that he had ATN from labile blood
pressures, and his Creatinine has been slowly improving. It is
2.0 on discharge, and it is expected to return to near baseline
of 0.8 with time.
.
#)HYPONATREMIA:
-- Patient presented with Na~124 on admission. It was normal on
recent discharge. Its unclear whether this is related to
underlying SAH and subdural hematoma, as in SIADH. He was also
on HCTZ prior to admission.
-- His sodium slowly corrected with flid restrictions (1200 -
1500 cc/day). He is no longer on fluid restrictions. Na is 142
on day of discharge.
.
#) DIABETES:
-- He was on Metformin and insulin sliding scale as outpatient.
His metformin was initially held because of his variable diet,
and he was kept on a sliding scale.
-- NPH was started at 5 units [**Hospital1 **] with SSI for breakthrough
hyperglycemia.
.
#) BPH:
-- His outpatient regimen of Detrol, Finasteride, and Tamsulosin
was discontinued in the setting of delirium, as all non-critical
meds were discontinued. A foley was placed to reduce
obstruction.
-- Eventually his tamsulosin and finasteride were restarted. He
is being discharged with a foley in the setting of ARF. It was
last changed on [**10-31**].
.
#) NUTRITIONAL STATUS:
-- Speech and swallow evaluated Mr. [**Known lastname 74557**] and felt was clear to
eat pureed solid foods with nectar-thickened liquids wiht TID
nutritional supplements. He is on aspiration precautions and
eats with asistance.
.
Medications on Admission:
Labetolol 200mg PO TID
HCTZ 12.5mg PO daily
Detrol 1mg PO BID
Tamsulosin 0.4mg PO QHS
Finasteride 5mg PO daily
Norvasc 10mg PO daily
Hydralazine 20mg PO QID
Vancomycin 750mg IV BID
Metformin 500mg PO daily
Senna
Colace
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12
Hours).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8
hours): Please hold if systolic blood pressure is less than 120
or pulse is less than 60. .
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: PRN for pain.
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
injection Subcutaneous every twelve (12) hours: 5 units Q12
hours.
10. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
subcutaneous injection Injection four times a day: See attached
sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
1. Subarachnoid hemorrhage and subdural hemorrhage ofthe brain
after a mechanical fall
2. Acute renal failure
3. MSSA bacteria infection of the lung.
Discharge Condition:
Improved from admission: patient still with intermittent
delirium, but overall significantly improved. He is
conversational and coherent, complaining of poor memory but much
more interactive than in prior weeks. He is able to get out of
bed to a chair with assistance.
Discharge Instructions:
Please return to the ED or call your doctor if you develop a
fever or have worsening cough.
.
Please make sure your fluid intake is at least one liter per day
(should be thickened liquids and should have someone assist in
taking in foods because there is a risk of aspirating if you eat
alone).
Followup Instructions:
(1) Please see your primary care doctor in 1 - 2 weeks to check
renal function and overall clinical status.
.
(2) You have an appointment with neurosurgery on [**2197-11-14**] at 2:15
pm. You also have an appointment at 1:30 pm on [**2197-11-14**] for a CT
scan of the head.
.
.
.
PENDING ISSUES FOR FOLLOW-UP:
(1) Creatinine and BUN need to be followed closely while in
rehab to make sure that they are trending down. Pending serum
sodium levels remain normal, please encourage PO fluid intake
with assistance for aspiration precautions. If creatinine does
increase and the patient seems dry (being discharged at 2.0),
please begin IV fluids.
.
(2) Please make sure systolic blood pressures [**Last Name (un) 7387**] between 120
- 160.
.
(3) It should be expected that Mr. [**Known lastname 74557**] have some waxing and
[**Doctor Last Name 688**] of mental status, as his brain is fragile from the bleeds
and very susceptible to slight derangements. Neurology
explained that this should slowly improve with time.
.
(4) Follow-up appointments as described above.
|
[
"250.02",
"401.0",
"038.11",
"584.9",
"263.0",
"600.01",
"293.0",
"852.20",
"276.8",
"E936.1",
"112.0",
"507.0",
"E888.9",
"428.0",
"693.0",
"428.22",
"486",
"276.1",
"780.39",
"852.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13852, 13924
|
6904, 12440
|
262, 268
|
14118, 14389
|
2291, 2291
|
14732, 15801
|
1809, 1830
|
12710, 13829
|
13945, 14097
|
12466, 12687
|
14413, 14709
|
2784, 3205
|
1845, 2272
|
178, 224
|
296, 1386
|
3214, 6881
|
2307, 2768
|
1408, 1661
|
1677, 1793
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,054
| 116,250
|
23004
|
Discharge summary
|
report
|
Admission Date: [**2183-7-19**] Discharge Date: [**2183-8-7**]
Date of Birth: [**2122-3-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
Cardiac Catherization
[**2183-7-20**]
1. Mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**] Epic
tissue valve, model number E-[**Medical Record Number 59354**].
2. His aortic valve replacement with a 21 mm cup, [**Last Name (un) 3843**]
[**Doctor Last Name **] pericardial tissue valve, model number 3300 TFX.
[**2183-8-6**] and [**7-30**] left thoracenteses
History of Present Illness:
This patient is a 61 year old female who is transferred from
outside hospital for dyspnea with known [**Doctor Last Name 27210**] syndrome and
known MR. History is very limited due to her acuity and is
mostly from EMS and outside hospital. The patient presented with
acute onset dyspnea, tachycardia, and was very tachypneic. Upon
arrival to the [**Hospital1 18**] ER she was intubated and admitted tothe
MICU. An ECHO was done this morning revealing 4+ Mitral regurg
w/ flail leaflet. She is presently acidotic in cardiogenic
shock, intubated, sedated on Levophed and Neo. Cardiac surgery
was consulted for emergent MVR.
Past Medical History:
bicuspid aortic valve
aortic stenosis
mitral regurgitation
s/p emergent aortic valve replacement and mitral valve
replacement this admission
PMH:
diverticulitis, [**Doctor Last Name 27210**] syndrome, hypothyroid
Past Surgical History: s/p sigmoid colectomy w/ [**Doctor Last Name 3379**] pouch
[**2178**] at [**Hospital1 18**]. Cervical Laminectomy [**2177**]
Social History:
Lives with husband
Family History:
NOn-contributory.
Physical Exam:
Pulse:102 ST Resp: AC 100%, peep 20, VT 350 x rate 34 O2 sat:
94%
B/P A-line 95/73
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: Pupils pinpoint- sedated. S/P cervical laminectomy [**2177**].
native dentition without obvious deformity.
Neck: Supple [] Full ROM []
Chest: Lungs crackles bilat
Heart: tacycardic Murmur V/VI SEM
Abdomen: Obese, hypoactive, Soft
Extremities: Cool, 4+ pitting edema all extremities
Neuro: intubated and sedated
Pulses: Doppler pulses lower extremities. Unable to appreciate
varicosities d/t edema
radial A-line left
Carotid Bruit : on vent Right: Left:
Pertinent Results:
[**2183-8-7**] INR 1.9 PT 20.5 Mg 2.2 creat 0.9
[**2183-8-5**] 04:30AM BLOOD WBC-18.4* RBC-3.13* Hgb-9.6* Hct-30.6*
MCV-98 MCH-30.7 MCHC-31.4 RDW-20.8* Plt Ct-177
[**2183-8-4**] 03:04AM BLOOD WBC-24.7* RBC-3.21* Hgb-10.1* Hct-30.8*
MCV-96 MCH-31.4 MCHC-32.8 RDW-21.0* Plt Ct-139*
[**2183-8-3**] 01:52AM BLOOD WBC-27.5* RBC-3.24* Hgb-10.0* Hct-31.1*
MCV-96 MCH-30.8 MCHC-32.0 RDW-20.2* Plt Ct-120*
[**2183-8-5**] 04:30AM BLOOD PT-25.8* INR(PT)-2.5*
[**2183-8-4**] 03:04AM BLOOD PT-26.1* PTT-30.2 INR(PT)-2.5*
[**2183-8-3**] 01:52AM BLOOD PT-32.9* PTT-36.0* INR(PT)-3.3*
[**2183-8-2**] 02:53AM BLOOD PT-33.3* PTT-33.6 INR(PT)-3.4*
[**2183-8-2**] 02:53AM BLOOD PT-33.3* PTT-33.6 INR(PT)-3.4*
[**2183-8-1**] 04:22AM BLOOD PT-22.7* PTT-57.5* INR(PT)-2.1*
[**2183-8-1**] 12:18AM BLOOD PT-21.8* PTT-63.5* INR(PT)-2.0*
[**2183-8-5**] 04:30AM BLOOD Glucose-182* UreaN-36* Creat-1.0 Na-133
K-4.2 Cl-94* HCO3-28 AnGap-15
[**2183-8-4**] 03:04AM BLOOD Glucose-138* UreaN-32* Creat-0.9 Na-137
K-4.8 Cl-100 HCO3-33* AnGap-9
[**2183-8-3**] 01:52AM BLOOD Glucose-158* UreaN-26* Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-30 AnGap-11
[**2183-7-19**] preop echo
Left ventricular wall thicknesses and cavity size are normal.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is moderately dilated with moderate global free wall
hypokinesis. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
No aortic regurgitation is seen. [Due to acoustic shadowing, the
severity of aortic regurgitation may be significantly
UNDERestimated.] The mitral valve leaflets are moderately
thickened. There is mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. At least moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] Due to the eccentric nature of the regurgitant
jet, its severity may be significantly underestimated (Coanda
effect). The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Small, hyperdynamic left ventricle. Dilated and
hypokinetic right ventricle. Mitral valve prolapse with at least
moderate mitral regurgitation. Moderate aortic stenosis.
Compared with the report of the prior study (images unavailable
for review) of [**2178-2-16**], severity of mitral regurgitation has
probably worsened and right ventricle is now hypocontractile.
This study might be significantly UNDERestimating the severity
of eccentric mitral regurgitation and if there is clinical
concern for acute severe mitral regurgitation, a transesophageal
study is recommended.
[**2183-7-19**] Chest CT
1. No evidence of pulmonary embolism or aortic dissection.
2. Cardiomegaly with marked left atrial enlargement. Bilateral
diffuse ground
glass opacity and interlobular and intralobular septal
thickening suggests
severe pulmonary edema. More consolidative areas within the
lower lobes
bilaterally may be due to pneumonia or atelectasis.
3. Small to moderate sized bilateral pleural effusions, left
larger than
right.
[**2183-7-19**] cardiac cath
FINAL DIAGNOSIS:
1. Anomolous coronary arteries with no hemodynamically
significant
2. Severely elevated left- and right-sided filling pressures.
3. Successful placement of intra-aortic balloon pump.
[**2183-7-20**] intra-op echo
Prebypass
No atrial septal defect is seen by 2D or color Doppler. 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.] with severe global RV free
wall hypokinesis. The ascending aorta is mildly dilated. The
aortic valve is bicuspid. The aortic valve leaflets are severely
thickened/deformed. Significant aortic stenosis is present (not
quantified). Unable to calculate gradients and [**Location (un) 109**] due to poor
doppler alignment in the deep transgastric views. No aortic
regurgitation is seen. The mitral valve leaflets are myxomatous.
There is partial mitral leaflet flail. Torn mitral chordae are
present. Severe (4+) mitral regurgitation is seen. Due to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). Moderate [2+]
tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2183-7-20**] at 1500 hours.
Post bypass
Patient is in sinus rhythm and receiving an infusion of
norepinephrine, epinephrine and milrinone. RV function is
slightly improved. LVEF= 35%. The inferior and inferoseptal
walls are hypokinetic.
Bioprosthetic valve seen on the aortic position. Valve appears
well seated and the leaflets move well. Trace central aortic
insufficiency present. There is a strut seen in the LVOT.
There is a bioprosthetic valve seen in the mitral position. This
valve appears well seated and the leaflets move well.
Aorta appears intact post decannulation.
Intraaortic balloon pump tip seems to be in good position.
Echo [**2183-7-31**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. A bioprosthetic aortic valve prosthesis
is present. The transaortic gradient is normal for this
prosthesis. No aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The transmitral gradient is
normal for this prosthesis. There is severe mitral annular
calcification. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2183-7-19**], the
mitral and aortic prostheses are new and are with normal
gradients
Chest CT, abdomen, pelvis [**2183-8-1**]
IMPRESSION:
1. No evidence of fluid collections or abscess.
2. New right pectoral hematoma.
3. Bilateral moderate-sized pleural effusions with adjacent
compressive
atelectasis.
4. Small pericardial effusion.
5. Small amount of ascites.
Brief Hospital Course:
61 year old female with a history of [**Doctor Last Name 27210**] syndrome and
aortic stenosis with bicuspid aortic valve who presents with
respiratory failure and cardiogenic shock. Emergent Cardiac
surgery evaluation was requested. Echo revealed severe MR and
severe AS with a bicuspid aortic valve. Cath did not reveal any
significant coronary disease. She was taken to the operating
room on [**2183-7-20**] where she underwent aortic valve replacement with
21mm [**Last Name (un) 3843**] [**Doctor Last Name **] tissue valve and Mitral Valve
replacement with 31mm St. [**Male First Name (un) 923**] porcine tissue valve.
Post-operatively was transferred to the CVICU for further
invasive monitoring in critical condition. She left the OR with
an intra-aortic balloon pump and on titrated levophed, milrinone
and epinephrine.
Post-operatively, she developed rapid atrial fibrillation with
hemodynamic instability and was electrically cardioverted. She
remained in atrial fibrillation, and rate control was achieved
with amiodarone. IABP was discontinued and eventually the
patient was weaned from inotropic and vasopressor support. A
Lasix drip was initiated to aggressively diurese her excessive
volume overload. Thrombocytopenia developed and HIT was
negative. Platelets would eventually trend up to normal levels.
Given the patient's complicated hospital course, and question
of vegetation on the mitral valve, ID was consulted for
antibiotic recommendations and leukocytosis. Additionally, the
patient developed a rash, and was tested for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**]
Spotted Fever- which would ultimately return negative. She was
eventually weaned from the ventilator and extubated on POD 6.
Due to right upper extremity swelling a right upper extremity
ultrasound was performed and negative for thrombus.Left
thoracentesis done on [**7-30**]. Dobhoff placed for tube feeds for
increased nutritional needs and poor intake. She continued to
progress and was transferred to the step down unit.On POD#17 A
700cc left pleural effusion was evacuated via repeat
thoracentesis. On POD#18 she was cleared by Dr.[**Last Name (STitle) **] for
discharge to [**Hospital **] rehab. All follow up appointments were
advised.
Target INR is 1.8-2.2 for postop Afib ( per Dr. [**Last Name (STitle) **] due to chest
hematoma). Blood draws should be Mon-Wed-Fri ( next draw [**8-8**]) .
Coumadin dose today is 1 mg, INR today 1.9.Please recheck BUN /
creat [**8-8**] for IV lasix dosing.
Please re-check LFTS to dtermine eligibility for statin therapy.
Medications on Admission:
unknown
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: 1 mg today, then 0.5 mg Fri and Sat;then further daily
dosing by provider; target INR 1.8-2.2 for postop A Fib .
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 weeks.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
30 minutes prior to IV lasix.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to affected area.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day): hold for K+ > 4.5 with IV lasix.
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours): last dose PM [**8-8**].
14. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q12H (every 12 hours): 750 mg IV; last dose PM [**8-8**].
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) 500 mg piggyback Intravenous Q8H (every 8 hours): last
dose PM [**8-8**].
16. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
[**Hospital1 **] (2 times a day): 40 mg IV; please recheck creat
[**8-8**];baseline creat 1.5.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: IV prn
line flush and daily for PICC; flush with 10 ml NS.
18. INSULIN fixed dose and sliding scale ( see attached)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
bicuspid aortic valve
aortic stenosis
s/p Mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**] Epic
tissue valve, model number E-[**Medical Record Number 59354**].
2. His aortic valve replacement with a 21 mm cup, [**Last Name (un) 3843**]
[**Doctor Last Name **] pericardial tissue valve, model number 3300 TFX
mitral regurgitation
s/p emergent aortic valve replacement and mitral valve
replacement this admission
PMH:
diverticulitis, [**Doctor Last Name 27210**] syndrome, hypothyroid
Past Surgical History: s/p sigmoid colectomy w/ [**Doctor Last Name 3379**] pouch
[**2178**] at [**Hospital1 18**]. Cervical Laminectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Does not ambulate-using [**Doctor Last Name 2598**] for lifts
Incisional pain managed with tramadol and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema : 2+ BLE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2183-9-3**]
1:30
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 59355**],[**First Name3 (LF) 32103**] [**Telephone/Fax (1) 59356**] in [**2-15**] weeks
Cardiologist Dr. [**Last Name (STitle) 171**] [**Telephone/Fax (1) 62**] in [**2-15**] 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
Target INR for this pt is 1.8-2.2 per Dr. [**Last Name (STitle) **] for postop A Fib
Blood draws Mon-Wed-Fri please
Please check BUN/creatinine tomorrow [**8-8**] ( baseline creat 1.5)
re-check LFTs for possible statin therapy in future
Completed by:[**2183-8-7**]
|
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"998.11",
"349.82",
"785.51",
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
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icd9pcs
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[
[
[]
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13738, 13811
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9092, 11692
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340, 763
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14499, 14722
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2522, 5922
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1856, 1875
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5939, 9069
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14746, 15485
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14362, 14478
|
1890, 2503
|
280, 302
|
791, 1418
|
1440, 1653
|
1819, 1840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,900
| 123,032
|
49119
|
Discharge summary
|
report
|
Admission Date: [**2165-12-24**] Discharge Date: [**2166-1-4**]
Date of Birth: [**2107-2-1**] Sex: M
Service: MEDICINE
Allergies:
Minoxidil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 58-year-old man with a history of atrial
fibrillation (anticoagulated on Coumadin), diastolic heart
failure, s/p [**First Name3 (LF) **] [**First Name3 (LF) **] and failed pancreas [**First Name3 (LF) **],
hypertesnion who is presenting following a mechanical fall at
home and found to be dyspneic in the Emergency Department. He
reports that he tripped over a backpack at home and struck his
head on the front of the sofa. he denies any dizziness or loss
of consciousness before or after the fall. He did not have any
confusion after the fall nor did he lose his urinary continence.
Mr. [**Known lastname 77002**] is experiencing pain in his right rib cage along the
mid-axillary line and in his neck and upper shoulder muscles. He
reports improvement in his pain after receiving morphine. The
patient also reports that his dyspnea on exertion has been
somehat worse for the last several months. He can walk a
straight line for about [**Age over 90 **] yards before becoming short of
breath; he can sometimes handle two flights of stairs. When he
feels like he has "fluid on board," his performance decreases.
He has had occasional lower leg swelling. He denies any recent
changes in his medications.
.
In the ED, the initial vital signs were T 97.8, HR 65, BP
121/69, RR 16 84% on RA. He received both CT head and neck, both
of which were negative. The patient also received chest X-ray
and dedicated rib films have enlarged heart, moderate pulmonary
edema slightly worsened, right pleural effusion resolved, no
left sided pleural effusion, remote fracture in rib 6, no acute
fracture. Bedside FAST negative. The patient received Zofran,
morphine, and 40mg IV Lasix in the Emergency Department. Vitals
on transfer were 97.2, 133/79, 70, 18, 94% 4LNC.
.
On the floor, the patient is comfortable at rest in bed, though
he has some pain with deep breaths and with movement. He is
somewhat sleepy but fully oriented and capable of providing his
history
Past Medical History:
-pheochromocytoma s/p R adrenalectomy [**4-13**] (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
-diabetes Mellitus, Type I - since age 21
-ESRD s/p CRT [**3-/2157**] - post-op course complicated by delayed
graft function and hydronephrosis s/p ureteral stent and
percutaneous nephrostomy in [**3-7**]. Now with [**Date Range **] insufficiency
with baseline creatinine 2.5-3.0.
-pancreas [**Date Range **] [**9-/2157**], rejected [**2158**]
-h/o partial SBO - treated conservatively
-hypertension
-coronary Artery Disease s/p stent of Ramus Intermedius in [**2156**]
-paroxysmal Atrial Fibrillation
-s/p ventral hernia repair with mesh in [**2153**]
-orthostatic hypotension
-medial malleolar fracture [**8-/2161**] - treated with Keflex and
Vicodin. Ortho evaluation [**9-21**] - no infection, no ulcer.
Social History:
Works as a golf instructor at [**Location (un) **] golf club. Married,
nonsmoker, rare alcohol use. Illicit drugs: none
Code: FULL code
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Brother has
diabetes.
Physical Exam:
Admission exam
VS - Temp 96.0F, BP 134/79, HR 67, R 18, O2-sat 94% 4L
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, oropharynx
clear
NECK - supple, no JVD, no carotid bruits
LUNGS - mild crackles at bases, good air movement, resp
unlabored, no accessory muscle use
CHEST: tenderness to palpation on right ribcage, midaxillary
HEART - S1, S2, 2/6 systolic murmur heard at USB
ABDOMEN - NABS, soft, nontender, no rebound/guarding
EXTREMITIES - WWP, no pitting edema of lower extermities, sking
changes in lower legs consistent with longstanding stasis/edema
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength 5/5 throughout, sensation grossly intact throughout
Discharge exam
Afebrile, BP HR R O2Sat 92% on RA @ rest, 91-94% when ambulating
Lungs clear to auscultation with minimal basilar crackles
Pertinent Results:
Admission labs
[**2165-12-24**] 05:50PM [**Month/Day/Year 3143**] WBC-6.9 RBC-3.22* Hgb-9.2* Hct-29.4*
MCV-91 MCH-28.6 MCHC-31.3 RDW-14.3 Plt Ct-339
[**2165-12-24**] 05:50PM [**Month/Day/Year 3143**] Neuts-88.0* Lymphs-6.4* Monos-3.3 Eos-1.8
Baso-0.5
[**2165-12-24**] 05:50PM [**Month/Day/Year 3143**] PT-28.1* PTT-47.8* INR(PT)-2.7*
[**2165-12-24**] 05:50PM [**Month/Day/Year 3143**] Glucose-191* UreaN-73* Creat-2.9* Na-137
K-4.1 Cl-105 HCO3-21* AnGap-15
[**2165-12-25**] 01:38AM [**Month/Day/Year 3143**] CK(CPK)-479*
[**2165-12-24**] 05:50PM [**Month/Day/Year 3143**] proBNP-[**Numeric Identifier **]*
[**2165-12-24**] 05:50PM [**Month/Day/Year 3143**] cTropnT-0.03*
[**2165-12-25**] 06:02AM [**Month/Day/Year 3143**] Calcium-8.2* Phos-5.7* Mg-1.9
Discharge labs
.
WBC 6.4 Hgb 8.9 Hct 27.1 Plts 361
.
PT: 17.2 PTT: 41.0 INR: 1.6
.
143 105 57
-------------< 113
3.6 24 4.0
.
Ca: 9.6 Mg: 2.0 P: 5.4
.
Important other labs
[**2165-12-26**] 06:32AM [**Month/Day/Year 3143**] TSH-5.3*
[**2165-12-26**] 06:32AM [**Month/Day/Year 3143**] T4-5.8
[**2165-12-26**] 06:32AM [**Month/Day/Year 3143**] PTH-183*
[**2165-12-26**] 06:32AM [**Month/Day/Year 3143**] Cyclspr-119
.
Studies
CT head [**12-24**]
There is no evidence of acute intracranial hemorrhage, mass
effect or shift of normally midline structures. There is no
cerebral edema or loss of [**Doctor Last Name 352**]-white matter differentiation to
suggest an acute ischemic event. Sulci and ventricles are
prominent, likely age related involutional changes. Mild
confluent periventricular hypodensities, likely represent
sequela of small vessel ischemic disease. A focal hypodensity of
in the right putamen (2:17), may represent a remote lacunar
infarct or a prominent virchow-[**Doctor First Name **] space. Extensive
intracranial and extracranial vascular calcifications are noted.
Rounded density within the right maxillary sinus, likely
represents a retention cyst. The remainder of paranasal sinuses
and mastoid air cells appear well aerated.
.
CT C-spine [**12-24**]
There is no evidence of acute fracture or malalignment.
Multilevel
degenerative disc disease involving the cervical spine is most
pronounced at C5-C6 and C6-C7 with endplate sclerosis and
intervertebral disc space
narrowing. There is posterior disc osteophyte complex formation
at the
corresponding levels with mild impingement on the thecal sac.
There is no
critical central canal stenosis. Imaged lung apices demonstrate
thickening of interlobular septae compatible with intersitial
edema. Thyroid displays homogeneous attenuation. Extensive
vascular calcifications are noted. Round density projecting over
right maxillary sinus is partially imaged and likely represents
a retention cyst. 1. No evidence of acute fracture or
malalignment. Multilevel degenerative
disc disease of the cervical spine, as described above. In the
setting of
high clinical suspicion for ligamentous or cord injury, may
consider MR for further assessment. 2. Instersitial edema in
imaged lung apices.
.
AP SUPINE VIEW OF THE CHEST, THREE VIEWS OF RIGHT-SIDED RIBS:
Heart remains moderately enlarged. The mediastinal and hilar
contours are stable. There is moderate interstitial pulmonary
edema, which appears slightly worse in the interval. Previously
noted right pleural effusion and right basilar opacification has
essentially resolved. There is no pneumothorax or left-sided
pleural effusion visualized. A BB marker indicating the site of
patient's tenderness is located adjacent to the sixth right
lateral rib. Irregularity of this rib is compatible with a
remote fracture, as seen on the prior chest CT from [**2163-10-10**]. No acute fractures are visualized. Multiple clips are
demonstrated within the right upper quadrant of the abdomen.
IMPRESSION: No acutely displaced rib fractures visualized, with
remote right lateral sixth rib fracture. Moderate interstitial
pulmonary edema.
.
Scrotal U/S
The patient reports a longstanding history of swelling in the
right
hemiscrotum, which is also corroborated with a CT from [**2-28**], [**2163**],
which shows right-sided hydrocele in the imaged portion of the
scrotum. On
today's examination, a complex-appearing hydrocele is again
present in the
upper part of the right hemiscrotum with internal echoes and
septations
(images 1 through 4). There is marked enlargement of the scrotum
on gross
inspection, which corresponds to a 5.2 x 6.6 x 8.0 cm
heterogeneously echoic collection without internal vascularity,
which is consistent in appearance with a hematoma. While on
initial imaging, this appeared to be located in the left
hemiscrotum, views obtained with a curved transducer showed that
the hematoma is located in the right inferior hemiscrotum (image
75). The left testis is displaced superiorly towards the
inguinal region. The right testis is slightly displaced by the
right hemiscrotal hematoma and measures 3.6 x 1.6 x 5.4 cm.
Normal color flow and waveforms are identified within the right
testis using color and spectral Doppler analysis. The testis
shows a homogeneous and symmetric echotexture without evidence
of laceration. The left testis, also displaced, measures 2.4 x
2.9 x 4.0 cm and shows a homogeneous echotexture with normal
color flow and waveforms. There is a trace left-sided hydrocele.
Vascular calcifications are noted bilaterally. On the right,
the epididymal head contains a tiny epididymal cyst. The
bilateral epididymides demonstrate normal echogenicity.
IMPRESSION: 1. The marked scrotal enlargement correlates with a
heterogeneously echoic hematoma located within the right
hemiscrotum measuring 8 cm with no internal vascularity. There
is no evidence of testicular parenchymal abnormality, though
both right and left testes are displaced by the hematoma. No
son[**Name (NI) 493**] evidence of testicular torsion or vascular
compromise. Recommend followup imaging after resolution of
symptoms to confirm resolution of the right testicular
collection. 2. Complex right-sided hydrocele and trace
left-sided hydrocele. The complex right-sided component has been
present since at least [**2163**].
.
CXR [**2165-12-26**]
Mild to moderately severe interstitial pulmonary edema has
improved since
[**2165-12-24**]. Mildly enlarged heart size is unchanged.
Mediastinal and hilar contours are stable. There are no discrete
lung opacities concerning for an superadded or coexisting
pneumonia. There is no pleural effusion or pneumothorax.
IMPRESSION: Mild to moderately severe interstitial pulmonary
edema has improved since [**2165-12-24**]. Mildly enlarged
heart size is stable.
.
CT Abd/Pelvis/chest [**2165-12-26**]
CT OF THE THORAX: There is diffuse alveolar consolidation
involving all
lobes, particularly the lower lobes as well as thickening of the
interlobular septa. There are small bilateral pleural effusions.
Air bronchograms are noted coursing through the areas of
consolidation. The thyroid gland is unremarkable. There is no
supraclavicular or axillary lymphadenopathy. There are several
prominent mediastinal lymph nodes (2:25) that do not meet
pathologic criteria. Hilar lymphadenopathy cannot be assessed
due to consolidation. A 10-mm calcification adjacent to the
brachiocephalic artery (2:13) is stable from [**2163-10-10**].
There is cardiomegaly and atherosclerotic calcifications of the
coronary arteries. Hypodensity of the cardiac [**Doctor Last Name 1754**] is
suggestive of anemia. There are atherosclerotic calcifications
of the aortic arch. Mitral annulus is calcified. A small hiatal
hernia is again noted. CT OF THE ABDOMEN: Surgical mesh for
repair of the ventral hernia is stable. No focal liver lesions
are identified on this non-contrast CT. Post-surgical clips from
prior right adrenalectomy are noted. The gallbladder is
distended, likely due to fasting. The pancreas is not well
visualized, and is likely
atrophic. The left adrenal gland is normal. The native kidneys
are atrophic. There are diffuse calcifications of the abdominal
vasculature. There is no mesenteric or retroperitoneal
lymphadenopathy. There is no free air or free fluid. The small
bowel is unremarkable. CT OF THE PELVIS: The appendix is normal.
There is sigmoid diverticulosis without evidence of
diverticulitis. The rectum, seminal vesicles, and prostate are
unremarkable. A Foley catheter is noted in the lumen of the
gallbladder. There is no pelvic lymphadenopathy or free fluid.
The [**Doctor Last Name **] [**Doctor Last Name **] is remarkable. OSSEOUS STRUCTURES: There is
severe intervertebral disc space narrowing and endplate
sclerosis at L3-L4. There are no suspicious osseous lytic or
blastic lesions. IMPRESSION: 1. Extensive bilateral pulmonary
consolidation and septal edema, consistent with pulmonary edema.
Bilateral small pleural effusions. 2. Severe degenerative
changes of the lumbar spine at L3-L4. No other CT findings to
explain acute back pain. 3. Cardiomegaly and coronary artery
disease.
.
CXR [**2166-1-3**]- Since [**2165-12-29**], mild pulmonary edema,
small bilateral pleural effusions and bilateral lower lung
atelectasis (left side more than right), have improved. Mildly
enlarged heart size, mediastinal and hilar contours are stable.
There is no pneumothorax.
IMPRESSION: Since [**2165-12-29**], mild pulmonary edema,
small effusions and left lower lung atelectasis have improved.
Brief Hospital Course:
Mr. [**Known lastname 77002**] is a 58 year old male with history of atrial
fibrillation (on coumadin), diastolic heart failure, s/p [**Known lastname **]
[**Known lastname **] (on mycophenolate, cyclosporine, prednisone
immunosuppresion), failed pancreas [**Known lastname **], hypertension,
admitted for injuries sustained after mechanical fall and
dyspnea, transferred to MICU for hypoxia.
# Hypoxia: History of chronic diastolic heart failure with
recent exacerbations over the past several months, has been
getting diuresed prior to transfer to the ICU but continued to
be hypoxic on NRB. BNP >[**Numeric Identifier 3301**] which was actually decreased from
most recent BNP in [**Month (only) **] although still signficantly
elevated. Temporal association of increasing hypoxia s/p FFP
tranfusion raises suspicion of fluid overload (transfusion
association circulatory overload). CXR consistent with fluid
overload, but also could not rule out infectious process in
patient that has underlying immunosuppression. He did develop a
fever in the MICU and CT torso showed multifactorial pneumonia
and Right-sided effusion. He was treated with diuresis and
antibiosed for 8 days with vancomycin/zosyn/levofloxacin for
HCAP. ECG showed atrial fibrillation with changes c/w old ECGs,
however new T wave changes in V5/V6, so his cardiac enzymes were
trended and remained flat. He was never intubated or placed on
bipap. He was weaned off high flow mask and was satting well on
nasal cannula so was transferred to the general medicine floor.
He was -1.8L fluid after ICU stay with elevated JVD suggesting
he was still volume up so he was continued on lasix at 80mg po
BID per [**Month (only) **] recs. He was discharged on lasix 60mg po BID. On
the floor, he was weaned off of oxygen with continued diuresis.
At the time of discharge, his oxygen saturations were 92-94% on
RA at rest, and 89-94% when ambulating.
.
# Acute on chronic [**Month (only) **] failure: s/p [**Month (only) **] [**Month (only) **] in [**2157**].
Creatinine was within patient's typical baseline range on
admission. He was continued on his immunosuppressive regimen
(mycophenolate, cyclosporine, and prednisone). Mycophenolate
was initially decreased to half dose in setting of infection,
but was back to home dose on transfer to the floor. Cinacalcet
was discontinued as patient's calcium was low. This should be
restarted based on outpatient follow-up labs. Calcium
supplementation was continued. Bactrim SS prophylaxis was
continued throughout admission. Per [**Year (4 digits) **] nephrology
recommendations, patient was started on renogel 800mg TID with
meals. Creatinine bumped slightly with lasix, and lasix was
decreased to 60mg [**Hospital1 **] at the time discharge. Patient will need
creatinine rechecked on Tuesday [**1-7**].
.
# Acute onset back pain: In setting of elevated INR w/ scrotal
hematoma retroperitoneal bleed is possible, although INR was
only midly elevated and his hematocrit has been stable. This
pain was different in nature and location from his pain s/p
fall. A CT torso was performed which showed no aortic pathology
or RP bleed but did show a single non-displaced rib fracture.
His pain was controlled with tylenol, oxycodone and lidocaine
patch and his hemotocrit remained stable.
.
# Atrial fibrillation: INR supratherapeutic. Coumadin held and
was reversed with FFP 4 units and vitamin K 5mg due to concern
for RP bleed as above. Restarted coumadin on [**2165-12-27**], and
patient was slowly titrated up to 4mg on the day of discharge.
INR was 1.6 on the day of discharge, and patient will need INR
checked at [**Hospital 191**] [**Hospital3 **] on Tuesday [**1-7**].
.
# Right scrotal hematoma: Secondary to fall and supratherapeutic
INR. Has been evaluated by Urology, no acute interventions
needed during this admission. Groin was monitored; it remained
stable and pt reported decrease in size at the time of discharge
to the general medicine floor.
.
# Adrenal insufficiency s/p right adrenalectomy in [**2163**]:
Continued home regimen of fludricortisone.
# Anemia: Patient appears to be around his typical baseline.
Anemia secondary to kidney failure.
# Type I diabetes mellitus: Continued home glargine regimen and
provided sliding scale insulin.
# Coronary artery disease (CAD) s/p stent of Ramus Intermedius
in [**2156**]: Continued home aspirin and statin therapy.
# GERD: Continued home pantoprazole.
TRANSITIONAL ISSUES:
# Will need INR and creatinine checked on TUESDAY [**1-7**]
# Cinacalcet held at time of discharge. Check ca/phos/PTH levels
as outpt
# Started renogel 800mg TID
# Lasix increased to 60mg PO BID as outpt
# Repeat testicular U/S once this acute episode resolves, to see
if there is an underlying predisposition to bleeding, urology
follow-up appointment scheduled
Medications on Admission:
amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
cyclosporine modified 25 mg Capsule Sig: Four (4) Capsule PO
Q12H (every 12 hours).
fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
insulin glargine 100 unit/mL Solution Sig: One (1) injection
Subcutaneous once a day: as directed, 12 unit at bedtime.
Metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
calcium carbonate-vitamin D2 600 mg calcium- 200 unit
Capsule Sig: One (1) Capsule PO twice a day.
omega-3 fatty acids-vitamin E Oral
sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Coumadin 2 mg Tablet Sig: 2-4 Tablets PO once a day: as
directed.
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. cyclosporine modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. calcium carbonate-vitamin D2 600 mg calcium- 200 unit Capsule
Sig: One (1) Capsule PO twice a day.
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
12. warfarin 2 mg Tablet Sig: 2-4 Tablets PO Once Daily at 4 PM.
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*0*
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. insulin glargine 100 unit/mL Solution Sig: Twelve (12) Units
Subcutaneous at bedtime.
17. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*0*
18. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation PRN as needed for shortness of breath or
wheezing.
Disp:*1 INH* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia
Congestive Heart Failure
Secondary:
End stage [**Month (only) **] disease s/p [**Month (only) **] [**Month (only) **]
Diabetes mellitus type 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 77002**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**].
You were admitted to the hospital after a fall and because you
were short of breath. You were evaluated with CT scans which
showed no evidence of acute fractures. Your breathing worsened
and you were transferred to the medical ICU for intensive
breathing support. You were diagnosed with and treated for
pneumonia and a exacerbation of your congestive heart failure.
We decreased the fluid overload in your lungs with lasix, and
you completed a course of antibiotics.
You were also found to have a [**Hospital1 **] clot (hematoma) in your
scrotum. You were seen by urology who felt that no intervention
was necessary.
Please have both your INR and CREATININE checked on tuesday [**1-7**], [**2166**]
We have made the following changes to your medications:
- INCREASE lasix to 60mg TWICE a day
- START iron pill twice daily
- START renogel 800mg three times a day, with meals
- STOP cinacalcet
Please continue the remainder of your medications as prescribed
prior to admission. Please see the attached medication list.
Followup Instructions:
Please call for an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**4-12**]
weeks.
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2166-1-7**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2166-1-8**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2166-1-10**] at 10:00 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"996.81",
"585.6",
"922.4",
"428.0",
"518.81",
"486",
"E849.0",
"286.9",
"255.5",
"285.21",
"250.03",
"584.9",
"V58.61",
"V45.82",
"428.33",
"E878.0",
"427.31",
"428.30",
"E885.9",
"414.01",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
21486, 21492
|
13694, 18135
|
285, 292
|
21699, 21699
|
4345, 13671
|
23024, 24073
|
3313, 3450
|
19786, 21463
|
21513, 21678
|
18546, 19763
|
21850, 22708
|
3465, 4326
|
18156, 18520
|
22737, 23001
|
229, 247
|
320, 2289
|
21714, 21826
|
2311, 3142
|
3158, 3297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,262
| 157,634
|
5183+55647
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-10-17**] Discharge Date: [**2107-10-25**]
Date of Birth: [**2034-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
instent restenosis
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x1(RIMA-RCA) [**2107-10-21**]
History of Present Illness:
This 73 year old male with known coronary disease has undergone
multiple prior interventions, including [**5-/2103**] Cypher to RCA
followed by
[**2104-12-23**] RCA restenosis treated with POBA and then [**1-/2107**]
treated with Promus DES placed in ostial RCA. Other stents
include an LAD stent which is patent and D2 GR stent. He
returns with increased chest heaviness on exertion, palpitations
limiting his exercise capacity. A stress test was positive and
he was cathetreizedd today to find a 99% ostial restenosis in
stent of the RCA. Cardiac surgery was consulted to evaluate for
operation.
Past Medical History:
hypertension
Hyperlipidemia
s/p multiple stents
Paget's disease
Renal cell carcinoma -s/p left nephrectomy
chronic kidney disease
Vertigo
gastroesophageal reflux
Social History:
Lives in [**Location 21200**] with wife, quit smoking 48 years ago, denies
ETOH or drug use; worked at [**Company 21201**].
Family History:
Father died at age 62; had MI and Diabetes.
Physical Exam:
admission:
Pulse: 51S Resp:18 O2 sat: 98%RA
B/P Right: Left:
Height:5'[**08**]" Weight:182#
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 Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2107-10-24**] 02:53AM BLOOD Hct-28.4*
[**2107-10-23**] 05:19AM BLOOD WBC-10.8 RBC-3.06* Hgb-9.8* Hct-28.3*
MCV-93 MCH-32.1* MCHC-34.7 RDW-13.3 Plt Ct-101*
[**2107-10-25**] 04:32AM BLOOD Na-137 K-4.7 Cl-102
[**2107-10-17**] 06:30PM BLOOD Glucose-117* UreaN-18 Creat-1.1 Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
[**2107-10-17**] 06:30PM BLOOD ALT-17 AST-22 LD(LDH)-174 CK(CPK)-77
AlkPhos-327* Amylase-39 TotBili-0.6 DirBili-0.2 IndBili-0.4
[**2107-10-17**] 06:30PM BLOOD %HbA1c-6.6* eAG-143*
Echo-
The left atrium is mildly dilated. The left atrium is elongated.
Left ventricular wall thicknesses are normal. Overall left
ventricular systolic function is normal (LVEF 65-70%). The
remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2104-12-24**], the findings are similar
Brief Hospital Course:
Following catheterization he underwent the usual preoperative
workup. On [**10-21**] he went to the Operating Room where
revascularization was performed. See operative note for
details. He weaned from bypass on NeoSyneohrine and Propofol.
He weaned and extubated easily, pressors were discontinued.
Beta blockers and diuresis were begun and Physical Therapy
consulted.
He progressed well, CTs and wires were removed per protocols. He
was discharged to a rehabilitation facility for further recovery
prior to returning home where he is the care giver for his
disabled wife. Wounds were clean and healing well at discharge.
Arrangements were made for follow up.
He was transferred to LifeCare Center in [**Location (un) **] on [**10-25**].
Medications on Admission:
AMLODIPINE 2.5mg daily
ATENOLOL 50 mg Tablet daily
CLOPIDOGREL 75mg daily
EZETIMIBE 10mg daily
IRBESARTAN 150 mg daily
METFORMIN 500 mg daily
NITROGLYCERIN 0.4 mg prn,
PREGABALIN 100 mg daily
ROSUVASTATIN 20 mg daily
TAMSULOSIN 0.4 mg HS
ASPIRIN 81mg Tablet daily
CALCIUM CARBONATE 600mg [**Hospital1 **]
CYANOCOBALAMIN 1,000 mcg daily
ERGOCALCIFEROL 400 unit Capsule - 2 daily
MULTIVITAMIN daily
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO once a day.
3. Rosuvastatin 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 DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p coronary stents
gastroesophageal reflux
hypertension
h/o renal cell cancer/nephrectomy
hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**11-16**] at 1:30
Cardiologist: Dr.[**Last Name (STitle) 11493**] on[**2107-11-14**] at 3:15pm
Please call to schedule appointments with your
Primary Care physician [**Last Name (NamePattern4) **] [**4-25**]-weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2107-10-25**] Name: [**Known lastname 3526**],[**Known firstname 2794**] E Unit No: [**Numeric Identifier 3527**]
Admission Date: [**2107-10-17**] Discharge Date: [**2107-10-25**]
Date of Birth: [**2034-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 135**]
Addendum:
In addition to listed medications he was on Lopressor 12.5mg [**Hospital1 **]
orally
Chief Complaint:
see summary
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 1 (RIMA-RCA)
left heart catheterization, coronary angiogram
History of Present Illness:
see sumary
Past Medical History:
hypertension
Hyperlipidemia
s/p multiple stents
Paget's disease
Renal cell carcinoma -s/p left nephrectomy
chronic kidney disease
Vertigo
gastroesophageal reflux
Social History:
Lives in [**Location 3528**] with wife, quit smoking 48 years ago, denies
ETOH or drug use; worked at [**Company 3529**].
Family History:
Father died at age 62; had MI and Diabetes.
Physical Exam:
see summary
Pertinent Results:
see summary
Brief Hospital Course:
see summary
Medications on Admission:
see summary
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO once a day.
3. Rosuvastatin 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 DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1620**] - [**Location (un) 1621**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass graft
s/p coronary stents
gastroesophageal reflux
hypertension
h/o renal cell cancer/nephrectomy
hyperlipidemia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
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) 1477**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on 1027 at 1:30 [**Telephone/Fax (1) 1477**]
Cardiologist: Dr. [**Last Name (STitle) 1653**] on [**11-14**] at 3;15
Please call to schedule appointments with your
Primary Care physician [**Last Name (NamePattern4) **] [**4-25**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2107-10-25**]
|
[
"E878.8",
"731.0",
"411.1",
"V45.82",
"996.72",
"250.00",
"585.9",
"414.01",
"530.81",
"403.90",
"272.4",
"V45.73",
"584.9",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"37.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10041, 10115
|
8693, 8706
|
8089, 8183
|
10322, 10481
|
8657, 8670
|
11324, 11972
|
8565, 8610
|
8768, 10018
|
10136, 10301
|
8732, 8745
|
10505, 11301
|
8625, 8638
|
8038, 8051
|
8211, 8224
|
8246, 8409
|
8425, 8549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,899
| 175,977
|
35389
|
Discharge summary
|
report
|
Admission Date: [**2178-4-21**] Discharge Date: [**2178-4-30**]
Date of Birth: [**2102-7-16**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Demerol
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Transfer for cath
Major Surgical or Invasive Procedure:
Intubation
Central Line Placement
PPM placement
History of Present Illness:
75 F with COPD, htn, bilateral hip replacements, depression,
anxiety transferred from OSH for NSTEMI. She was recently
hospitalized at [**Hospital3 **] from [**4-10**] to [**4-13**] for a R hip
dislocation s/p closed reduction. The hospital course was
complicated by respiratory failure requiring ICU stay for
bilateral PNA and COPD flare. She was discharged to home on a
course of doxycycline and steroid taper which she has not
finished yet. At home, she really has not been active and on the
night of [**4-20**], she felt so SOB she could not sleep. She had
trouble lying flat but did not notice weight gain or leg edema.
She also reports having increased clear sputum over the past
three days.
She was brought to [**Hospital3 417**] Hospital where initial CXR did
not show infiltrate or CHF. She was thought to have another COPD
flare and was given Ceftriaxone and steroids. She was thought to
be dry in fact and was given fluids initially. Eventually, her
cardiac markers came back positive: Troponins 8.8, 8.8 and 4.6,
CK 237, 190, 163; MB 56, 43, 40. She was given plavix and
lovenox and was transferred to [**Hospital1 18**] for cath.
During cath, she was found to have diffuse disease and she got 4
DES to the LAD. She was hypoxic and got 40 IV lasix and put out
1L. A RHC was not done. She was on a non-rebreather saturating
100% with SBP 110. She was then transferred to the CCU.
ROS: Denies chest pain, abd pain, n/v/d. Denies palpitations,
LH, syncope. Denies claudications. Denies bleeding disorder or
hematachezia or strokes.
Past Medical History:
COPD on home O2 at one pt, and required intubation in the past
Bilateral Hip replacement
Wrist fracture
Anxiety
Depression
GERD
Social History:
Lives with her husband, 40 pack year smoking history, currently
still smokes about 5 cigarretts a week. Retired school nurse.
Family History:
No early family history of CAD.
Physical Exam:
GEN: A+Ox3, NAD, mildly drowsy but answers questions
appropriately
HEENT: PERRL, EOMI, OP clear, MMM
NECK: JVP to angle of jaw
CV: RRR, no M/G/R, PMI at 5th intercostal space midclavicular
line, no heaves or thrills
PULM: Diffuse crackles and tight air movement, minimal wheezing,
no rhonchi.
ABD: Soft, NT, ND, +BS
EXT: No peripheral edema
NEURO: CN II-XII intact, mobilizes all extremities
Pertinent Results:
Admission labs:
[**2178-4-21**] 07:51PM BLOOD WBC-13.2* RBC-4.24 Hgb-12.7 Hct-39.6
MCV-93 MCH-29.9 MCHC-32.0 RDW-13.9 Plt Ct-221
[**2178-4-21**] 07:51PM BLOOD PT-16.5* PTT-51.1* INR(PT)-1.5*
[**2178-4-21**] 07:51PM BLOOD Glucose-117* UreaN-18 Creat-0.9 Na-137
K-4.5 Cl-98 HCO3-35* AnGap-9
[**2178-4-21**] 07:51PM BLOOD CK(CPK)-110
[**2178-4-21**] 07:51PM BLOOD CK-MB-15* MB Indx-13.6*
[**2178-4-22**] 02:51AM BLOOD ALT-165* AST-68* LD(LDH)-417* CK(CPK)-76
AlkPhos-83 TotBili-0.2
[**2178-4-22**] 02:51AM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.8 LDLcalc-78
[**2178-4-21**] 08:30PM BLOOD pO2-166* pCO2-91* pH-7.18* calTCO2-36*
Base XS-2
[**2178-4-21**] 08:30PM BLOOD Lactate-0.6
Micro:
Urine cx: negative x2
Blood cx: NGTD x2
RESPIRATORY CULTURE (Final [**2178-4-24**]): OROPHARYNGEAL FLORA
ABSENT. YEAST, SPARSE GROWTH. MOLD, 1 COLONY ON 1 PLATE.
Imaging:
[**2178-4-21**] Cardiac cath:
Selective coronary angiography of this right dominant system
revealed
nonobstructive left main and 2 vessel obstructive coronary
artery
disease. The LMCA had a 40% stenosis distally, extending into
the ostium
of the LAD. The LAD was a large vessel that supplied the apex,
and was
diffusely diseased and calcified. There was a 40% ostial
stenosis,
followed by sequential 70% and 90% stenoses of the proximal and
mid LAD.
The LCX was totally occluded, and was collateralized distally by
the
RCA. The RCA had lumenal irregularities up to 30-40% stenosis of
the
proximal and mid vessel, but was otherwise patent. Patient
received 4 DES to the LAD.
[**2178-4-21**] CXR:
The heart size is mildly enlarged. The mediastinum is slightly
shifted
towards the right that might be due to atelectasis or scarring
in the right upper lobe. Lungs are overall hyperinflated with
start increase in
interstitial prominence in both lungs which might represent
interstitial
pulmonary edema in the presence of emphysema. Round dense
approximately 2 cm opacity projecting over the right hilus and
may represent calcified lymph node.
[**2178-4-22**] CXR:
The ET tube tip is 5 cm above the carina. The cardiomediastinal
silhouette is stable with slightly decreased heart size. It
might be due to initiation of mechanical ventilation. The lungs
remain over- inflated and essentially clear except for minimal
opacity at the right base which may represent atelectasis versus
small aspiration and linear right perihilar scarring. The
previously suspected nodular opacity is not seen on the current
study and may be obscured, thus evaluation with follow-up
radiograph is recommended. Interstitial edema has resolved.
[**2178-4-22**] ECG:
Probable atrial fibrillation with rapid ventricular response
rate at 165.
Non-specific generalized repolarization changes consistent with
tachycardia and/or ischemia. Cannot exclude left ventricular
hypertrophy. Compared to the previous tracing of [**2178-4-21**] normal
sinus rhythm with probable left atrial abnormality has given way
to atrial fibrillation with rapid ventricular rate and the heart
rate has nearly doubled.
[**2178-4-23**] TTE:
Moderate regional left ventricular systolic dysfunction (EF
40-45%) with severe hypokinesis of the basal to mid inferior and
inferolateral segments and mild hypokinesis of the basal to mid
anterior wall and anterior septum. Systolic function of apical
segments is relatively preserved. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). (1+) mitral regurgitation. Mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2178-4-26**] ECG: Sinus rhythm. Non-specific ST-T wave changes.
Compared to the previous tracing sinus rhythm has replaced
atrial fibrillation.
[**2178-4-26**] CXR: Severe hyperinflation reflects COPD. Elevation of
the minor fissure reflects volume loss in the right upper lobe.
Fullness in the right hilus may indicate adenopathy. Routine
radiographs are recommended as a first step and to see if
additional imaging with CT scanning is indicated.
Lungs clear of focal abnormality. Heart size normal. Thoracic
aorta is
generally large but not focally aneurysmal. No pneumothorax.
Brief Hospital Course:
1. NSTEMI: Patient transferred with positive biomarkers but
already trending down at OSH. Event possibly from OSH admission
when she developed respiratory failure from bilateral PNA, or
shortly after discharge. Had diffuse disease now s/p 4 DES to
LAD. Medical regimen includes aspirin, beta blocker, plavix,
statin. Also encouraged smoking cessation, nicotine patch use.
No further complaints of chest pain during hospitalization.
Please note that she should have her aspirin dose reduced to 81
mg on [**2178-5-19**] (i.e. 4 weeks after her cath). [**Last Name (un) **]
2. Acute on chronic systolic and diastolic HF: Had crackles all
the way up the lung fields bilaterally on admission. She
diuresed with good response to lasix 40 IV. EF in [**12-6**] was
45-50%, now 40-45%. She was continued on her blocker and [**Last Name (un) **]
(initially held with hypotension but restarted as hypotension
resolved). Exam improved with diuresis.
3. COPD: Increased sputum production and wheezing as well as
hypercarbia suggestive of COPD flare. Was treated with
levofloxacin 5 day course and steroid taper, which she had still
been on from her last COPD flare. Sputum culture with yeast and
1 colony of mold, no clinical evidence of infection. She was
continued on her inhaler regimen, and started on tiotropium.
4. Afib/Arrhythmias: Pt developed afib with RVR on [**2178-4-22**] with
HR to 150s. She was given IV diltiazem and amiodarone with good
response. She had several subsequent episodes (approx 1-2 per
day) which responded well to diltiazem IV. She was started on
carvedilol which was uptitrated as tolerated, and amiodarone was
continued PO. She was started on coumadin without bridge.
However, on [**2178-4-26**] she had a 20 second asystolic episode,
likely secondary to vagal episode. Code blue was called but
patient quickly recovered blood pressure, heart rate and
respirations wihtout intervention. Review of tele appeared to
have sinus brady and slowing before 20sec pause then sinus tachy
with recovering of pulse. She was transferred back to the CCU,
beta blockers, amiodarone and coumadin were held in the
preparation for pacemaker placement by EP. The pacemaker was
placed on [**2178-4-28**]. She was treated with 72 hours of antibiotics
following. She will have her device checked in the [**Hospital **] clinic in
one week.
5. Blood pressure: Patient developed hypotension requiring
pressors after intubation likely related to intubation. Given
initial concern for infection or sepsis since she had a fever on
arrival, she was treated with vanc <24 hours. This was
discontinued as patient's BP improved after extubation. Her
losartan was discontinued since she was noted to be hypotensive,
especially post pranidially.
Medications on Admission:
Prednisone taper (starting on [**4-14**]: 40mg x2d, 30mg x2d, 20mg
x2d, 10mg x3d)
Doxycycline
Klonipin 0.5 in the AM and q4H PRN
Paxil 20
Cozaar 50
Nexium 40
Simvastatin 10
Calcium Vit D 1200/400
Advair 250/50 [**Hospital1 **]
Spiriva
Albuterol PRN
MVI
Discharge Medications:
1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO q AM.
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for anxiety.
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 3 doses.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
16. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months: After 1month change to 81mg daily.
18. Pneumoboots
When in bed patient should have pneumboots on for DVT
prophylaxis
19. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 6 weeks.
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. COPD Exacerbation
2. NSTEMI
3. Atrial Fibrillation
4. Vagal episode
.
SECONDARY DIAGNOSES:
1. Bilateral Hip replacement
2. Anxiety
Discharge Condition:
Stable. Patient is tolerating oral intake and ambulating with
assistance.
Discharge Instructions:
You were admitted to the hospital with shortness of breath. This
is most likely related to your COPD and heart disease. For your
COPD, you were treated with steroids, antibiotics, and inhalers.
For your heart disease, you underwent a cardiac catheterization
which demonstrated disease in your heart vessels. You had
several stents placed in your heart vessels. While you were
hospitalized, you also had an abnormal heart rhythm. This was
improved with medications.
.
your weight increases by 3 lbs. Please adhere to a low salt
diet.
.
We have made the following changes to your medications:
These medications were started:
- Atorvastatin
- Aspirin (please decrease to 81mg after one month)
- Plavix
- Lasix
- Coumadin
- Carvedilol
- Xopenex (as needed): this is in place of your albuterol
inhaler
- Cephalexin (three more doses)
.
These medications were discontinued:
- Albuterol
- Simvastatin
- Losartan
.
These medications were continued:
- Advair
- Spiriva
- Paxil
- Klonipin
- Nexium
- Calcium and Vit D
.
Please seek immediate medical attention if you develop chest
pain, shortness of breath, light-headedness, dizziness, passing
out, wheezing, swelling in your lower extremities, headache,
fevers, shaking chills, or night sweats.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on after you are discharged from rehabilitation. He
can check your coumadin levels using a fingerstick test and will
tell you how much coumadin to take.
.
Please also follow-up with your cardiologist Dr [**Last Name (STitle) **] Phone:
[**Telephone/Fax (1) 62**] Date/time: [**6-8**] at 2:00 pm [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) **] [**Hospital Ward Name 516**],
.
Pulmonology:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 80661**] Date/time: [**5-8**]
at 10:30am.
.
Pacemaker follow-up:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2178-5-5**] 1:30 [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) 436**]. [**Hospital Ward Name **]
Completed by:[**2178-4-30**]
|
[
"428.43",
"305.1",
"518.81",
"272.4",
"410.71",
"427.32",
"V46.2",
"780.2",
"428.0",
"300.4",
"427.31",
"491.21",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.48",
"37.22",
"96.04",
"88.56",
"96.71",
"00.40",
"37.72",
"00.66",
"37.83",
"36.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11771, 11824
|
6848, 9592
|
319, 369
|
12022, 12098
|
2712, 2712
|
13384, 14305
|
2252, 2285
|
9896, 11748
|
11845, 11845
|
9618, 9873
|
12122, 12685
|
2300, 2693
|
11958, 12001
|
12714, 13361
|
262, 281
|
397, 1942
|
2728, 6825
|
11864, 11937
|
1964, 2093
|
2109, 2236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,018
| 105,743
|
44810
|
Discharge summary
|
report
|
Admission Date: [**2150-1-1**] Discharge Date: [**2150-1-8**]
Date of Birth: [**2071-7-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Diuretics / Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2150-1-1**] Aortic valve replacement 21-mm Biocor Epic tissue valve
History of Present Illness:
78 year female with a history of aortic stenosis followed by
serial echocardiogram. Over the past several months, she has
noted worsening symptoms of dyspnea with exertion and lower
extremity swelling. He last echocardiogram in [**2149-3-7**]
revealed an LVEF of 55%, mild left ventricular hypertrophy and
moderate to severe aortic stenosis. Given the progression of her
symptoms and severity of her disease, she was referred for
surgical evaluation.
Past Medical History:
Severe aortic stenosis
Nonobstructive diffuse coronary artery disease on cardiac
catheterization in [**2147-8-8**]
Insulin-dependant diabetes
Hypertension
Hyperlipidemia
Chronic diastolic Congestive heart failure
Chronic low back pain
depression
Reactive airway disease
Face lift, cheek implants
Right cataract surgery
Cesarean sections
Social History:
Race: Caucasian
Last Dental Exam: Full dentures
Lives: Alone
Occupation: Retired
Tobacco use: Remote, quit more than 30 years ago
ETOH: occasional wine, one glass per week
Illicit drug use: denies
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 79 Resp: 18 O2 sat: 97%
B/P Right: 146/56 Left: 149/63
Height: 61 inches Weight: 190 lbs
General: Elderly female in no acute distress. Obese
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace
Varicosities: None
Neuro: Grossly intact
Pulses:
Femoral Right: 1 Left: 1
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: 1
Carotid Bruit: transmitted murmurs bilaterally
Pertinent Results:
[**2150-1-1**] Echo: PRE-CPB: The left atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is severe mitral annular
calcification. Mild to moderate ([**12-8**]+) mitral regurgitation is
seen.
POST-CPB: There is a bioprothetic valve in the aortic position.
The valve appears well-seated with normally mobile leaflets.
There are no paravalvular leaks and no AI. The LV systolic
function remains normal, estimated EF>55%. There is no evidence
of dissection.
Chest X-Ray: PA and lateral chest compared to [**2150-1-4**]
Previous vascular congestion and borderline interstitial edema
have cleared. Cardiomediastinal silhouette has a normal
postoperative appearance. Lateral view shows small bilateral
pleural effusions and mild to moderately severe bibasilar
atelectasis. No pneumothorax.
[**2150-1-5**] WBC-9.9 RBC-2.94* Hgb-9.1* Hct-26.7* MCV-91 MCH-31.1
MCHC-34.3 RDW-16.1* Plt Ct-111*
[**2150-1-1**] WBC-5.5 RBC-2.90* Hgb-9.1* Hct-26.2* MCV-90 MCH-31.4
MCHC-34.7 RDW-16.2* Plt Ct-143*
[**2150-1-5**] UreaN-30* Creat-1.1 Na-135 K-4.6 Cl-98
[**2150-1-2**] Glucose-97 UreaN-13 Creat-1.0 Na-139 K-4.8 Cl-107
HCO3-27
[**2150-1-5**] Mg-2.6
Brief Hospital Course:
Mrs. [**Known lastname 95874**] was a same day admit and on [**2150-1-1**] was brought
directly to the operating room where she underwent an aortic
valve replacement. Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one she was started on beta-blockers and
diuretics and diuresed towards her pre-op weight. On post-op day
two she was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. On post-op day three she had an episode of atrial
fibrillation which converted to sinus rhythm with beta-blockers
and Amiodarone. She was started on coumadin for her afib. she
was agressively diuresed toward her pre-op weight. She
experienced post-op confusion and all narcotics were
discontinued and her mental status claered. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility amd rehab was recommended. By the time of
discharge on POD #7 the patient was ambulating with assist, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to [**Hospital 1514**] rehab in good condition
with appropriate follow up instructions.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by
mouth every four (4) to six (6) hours as needed for
cough/wheezing
ALENDRONATE - (Not Taking as Prescribed) - 70 mg Tablet - 1
tab(s) by mouth weekly in the AM with 6-8oz of plain water, do
not eat, drink or lie down for 30 mins
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth
once a day
GLYBURIDE - (Not Taking as Prescribed) - 5 mg Tablet - 2
Tablet(s) by mouth twice a day
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 110 units sc once a day
SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 puff po daily
TORSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth daily
TRIAMCINOLONE ACETONIDE - (chart conversion) - 0.025 % Cream -
Apply to affected area on back twice a day
VALSARTAN [DIOVAN] - (Not Taking as Prescribed) - 80 mg Tablet
- 1 Tablet(s) by mouth once a day
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [GLUCOCOM GLUCOSE] - (chart conversion) -
Strip - use as directed 1 time per day
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for
bronchospasm.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ranitidine HCl 150 mg Capsule Sig: One (1) Tablet PO once a
day for 2 weeks.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever or pain.
11. torsemide 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): home dose.
12. ipratropium bromide 0.02 % Solution Sig: One (1) neb IH
Inhalation Q6H (every 6 hours) as needed for wheezing.
13. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for SBP <90 or HR < 55.
15. insilin sliding scale and fixed dose ( see attached)
16. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg [**Hospital1 **] through [**1-12**].
17. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks: 400 mg daily [**1-13**] through [**1-19**].
18. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
200 mg daily starting [**1-20**] ongoing.
19. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day: hold for K+ > 4.5;
please recheck potassium level in [**1-9**] days.
20. warfarin 1 mg Tablet Sig: daily dosing per rehab provider;
dose today [**1-8**] only is 4 mg; all further dosing per rehab;
target INR 2.0-2.5 for A Fib Tablets PO Once Daily at 4 PM: dose
today only [**1-8**] is 4 mg.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1514**] Health Care Center - [**Location (un) 1514**]
Discharge Diagnosis:
Severe aortic stenosis s/p Aortic valve replacement
Past medical history:
Nonobstructive diffuse coronary artery disease on cardiac
catheterization in [**2147-8-8**]
Insulin-dependant diabetes
Hypertension
Hyperlipidemia
Chronic diastolic Congestive heart failure
Chronic low back pain
depression
Reactive airway disease
Face lift, cheek implants
Right cataract surgery
Cesarean sections
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema BLE 2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0- 2.5
First draw [**1-9**]
***please arrange for coumadin followup prior to discharge from
rehab
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2150-2-4**] at 1:30PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] on [**2150-2-5**] at 11:00AM
Primary Care: Dr. [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**] on [**2150-3-4**] at 2:30PM
**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
Goal INR 2.0- 2.5
First draw [**1-9**]
***please arrange for coumadin followup prior to discharge from
rehab
Completed by:[**2150-1-8**]
|
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icd9cm
|
[
[
[]
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[
"39.61",
"35.21"
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icd9pcs
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[
[
[]
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|
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320, 392
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,418
| 192,754
|
4981
|
Discharge summary
|
report
|
Admission Date: [**2112-5-30**] Discharge Date: [**2112-6-3**]
Date of Birth: [**2036-12-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Lyrica / Ace Inhibitors / Metformin /
Dofetilide / Quinidine / Fentanyl
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obtained from medical record and patient. 75 yo man with
history of CHF (EF 15%), afib on coumadin, CAD s/p MI, diabetes,
HTN, presented from rehab [**5-30**] with altered mental status after
recent [**Hospital1 18**] admit [**Date range (1) 20648**] for RLL pna. He had been
discharged to rehab on [**5-27**] ([**Hospital1 **] in [**Location (un) 701**]), to
complete a 7-day course of vanco/zosyn (last day was to be [**6-1**]).
He became increasingly combative and confused at rehab with
lethargy. Per Rehab records, patient was noted to have some
confusion on [**2112-5-28**]. On [**2112-5-29**] he had a new roommate in his
room, who per nursing report was confrontational with the
patient. Mr. [**Known lastname 20649**] lost a night of sleep and was noted to
subsequently have increasing agitation and confusion.
Unfortunately, he was given 2mg IV Ativan for his confusion, and
continued to be agitated- and became a verbal and physical
threat to the staff, requiring administration of a Posey. He was
then transferred to [**Hospital1 18**] on [**5-30**] for altered mental status. Per
report his daughter noted visual hallucinations for a few weeks
prior to admit on risperdal (new med).
In the ED to 101.8 rectal and was admitted to the ICU out of
concern for sepsis (given WBC 14.8) with altered mental status
and lactate of 2.3. Presumed source for infection was persistent
pneumonia. He was given meropenum x2 doses only then continued
on vanco/zosyn to complete the original course with the addition
of azithromycin. He defervesced after admit. Duloxetine and
risperdal were held on this admission given mental status
change. Currently he is confussed, but does know he is in [**Location (un) 86**]
in a hospital ([**Hospital1 756**]), not why he is in the hospital. He
notes cough but no other complaints.
Review of his record reveals he was never restarted on an ace
inhibitor or [**Last Name (un) **] after last discharge. Prior dose reportedly
10mg of diovan daily (?), prior noted to be 20mg.
Review of systems: He complains of cough and choking on food but
all other review of systems extensively (10 systems) negative.
Past Medical History:
Congestive heart failure with cardiomyopathy, EF 15%
CAD s/p MI
Dual chamber PCM
gout
CKD
Depression
Atrial fibrillation and ventricular ectopy with a pacemaker
Diabetes with associated neuropathy
Hypertension
History of lower extremity ulcers
Left vestibular schwannoma
Social History:
Social History: Has been living in rehab recently given failure
to thrive at home over past few months. Formerly smoked cigars,
quit about 30 years ago. Former heavy EtOH use, quit about 20
years ago.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.1 BP: 119/65, P: 70, R: 20, O2: 99% 3L NC
General: Obese elderly man, NAD
Eyes: sclear anicteric, anisocoria (3mm OD, 2mm OS) but equally
reactive
HEENT: dry mucous membranes, oropharynx clear
Neck: supple, JVP flat, no LAD
Respiratory: Gurgling upper airway sounds, lower lungs are
rhochorus but no wheezing, rales right base
Cardiovascular: Distant heart sounds, irregularly irregular but
normal rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound guarding
Ext: Cool brawny skin changes and decreased hair growth on the
bilateral lower legs, multiple skin tears/excorations over the
legs and and arms, 2+ edema bilateral lower extremities
Integument: multiple skin tears on extremities, erythema over
sacrum (stage 1) but no ulceration, multiple scattered
ecchymosis
Neurologic Exam: alert, oriented to 'boston, [**Hospital **] hospital,
[**2105**], [**Month (only) 596**],' strength 5/5 upper and lower extremities, decreased
sensation distal lower extremities bilaterally
Foley in place
Pertinent Results:
[**2112-5-30**] 12:49PM LACTATE-4.3*
[**2112-5-30**] 12:40PM GLUCOSE-314* UREA N-33* CREAT-1.8* SODIUM-141
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16
[**2112-5-30**] 12:40PM ALT(SGPT)-12 AST(SGOT)-20 ALK PHOS-87 TOT
BILI-2.2*
[**2112-5-30**] 12:40PM LIPASE-41
[**2112-5-30**] 12:40PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2112-5-30**] 12:40PM DIGOXIN-0.8*
[**2112-5-30**] 12:40PM WBC-14.8* RBC-4.34* HGB-12.3* HCT-40.9 MCV-94
MCH-28.5 MCHC-30.2* RDW-14.6
[**2112-5-30**] 12:40PM NEUTS-85.1* LYMPHS-9.5* MONOS-4.6 EOS-0.5
BASOS-0.3
[**2112-5-30**] 12:40PM PLT COUNT-224
[**2112-5-30**] 12:40PM PT-29.5* PTT-37.3* INR(PT)-2.9*
[**2112-5-30**] 12:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.026
[**2112-5-30**] 12:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2112-5-30**] 12:40PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0
Radiology
Head CT [**6-1**]: No evidence of acute intracranial abnormalities.
Mild-to-moderate chronic small vessel ischemic disease. If there
is a clinical suspicion for an acute infarction, then MRI would
be a more sensitive study.
CXR portable [**5-30**]: Continued improvement of right lower lobe
pneumonia.
CXR [**5-31**]: Moderate pulmonary edema.
[**2112-6-2**] Radiology CHEST (PA & LAT)
General improvement of chest findings, marked improvement of
previously identified pulmonary congestion and central edema
pattern. Some
bilateral basal infiltrates persist and further followup is
recommended.
Micro:
[**5-30**] Blood cultures: no growth to date, pending
[**5-30**] Urine cultures: no growth
[**5-31**] urine legionella antigen negative
[**2112-6-2**] STOOL CONSISTENCY: SOFT
FECAL CULTURE (Final [**2112-6-3**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Pending):
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-6-2**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**Month/Day/Year **] [**2112-6-3**] (DATE OF TRANSFER)
[**2112-6-3**] 06:05AM BLOOD WBC-11.3* RBC-3.79* Hgb-11.2* Hct-34.0*
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.8* Plt Ct-217
[**2112-6-2**] 06:00AM BLOOD Neuts-85.9* Lymphs-7.0* Monos-6.5 Eos-0.4
Baso-0.2
[**2112-6-3**] 06:05AM BLOOD Plt Ct-217
[**2112-6-3**] 06:05AM BLOOD PT-32.4* PTT-46.1* INR(PT)-3.3*
[**2112-6-2**] 06:00AM BLOOD Fibrino-524*
[**2112-6-3**] 06:05AM BLOOD Glucose-51* UreaN-35* Creat-1.5* Na-141
K-3.3 Cl-104 HCO3-26 AnGap-14
[**2112-6-3**] 06:05AM BLOOD ALT-12 AST-21 AlkPhos-74 TotBili-1.0
[**2112-6-3**] 06:05AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.1
[**2112-6-3**] 07:53AM BLOOD freeCa-1.11*
[**2112-6-2**] 06:00AM BLOOD VitB12-546 Folate-8.7
[**2112-6-2**] 06:00AM BLOOD TSH-2.0
[**2112-5-31**] 05:11AM BLOOD Vanco-15.2
[**2112-6-1**] 04:41AM BLOOD Digoxin-1.2
[**2112-6-2**] Bedside Swallow Evaluation
SWALLOWING ASSESSMENT:
PO trials included ice chips, thin liquids via tsp/cup, nectar
thick liquids via tsp/cup, bites of puree. Oral phase was mildly
prolonged with no oral residue remaining. Laryngeal elevation
felt adequate to palpation. Wet vocal quality and immediate wet
breathing noted with thin liquids followed by coughing. Delayed
cough and audible wet breathing noted on all further trials of
nectar thick liquid and puree. Patient denied the sensation of
food or liquid stuck in his throat or going down the wrong way,
but did report several instances where he said he needed to
cough.
SUMMARY / IMPRESSION:
Mr. [**Known lastname 20649**] presents with lethargy, generalized weakness, and s/sx
of aspiration on all consistencies trialed at the bedside as
evidenced by wet vocal quality, wet breathing immediately after
swallow and immediate and delayed reflexive coughing. Recommend
patient remain NPO at this time. Team to monitor and decide on
tube feeds as indicated over the weekend. Recommend changing
tomorrow. We will follow-up on Monday if patient remains
in-house.
Brief Hospital Course:
75 yo man with fever, mental status change, recent pneumonia p/w
delirium, persistent leukocytosis, acute on chronic systolic
heart failure. Delirium is likely multifactorial- change in
environment at nursing home, benzodiazepines at nursing home,
and infection (suspected C. Diff). Mental status, fluid balance,
and clinical features of infection all improved during this
hospitalization. The patient was transferred to [**Hospital3 2358**]
Cardiology service per patient request.
# Altered Mental Status/Delirium-Multifactorial: Suspect [**1-4**]
changes in environment, medications, and infection. Markedly
improved from admission, likely superimposed on dementia (though
daughter denies).
- Infectious w/up as below
- Zyprexa 6qpm initiated. Monitor for sedation.
- Avoid other sedating meds (e.g., benzos)
- Frequent assessment of orientation
- Maintain sleep wake cycle
- Foley removed; PT out-of-bed
- fall precuations.
- continue to hold cymbalta for now
# Leukocytosis: Rising despite defervescence and completed abx
for pneumonia. Concern for c.diff given abx treatment, loose
foul-smelling stool, rehab/hospitalization. Patient remained
afebrile with improved WBC since intiation of flagyl.
- c.diff culture negx1, precautions
- f/u blood cultures and fever curve
- Reassess for sign/symptoms of localizing infection
- Culture if spikes
#Dysphagia: Given delirium and visible aspiration during ICU
course, he was evaluated by the speech and swallow service on
[**6-2**] (see results above). Recommended
NPO status when mental status improved. Strict Q4 oral care.
# Pneumonia: Radiographically resolved s/p previous therapy.
- d/c vanco/zosyn as were due to stop [**6-1**]
- on azithromycin, but d/cd [**6-2**] given unclear indication.
- continue albuterol and ipratropium nebs
- wean oxygen to maintain sat >95%
- Sats were 98% RA on discharge
# Coagulopathy: INR up to 4.6 [**5-31**]; Hct stable. On coumadin at
rehab.
- restart coumadin if inr improved to theraputic level
- guaiac all stools
- serial hct and active type and screen
# Congestive Heart Failure, systolic: Not currently obviously
exacerbated, unclear home regimen with many medications held in
the icu given elevated lactate.
- continued spironolactone 12.5mg daily, digoxin 0.125 mg every
other day, diovan 20mg daily, lasix 40mg oral daily; lasix IV
prn
- restarted metoprolol tartrate 25mg tid (home dose 100mg
succinate daily)
- monitor volume status
- Sats were 98% RA on discharge, but noted with peripheral
edema/neck veins flat
# Acute on Chronic renal failure: Unknown baseline creatinine
but nadir in our records is 1.5, which he has returned to.
- monitor given diuresis
- restarted diovan, lasix, spironolactone
- renally dose medications
# CAD: The patient had no evidence of active disease.
- continued aspirin, metoprolol, diovan
# Type II diabetes melitus, uncontrolled, with neuropathy and
nephropathy: Not currently on full dose of his 70/30 givne not
taking po reliably,
-continued the 15 units every am for now with sliding scale
humalog insulin and monitor blood glucose q6
# Atrial fibrillation: Adequately rate control, with pacer,
continue amiodarone, digoxin, restart metoprolol as above; held
coumadin
# Depression: holding cymbalta currently, unclear if this is for
neuropathy vs. mood. likely should be discussed with pcp if
possible in am.
- hold cymbalta for now
# Gout: continue allopurinol at renal dose (150mg daily) and
monitor for symptoms, none currently.
# PPX: pneumoboots, supratheraputic on coumadin, follow inr.
# Code: DNR/DNI.
Medications on Admission:
Medications on admission:
Piperacillin-Tazobactam 4.5 g IV Q8H (day [**5-8**])
Vancomycin 750 mg IV Q 12H (day [**5-8**])
Amiodarone 200 mg PO DAILY
Digoxin 125 mcg PO QOD
Metoprolol XL 100 mg PO daily
Aspirin 81mg PO daily
Furosemide 40 mg PO DAILY
Insulin 70/30 24 units daily
Regular sliding scale
Allopurinol 300 mg PO daily.
Risperdal 0.5 mg Tablet PO qHS
Albuterol neb Q4H prn
Atrovent neb Q6H
Duloxetine 20 mg, Delayed Release(E.C.) PO DAILY
Ranitidine 150 mg PO BID
Colace 100 mg PO BID
Senna 8.6 mg PO daily
Miralax 17 gram (100 %) Powder 1 packet daily prn
Lorazepam 1mg IV q8 prn
.....................................
Medications per prior admit [**Date range (1) 20648**]:
Amiodarone 200mg once daily
Aspirin 81mg daily
Coumadin 2.5mg daily (d/c'd?)
Digoxin 125mcg every other day
Diovan 10mg daily
Novolin 70/30 24 units SQ QD
Humalog sliding scale
Lasix 40mg daily
Metoprolol succinate 100mg daily
Spironolactone 12.5 mg daily
Duonebs
guaifenisin
allopurinol 300 qd
cymbalta 20mg
risperdal 0.5mg hs
................................
Medications on transfer:
Piperacillin-Tazobactam 2.25 g IV Q6H (to finish [**6-1**])
Vancomycin 1000 mg IV Q 24H (to finish [**6-1**])
Amiodarone 200 mg PO DAILY
Aspirin 81 mg PO DAILY
Senna 1 TAB PO BID:PRN Constipation
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Digoxin 0.075 mg IV EVERY OTHER DAY Start: In am
Spironolactone 25 mg PO DAILY Start: In am
Docusate Sodium (Liquid) 100 mg PO BID
Furosemide 40 mg PO BID
Valsartan 20 mg PO DAILY
Insulin: 15 units 70/30 q am and sliding scale of humalog
insulin
Warfarin 2.5 mg PO DAILY16 Start: In am [**6-2**]
Olanzapine (Disintegrating Tablet) 2.5-5 mg PO BID:PRN agitation
hold for oversedation, resp depression
....................................
Allergies: Sulfa (Sulfonamides) / Lyrica / Ace Inhibitors /
Metformin / Dofetilide / Quinidine / Fentanyl
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Valsartan 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): First dose given [**6-2**].
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO Q6PM ().
13. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Fifteen (15) Subcutaneous qam: Patient also given Regular
insulin sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 20650**]
Discharge Diagnosis:
1) Delirium
2) Supsoected C. difficle colitis
3) Congestive heart failure
4) Diabetes
Discharge Condition:
Stable
Discharge Instructions:
You are being transferred to [**Hospital3 2358**] cardiology service per
your family request.
Followup Instructions:
N/A
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
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[
[
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14901, 14949
|
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377, 384
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15079, 15088
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6,398
| 174,417
|
3997
|
Discharge summary
|
report
|
Admission Date: [**2127-6-9**] Discharge Date: [**2127-6-18**]
Service: MEDICINE
Allergies:
Zestril / Keflex
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
Cardioversion
History of Present Illness:
Patient is an 87yo male with PMH of CAD s/p CABGx4, chronic
dCHF, HTN, and COPD who presents with 3d of cough and fevers.
Patient was last in his USOH until approximately 1 week PTA when
he began to feel general malaise. His wife has been recovering
over the past 3 weeks from an upper respiratory tract infection.
Then, about 3 days PTA, patient felt feverish at home and had
prodressive shortness of breath and cough. He also had
increasing production of yellow sputum. The dyspnea, cough, and
sputum production increased to the point where he presented to
the ED for evaluation.
In the ED, initial VS were: 98.6 132 124/58 22 100% 10LNC, but
hypoxic to low 80s on room air. He had no chest pain, abd pain,
nausea, vomiting, dysuria, diarrhea. Patient was given dilt 20mg
x 1, 25mg x 1 for a flutter, then dropped pressures to 70s. They
were then 90s after starting dopamine, but patient became tachy.
He was off dopamine before transfer to the floor. He recieved
levofloxacin for PNA and lasix 20 IV. He received aspirin as
well. He did not give levophed though listed. He has an 18x2 and
20PIV, and left IJ for access. His BNP was elevated at 6800 and
troponin was 0.02.
On arrival to the MICU, Vital signs: T97.2, HR127, BP134/58,
RR21, O2sat: 99%NRB. Patient had dyspnea but was speaking in
full sentences. He was A+O and able to participate in exam and
in mild respiratory distress.
Review of systems:
(+) Per HPI
(-) Denies headache, Denies chest pain, chest pressure, Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Positive right hemiscrotal pain with coughing
Past Medical History:
1. Coronary artery disease s/p CABG [**2119**], LIMA to the LAD, SVG
to O1, SVG to the PDA to the OM1.
2. Hyperlipidemia.
3. Hypertension.
4. Benign prostatic hypertrophy.
5. Gastroesophageal reflux disease.
6. Asthma.
7. Allergic rhinitis.
8. Mod b/l tibial aa occlusive dz, dx'd [**3-23**]
Social History:
The patient lives with his wife, is a nonsmoker, former heavy
alcohol usage - last heavy use >10 years ago, up to 1 L
vodka/QOD. Denies current alcohol abuse, Denies any IVDU.
Family History:
several family members with diabetes
Physical Exam:
Physical Exam on Admission:
Vitals: 98.6 132 124/58 22 100% 10LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: rapid rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: no wheezes, ronchi, poor air movement in posterior fields
bilaterally with rare rales at the bases
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly, small umbilical hernia, small bulge
with cough in the right hemiscrotum
GU: foley catheter in place
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis, 1+
pitting edema in the right lower extremity and trace pitting
edema in the left lower extremity, surgical scar of saphenous
vein removal in the right lower extremity
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Physical Exam on Discharge:
VS: T 97.4 HR 69-74 BP 103-123/42-52 RR 18-20 O2at 96(2L)
Weight 69.2kg
I/O: +95/-425
General: Well-appearing man in bed in no acute distress
HEENT: PERRL, EOMI, oropharynx clear, no JVD
Heart: RRR, nl s1 and s2, no murmurs
Lungs: CTAB with no crackles or wheezes
Abd: normoactive bowel sounds, nontender, nondistendfed, no
organomegaly
Ext: no peripheral edema, warm
Pertinent Results:
Admission labs:
[**2127-6-9**] 01:30PM BLOOD WBC-7.3 RBC-4.24* Hgb-12.6* Hct-39.1*
MCV-92 MCH-29.6 MCHC-32.1 RDW-13.6 Plt Ct-237#
[**2127-6-9**] 01:30PM BLOOD Neuts-79.6* Lymphs-15.9* Monos-4.2 Eos-0
Baso-0.3
[**2127-6-9**] 01:30PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3*
[**2127-6-9**] 01:30PM BLOOD Glucose-182* UreaN-48* Creat-1.4* Na-136
K-5.3* Cl-99 HCO3-27 AnGap-15
[**2127-6-9**] 01:30PM BLOOD proBNP-6808*
[**2127-6-9**] 01:30PM BLOOD cTropnT-0.02*
[**2127-6-9**] 09:00PM BLOOD cTropnT-0.01
[**2127-6-9**] 08:51PM BLOOD Type-ART pO2-100 pCO2-51* pH-7.37
calTCO2-31* Base XS-2
[**2127-6-9**] 01:44PM BLOOD Lactate-1.6
Pertinent labs:
[**2127-6-9**] 01:30PM BLOOD proBNP-6808*
[**2127-6-9**] 01:30PM BLOOD cTropnT-0.02*
[**2127-6-9**] 09:00PM BLOOD cTropnT-0.01
[**2127-6-10**] 05:11AM BLOOD cTropnT-0.01
[**2127-6-10**] 05:11AM BLOOD ALT-25 AST-23 AlkPhos-72 TotBili-0.4
[**2127-6-9**] 08:51PM BLOOD Type-ART pO2-100 pCO2-51* pH-7.37
calTCO2-31* Base XS-2
[**2127-6-9**] 01:44PM BLOOD Lactate-1.6
Labs on Discharge:
[**2127-6-18**] 07:05AM BLOOD WBC-11.6* RBC-4.45* Hgb-13.1* Hct-40.1
MCV-90 MCH-29.5 MCHC-32.7 RDW-13.5 Plt Ct-306
[**2127-6-18**] 07:05AM BLOOD PT-23.9* PTT-31.5 INR(PT)-2.3*
[**2127-6-18**] 07:05AM BLOOD Glucose-149* UreaN-42* Creat-1.2 Na-140
K-4.1 Cl-100 HCO3-34* AnGap-10
Urine
[**2127-6-9**] 04:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2127-6-9**] 04:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2127-6-9**] 04:20PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
[**2127-6-9**] 04:20PM URINE CastHy-1*
Micro
Blood Culture, Routine (Final [**2127-6-15**]): NO GROWTH.
URINE CULTURE (Final [**2127-6-10**]): NO GROWTH.
[**2127-6-10**] 6:08 am SPUTUM
Source: Expectorated.
GRAM STAIN (Final [**2127-6-10**]):
[**11-13**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
.
Imaging:
CHEST (PORTABLE AP) Study Date of [**2127-6-9**] 1:38 PM
IMPRESSION: Mild pulmonary edema. Left base opacity may be
atelectasis,
however, pneumonia should be excluded in the appropriate
clinical setting.
Post-diuresis films would be of utility in excluding underlying
infection.
CHEST PORT. LINE PLACEMENT Study Date of [**2127-6-9**] 5:08 PM
FINDINGS: As compared to the previous radiograph, the patient
has received a
new left internal jugular vein catheter. The tip of the
catheter projects
over the upper to mid SVC. The course of the catheter is
unremarkable. There is no evidence of complications, notably no
pneumothorax.
Otherwise, the radiograph is unchanged as compared to 1:32 p.m.
on the same day.
TTE (Complete) Done [**2127-6-10**] at 3:43:44 PM FINAL
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 65%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-20**]+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
ECHO [**6-13**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic at 35cm from incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION:No intracardiac clot was found. Mild MR was noticed
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is an 87yo male with
PMH of CAD s/p CABGx4, COPD, and chronic dCHF who presented from
home with cough and shortness of breath for 3 days with oxygen
sats in the 80's on room air.
Active Diagnoses:
1. COPD exacerbation: Patient had viral prodrome for one week,
then for 3 days prior to admission had cough, dyspnea, and
increased production of sputum that was purulent. His wife, a
lifelong smoker, also had a syndrome of malaise and URI the week
preceeding his illness. He also has a history of PFT's
suggestive of COPD. He was started on Bipap on admission, and
had an ABG which showed hypercarbia to pCO2 51. He was treated
with a 5-day course of prednisone, levofloxacin, and ipratropium
nebs with improvement. The pt was difficult to wean off oxygen.
After further diuresis, by the time of discharge, he was on room
air.
2. Atrial fibrillation/flutter: Patient presented in atrial
flutter. Echocardiogram revealed mitral and aortic regurgitation
and dilated atria. This, in conjuction with his COPD and acute
distress in the context of COPD exacerbation, is likely what led
to the onset of aflutter. He required diltiazem gtt for rate
control with gradual transition to oral dosing. He went for TEE
which did not show thrombus and then completed cardioversion. He
went into sinus rhythm afterwads with some bigeminy. He was
taken off diltiazem and restarted on lopressor 50mg [**Hospital1 **].
Subsequently, he went back into afib with RVR and required a
second cardioversion with amiodarone loading. He was discharged
on amiodarone and off of diltiazem and metoprolol.
.
3. Acute diastolic CHF: Patient has history of dCHF and in the
setting of tachycardia and pulmonary edema likely has acute on
chronic exacerbation. A-flutter was a likely precipitant which
may be seen in a heart exposed to chronic lung disease and
hypertension. His admission chest xray confirmed pulmonary edema
and echo showed normal EF with mild aortic regurgitation and
mild to moderate MR. [**First Name (Titles) **] [**Last Name (Titles) 1834**] lasix diuresis with
improvement in oxygen saturation and physical exam. At
discharge, his O2 sat was 98 on room air. He was discharged
home with PO lasix 20mg daily, and he will follow-up with his
PCP regarding dosing adjustments.
4. HTN: Patient was taken of his home diovan. and restarted on
nifedipine as tolerated and on lopressor. After second
cardioversion when patient returned to [**Location 213**] sinus rhythm, he
was taken off of nifedipine and lopressor. He remained
normotensive.
5. Diarrhea: Patient has hx of diarrhea at home for which he
takes imodium [**Hospital1 **]. He has not been having diarrhea in the
setting of imodium. 3 days prior to discharge, patient had one
episode of watery diarrhea, in the setting of having imodium
held during hospitalization. Since he did not have a fever or
leukocytosis, and diarrhea resolved, C diff was not sent. Has
did not have any more diarrhea by the time of discharge.
.
6.CAD: He was continued on daily simvastatin and ASA.
7.GERD: He was continued on omeprazole.
Transitional Issues:
Patient was started on anticoagulation, which will be managed by
his primary care doctor.
He should undergo cardiac catheterization sometime in the
future.
Medications on Admission:
LOPERAMIDE - (On Hold from [**2126-5-6**] to unknown for on
lomotil)
- 2 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for
diarrhea
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr -
0.5
(One half) Tablet(s) by mouth once a day bp, CHF presumed
diastolic
NIFEDIPINE - 30 mg Tablet Extended Release - 1 Tablet(s) by
mouth
once a day for bp
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day gerd
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a
day for urinating
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
chol
VALSARTAN [DIOVAN] - 80 mg Tablet - 1 Tablet(s) by mouth once a
day bp, correct dose
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day prevention
GUAR GUM [BENEFIBER (GUAR GUM)] - (OTC) - Dosage uncertain
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
prevention
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - 1,000 mg Capsule - 1
Capsule(s) by mouth once a day prevention1
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient Lab Work
INR
Take with you to B.I. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] (Dr. [**Last Name (STitle) **]on
[**2127-6-20**]
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inhalation Inhalation once a day.
Disp:*1 device* Refills:*2*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg twice/day for 2 weeks (until [**2127-7-1**]), 200mg
twice/day for 2 weeks (until 626/12) and 200mg daily thereafter.
Disp:*60 Tablet(s)* Refills:*0*
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Atrial Flutter/Fib
COPD exacerbation
Acute on chronic diastolic heart failure
Atrial Fibrillation
Secondary:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 449**],
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted to the hospital after presenting with a cough
a fever. You were found to have an elevated heart rate and low
oxygen saturation. You heart rhythm was in atrial flutter
(irregular rhythm). You were also found to be in a COPD
exacerbation and CHF exacerbation.
To get your heart rate under control you were initially given IV
medications and eventually you were transitioned to an oral
regimen. Your heart rate remained high, and you were taken for
cardioversion twice, the second time with a new medication
called amiodarone. The procedure went well without
complications. You were started on coumadin to prevent clots
from forming by thinning your blood.
For your COPD exacerbation, you were given steroids, nebulizer
treatments, and antibiotics. You completed a steroid burst and
full antibiotic course in the hospital.
For your heart failure, you were diuresed with lasix. We are not
discharging you with lasix, but you should discuss whether you
need to be on lasix with your PCP when you go for follow-up.
You should have your INR checked on [**6-18**] at the Dr.[**Name (NI) 10822**]
clinic. This is very important that you follow up on this
appointment.
Please note that the following changes have been made to your
medications:
CHANGE Aspirin 325mg to 81mg once daily
START Spiriva (tiotropium) for COPD
START Coumadin 4mg once daily; you must follow up with your PCP
regarding your INR
START Amiodarone 400mg twice/day for 2 weeks, then 200mg
twice/day for 2 weeks, then 200mg daily
START Furosemide 20mg by mouth daily
STOP Diovan
STOP Oxybutynin
STOP Metoprolol succinate
STOP nifedipine
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: Friday [**2127-6-20**] at 11:00 AM
With: ADULT MEDICINE NURSE [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*This appointment is for a coumadin check. Dr. [**Last Name (STitle) **] is
working on an additional appointment for you for next week. You
will receive a call from his office with appointment details.
Department: CARDIAC SERVICES
When: TUESDAY [**2127-7-22**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call Dr.[**Name (NI) 10822**] office at [**Telephone/Fax (1) 1144**] to schedule
a followup appointment within the next week.
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: WEDNESDAY [**2127-7-30**] at 10:25 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: RADIOLOGY
When: MONDAY [**2127-7-21**] at 10:00 AM
With: RADIOLOGY [**Telephone/Fax (1) 9045**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2127-6-19**]
|
[
"428.33",
"426.4",
"427.32",
"493.22",
"427.31",
"414.00",
"790.92",
"V45.81",
"403.90",
"424.0",
"428.0",
"787.91",
"585.3",
"V70.7",
"272.4",
"600.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90",
"99.62",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
14298, 14356
|
8812, 9036
|
238, 285
|
14532, 14532
|
3993, 3993
|
16423, 18031
|
2563, 2601
|
13195, 14275
|
14377, 14511
|
12128, 13172
|
14683, 16400
|
2616, 2630
|
6221, 8789
|
3601, 3974
|
11944, 12102
|
1726, 2038
|
184, 200
|
5015, 6180
|
313, 1707
|
4009, 4616
|
2644, 3573
|
14547, 14659
|
4632, 4996
|
9054, 11923
|
2060, 2353
|
2369, 2547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,054
| 146,124
|
44799+44800+44801+58758+58759+58761
|
Discharge summary
|
report+report+report+addendum+addendum+addendum
|
Admission Date: [**2166-7-23**] Discharge Date:
Date of Birth: [**2119-5-12**] Sex: M
Service:
ADDENDUM:
HOSPITAL COURSE BY SYSTEM:
1. CARDIAC: The patient was admitted with acute myocardial
infarction in the setting of active gastrointestinal bleed.
Given instability of patient's course and profound anemia, he
was not taken to the catheter lab but medically managed with
beta blockers, ACE inhibitors, lipid lowering agents and
monitoring in the CCU. A follow up echocardiogram did show
his ejection fraction to be depressed to 20% with severe
global left ventricular dysfunction and an akinetic apex. He
was followed in consultation with cardiology, who decided to
continue him on his medical regimen. He will need to be seen
in follow up with cardiology. His prior cardiologist was Dr.
[**Last Name (STitle) **] who has retired and it appears that the patients have
now been taken over by Dr. [**Last Name (STitle) 22956**]. The patient will need
referral when outpatient to Dr. [**Last Name (STitle) 22956**] for follow up. The
patient will need a repeat echocardiogram in approximately
four to six weeks to evaluate his apical movement. If it is
still akinetic and ejection fraction is significantly
depressed, the risks and benefits of anticoagulation for this
indication given his gastrointestinal bleed will need to be
weighed.
2. NEUROLOGIC: On [**2166-7-27**], the day after his admission, the
patient developed an acute change in mental status with the
onset of aphasia and right sided weakness. A stat MRI was
obtained which showed a left insular/frontotemporal stroke
most likely embolic. He was not a candidate for lysis, given
his ongoing gastrointestinal bleed. He was conservatively
managed with monitoring in the Intensive Care Unit, blood
pressure monitoring continued transiently on his Plavix 75 mg
a day and followed with the stroke team throughout his
hospital course. He did remarkably well in recovering almost
full function of his right and left leg, however at this time
still had significant language deficit and is profoundly
aphasic. Additionally, he failed two speech and swallow
studies and a PEG tube had to be placed for discoordinated
swallowing. The patient will need aggressive cognitive
physical and speech therapy in the outpatient setting which
is being set up through a rehabilitation hospital through the
[**Hospital **] [**Hospital **] Rehabilitation.
3. GASTROINTESTINAL: Patient with active gastrointestinal
bleed on admission was taken for endoscopy which showed a
large amount of blood in the stomach and no focal lesion that
could be identified. Attempts at hemostasis were
unsuccessful. He the underwent an emergent angiography and
evaluation by interventional radiology with successful
embolization to his left gastroduodenal artery and
stabilization of his gastrointestinal bleed. He did,
however, require transfusion of up to 12 units of packed red
blood cells, 2 to 4 units of FFP and platelets during the
acute course of his gastrointestinal bleed. He was followed
by gastrointestinal throughout his hospital course,
maintained on intravenous Protonix throughout, re-scoped on
[**8-5**] and found not to have any further bleeding in his
stomach. A successful PEG tube was placed to be used for
tube feed and the patient will need to continue on proton
pump inhibitor for the next eight weeks and follow up with
gastrointestinal in an outpatient setting.
4. ENDOCRINE: The patient had been on multiple oral
hypoglycemics prior to his hospitalization and throughout the
hospitalization, controlled with NPH and sliding scale
regular insulin. At this time, plan is to discharge the
patient back on his oral hypoglycemics of glyburide 10 [**Hospital1 **]
and aggressive fingerstick checks by DNA, as he is only on
tube feeds right now and fingersticks have been well
controlled. He may, however, in the future, need to add
insulin to his regimen if fingersticks become more difficult.
5. DISPOSITION: Multiple issues surrounding patient's
discharge secondary to the fact that the patient is not a US
citizen (Canadian) and does not have any insurance, efforts
were made and he did receive free care while in the hospital.
However, this would not cover outpatient or inpatient
rehabilitation services. Given the constraints of the family
and the fact that the patient was extremely successful with
physical therapy and cleared to go home, he will be going
home with extensive services, including home physical
therapy, outpatient speech therapy, VNA for medication checks
and coordination of his tube feeds.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg po bid
2. Lipitor 40 mg po q day
3. Captopril 12.5 mg po tid
4. Prevacid 30 mg suspension po q day
5. Zoloft 25 mg po q day
6. Glyburide 10 mg per G-tube [**Hospital1 **]
7. On [**2166-8-13**] the patient will need to start Plavix
75 mg po q day.
The patient will need fingersticks twice a day. The patient
will need to get his tube feeds, Replete with fiber at 90 cc
an hour and the patient will need follow up with at the
[**Hospital **] [**Hospital **] Rehabilitation with physical therapy, occupational
therapy and possibly at [**Hospital1 2025**] for prorated speech therapy.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSES:
1. Duodenal ulcer with bleeding, status post embolization of
gastroduodenal artery
2. Acute myocardial infarction
3. Hyperbilirubinemia
4. Hypertension
5. DBA
The patient will be discharged to home with services as
outlined below and to follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 95851**]
MEDQUIST36
D: [**2166-8-6**] 09:34
T: [**2166-8-6**] 11:42
JOB#: [**Job Number 95852**]
Admission Date: [**2166-7-23**] Discharge Date:
Date of Birth: [**2119-5-12**] Sex: M
Service:
ADDENDUM:
HOSPITAL COURSE BY SYSTEM:
1. CARDIAC: The patient was admitted with acute myocardial
infarction in the setting of active gastrointestinal bleed.
Given instability of patient's course and profound anemia, he
was not taken to the catheter lab but medically managed with
beta blockers, ACE inhibitors, lipid lowering agents and
monitoring in the CCU. A follow up echocardiogram did show
his ejection fraction to be depressed to 20% with severe
global left ventricular dysfunction and an akinetic apex. He
was followed in consultation with cardiology, who decided to
continue him on his medical regimen. He will need to be seen
in follow up with cardiology. His prior cardiologist was Dr.
[**Last Name (STitle) **] who has retired and it appears that the patients have
now been taken over by Dr. [**Last Name (STitle) 22956**]. The patient will need
referral when outpatient to Dr. [**Last Name (STitle) 22956**] for follow up. The
patient will need a repeat echocardiogram in approximately
four to six weeks to evaluate his apical movement. If it is
still akinetic and ejection fraction is significantly
depressed, the risks and benefits of anticoagulation for this
indication given his gastrointestinal bleed will need to be
weighed.
2. NEUROLOGIC: On [**2166-7-27**], the day after his admission, the
patient developed an acute change in mental status with the
onset of aphasia and right sided weakness. A stat MRI was
obtained which showed a left insular/frontotemporal stroke
most likely embolic. He was not a candidate for lysis, given
his ongoing gastrointestinal bleed. He was conservatively
managed with monitoring in the Intensive Care Unit, blood
pressure monitoring continued transiently on his Plavix 75 mg
a day and followed with the stroke team throughout his
hospital course. He did remarkably well in recovering almost
full function of his right and left leg, however at this time
still had significant language deficit and is profoundly
aphasic. Additionally, he failed two speech and swallow
studies and a PEG tube had to be placed for discoordinated
swallowing. The patient will need aggressive cognitive
physical and speech therapy in the outpatient setting which
is being set up through a rehabilitation hospital through the
[**Hospital **] [**Hospital **] Rehabilitation.
3. GASTROINTESTINAL: Patient with active gastrointestinal
bleed on admission was taken for endoscopy which showed a
large amount of blood in the stomach and no focal lesion that
could be identified. Attempts at hemostasis were
unsuccessful. He the underwent an emergent angiography and
evaluation by interventional radiology with successful
embolization to his left gastroduodenal artery and
stabilization of his gastrointestinal bleed. He did,
however, require transfusion of up to 12 units of packed red
blood cells, 2 to 4 units of FFP and platelets during the
acute course of his gastrointestinal bleed. He was followed
by gastrointestinal throughout his hospital course,
maintained on intravenous Protonix throughout, re-scoped on
[**8-5**] and found not to have any further bleeding in his
stomach. A successful PEG tube was placed to be used for
tube feed and the patient will need to continue on proton
pump inhibitor for the next eight weeks and follow up with
gastrointestinal in an outpatient setting.
4. ENDOCRINE: The patient had been on multiple oral
hypoglycemics prior to his hospitalization and throughout the
hospitalization, controlled with NPH and sliding scale
regular insulin. At this time, plan is to discharge the
patient back on his oral hypoglycemics of glyburide 10 [**Hospital1 **]
and aggressive fingerstick checks by DNA, as he is only on
tube feeds right now and fingersticks have been well
controlled. He may, however, in the future, need to add
insulin to his regimen if fingersticks become more difficult.
5. DISPOSITION: Multiple issues surrounding patient's
discharge secondary to the fact that the patient is not a US
citizen (Canadian) and does not have any insurance, efforts
were made and he did receive free care while in the hospital.
However, this would not cover outpatient or inpatient
rehabilitation services. Given the constraints of the family
and the fact that the patient was extremely successful with
physical therapy and cleared to go home, he will be going
home with extensive services, including home physical
therapy, outpatient speech therapy, VNA for medication checks
and coordination of his tube feeds.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg po bid
2. Lipitor 40 mg po q day
3. Captopril 12.5 mg po tid
4. Prevacid 30 mg suspension po q day
5. Zoloft 25 mg po q day
6. Glyburide 10 mg per G-tube [**Hospital1 **]
7. On [**2166-8-13**] the patient will need to start Plavix
75 mg po q day.
The patient will need fingersticks twice a day. The patient
will need to get his tube feeds, Replete with fiber at 90 cc
an hour and the patient will need follow up with at the
[**Hospital **] [**Hospital **] Rehabilitation with physical therapy, occupational
therapy and possibly at [**Hospital1 2025**] for prorated speech therapy.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSES:
1. Duodenal ulcer with bleeding, status post embolization of
gastroduodenal artery
2. Acute myocardial infarction
3. Hyperbilirubinemia
4. Hypertension
5. DBA
The patient will be discharged to home with services as
outlined below and to follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 95851**]
MEDQUIST36
rp06/29/[**2166**]
D: [**2166-8-6**] 09:34
T: [**2166-8-6**] 11:42
JOB#: [**Job Number 95852**]
Admission Date: [**2166-7-23**] Discharge Date: [**2166-8-7**]
Date of Birth: [**2119-5-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 47 -year-old
gentleman with a past medical history of coronary artery
disease status post coronary artery bypass graft, diabetes
mellitus, hypertension, hyperlipidemia, and peptic ulcer
disease, who was in his usual state of health until the day
prior to admission when he noted the onset of dizziness. The
dizziness occurred with standing and resolved when he lay
flat. He held his blood pressure medicine after discussing
it with his wife's primary care physician. [**Name10 (NameIs) **]
afternoon, he began to have black, semi-liquid stools.
Approximately four episodes prior to coming to the Emergency
Department.
At 01:00 PM he began to have chest pain that resembled his
anginal equivalent which was sharp, substernal chest pain
with radiation to the left arm without shortness of breath,
nausea, or diaphoresis. He took one to two sublinguals with
relief for one hour, but then the chest pain recurred. He
took two more sublingual nitroglycerin every hour for four
hours, and then decided to come to the Emergency Room. He
developed chest pain in the ambulance on the way in.
He has a past medical history peptic ulcer disease without
bleeding twenty years ago. No recent reflux, abdominal pain,
nausea or vomiting, or bright red blood per rectum. He has
been taking Naprosyn 500 mg [**Hospital1 **] over the past month after a
motor vehicle accident.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2155**] with a left internal mammary artery to
the left anterior descending, saphenous vein graft to the
right coronary artery, saphenous vein graft to the RI. In
[**2161**] he had a stent placed at the saphenous vein graft to the
RI which was redilated after he had filled with stenosis. He
also had a percutaneous transluminal coronary angioplasty of
the distal left anterior descending at the touchdown site in
[**2162**]. All of his native coronary arteries are occluded. He
had a positive exercise tolerance test in [**2163**] which showed
previously seen anterolateral deficits. He had a
catheterization in [**2163**] which showed an ejection fraction of
20%, global hypokinesis, and saphenous vein graft #2 to the
percutaneous transluminal coronary angioplasty was totally
occluded and his distal left anterior descending at touchdown
site was 70%.
2. Diabetes.
3. Hypertension.
4. Hyperlipidemia.
5. Status post breast carotid endarterectomy in [**2161**] after
cancer.
6. Transient ischemic attack.
7. Proteinuria.
8. Gastroesophageal reflux disease.
9. Peptic ulcer disease.
ADMITTING MEDICATIONS: Glucophage 800 mg po tid, Lipitor 40
mg po bid, Naprosyn 500 mg po bid, Glucotrol 20 mg q day,
Diltiazem 240 mg q day, nitroglycerin prn, Isordil 20 mg tid,
Norvasc 10 mg q day, Glyburide 10 mg [**Hospital1 **], Captopril 12.5 mg
tid, Wellbutrin 100 mg [**Hospital1 **], Atenolol 100 mg q day, aspirin
325 mg q day.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION: On admission, he was afebrile, heart
rate was 100, blood pressure was 130/80, respirations of 16,
saturating 100% on two liters. In general, he was an
uncomfortable appearing male, but alert. Head, eyes, ears,
nose and throat: had anicteric sclerae, his mucous membranes
were moist. Neck was supple, no lymphadenopathy or jugular
venous distention. Heart was tachycardic, but had a regular
rate and rhythm, no murmurs, rubs, or gallops. Lungs are
clear bilaterally. Abdomen was soft, nontender,
nondistended. Guaiac positive. Extremities showed no
cyanosis, clubbing or edema.
ADMISSION LABORATORY DATA: He had a white count of 12.0 and
a hematocrit of 23 with a hemoglobin of 7.8 and platelets
250,000. BUN and creatinine 65 and 1.0. PT INR 1.2, PTT 21.
First CK was 77 with a troponin of less than 0.3.
Chest x-ray showed no infiltrates or effusions.
Electrocardiogram was sinus tachycardia, normal axis and
intervals, with 2.[**Street Address(2) **] depressions and T-wave inversions
in I, AVL, and also ST depressions in II, III, and F, 4.[**Street Address(2) 26378**] depressions in V2 through V6.
ASSESSMENT: A 47 -year-old man with severe coronary artery
disease affecting his native vessels in one out of three
bypass grafts who presents with chest pain and dramatic
electrocardiogram changes in the setting of an acute
gastrointestinal bleed.
HOSPITAL COURSE:
1. Cardiac: The patient was admitted to the Cardiac Care
Unit and serial CKs were cycled, which peaked at close to
3,000, with evolution of his electrocardiogram changes.
Given the active gastrointestinal bleed and profound anemia,
felt to cause a strain on his heart, a decision was made not
to take the patient to the Catheterization Lab, but to
medically manage his gastrointestinal bleed first. He was
continued on beta blockers as tolerated, his ACE inhibitor,
his Lipitor, and aggressively medically managed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 95851**]
MEDQUIST36
D: [**2166-8-6**] 09:23
T: [**2166-8-6**] 11:23
JOB#: [**Job Number 46865**]
Name: [**Known lastname 4175**], [**Known firstname **] Unit No: [**Numeric Identifier 15212**]
Admission Date: [**2166-7-23**] Discharge Date: [**2166-8-8**]
Date of Birth: [**2119-5-12**] Sex: M
Service:
The patient stayed in the hospital a couple extra days to
work out the best way for tube feedings. It was recommended
by nutrition that the patient get boluses of the tube feeding
rather than continuously as the patient is being cared for by
his wife at home. Final recommendation for tube feed was 1.5
cans q3hours as tolerated during the daytime. Fingerstick
q.i.d. prior to getting the tube feeds. Additionally, 100 cc
of water bolus per percutaneous endoscopic gastrostomy t.i.d.
for fluid needs. The patient is also to follow-up with home
physical therapy and speech therapy. The student program at
[**Hospital1 2239**] was recommended via [**Doctor First Name **] at [**Telephone/Fax (1) 15213**].
Additionally, repeat video swallowing in four to six weeks.
Graduate student intern, Vinidaka, at [**Telephone/Fax (1) 15214**], was
recommended for the patient.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg p.o. t.i.d., hold for systolic blood
pressure less than 100 or heart rate less than 60.
2. Lipitor 40 mg p.o. q.d.
3. Captopril 12.5 mg p.o. t.i.d., hold for systolic blood
pressure less than 120.
4. Prevacid 30 mg p.o. q.d.
5. Zoloft 25 mg p.o. q.d.
6. Glucophage 500 mg p.o. b.i.d. with meals and increase up
to 500 mg p.o. t.i.d. in one to two weeks if b.i.d. is
tolerated.
7. Glyburide 10 mg crushed per gastrostomy tube b.i.d.
8. Plavix 75 mg p.o. q.d. The patient is to start this
medication [**2166-8-13**].
[**First Name8 (NamePattern2) 10279**] [**First Name8 (NamePattern2) 69**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15215**]
Dictated By:[**Name8 (MD) 15216**]
MEDQUIST36
D: [**2166-8-8**] 14:34
T: [**2166-8-10**] 09:59
JOB#: [**Job Number 15217**]
Name: [**Known lastname 4175**], [**Known firstname **] Unit No: [**Numeric Identifier 15212**]
Admission Date: [**2166-7-23**] Discharge Date: [**2166-8-8**]
Date of Birth: [**2119-5-12**] Sex: M
Service:
Additionally on discharge, it was noted that the patient's
platelet count had been increasing. The last count was
623,000 on [**2166-8-7**]. It is recommended that the patient have
this followed up with his primary care physician. [**Name10 (NameIs) **] than
likely, this is a severe reactive thrombocytosis secondary to
the large amount of blood volume that was lost during the
patient's original gastrointestinal bleed.
[**First Name8 (NamePattern2) 10279**] [**First Name8 (NamePattern2) 69**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15215**]
Dictated By:[**Name8 (MD) 15216**]
MEDQUIST36
D: [**2166-8-8**] 14:37
T: [**2166-8-10**] 10:12
JOB#: [**Job Number **]
Name: [**Known lastname 4175**], [**Known firstname **] Unit No: [**Numeric Identifier 15212**]
Admission Date: [**2166-7-23**] Discharge Date: [**2166-8-8**]
Date of Birth: [**2119-5-12**] Sex: M
Service:
This addendum should serve as a clarification of the events
and occurrences of the [**Hospital 1325**] hospital course.
1. Esophagogastroduodenoscopy done on admission for the
patient's gastrointestinal bleed on [**2166-7-23**] found a 1.0 cm
ulcer in the posterior bulb. Epinephrine was injected, BICAP
electrocautery was applied, and hemostasis was successfully
achieved on [**2166-7-23**]. When the patient had a second
gastrointestinal bleed, on [**2166-7-27**], again extensive blood
was seen throughout the anterior and posterior bulbs.
Epinephrine was injected, but hemostasis was not successfully
achieved and the patient went on to arteriography.
2. Neurologic: The date of the patient's stroke was
[**2166-7-26**], not [**2166-7-27**] as stated in previous discharge
summary.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 15230**]
MEDQUIST36
D: [**2166-8-15**] 10:08
T: [**2166-8-15**] 21:35
JOB#: [**Job Number 15231**]
|
[
"276.5",
"532.40",
"250.00",
"414.01",
"410.71",
"428.0",
"V45.81",
"434.11",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"44.44",
"45.13",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
11146, 11154
|
11175, 11898
|
18229, 21327
|
16305, 18206
|
6028, 10491
|
14920, 16288
|
11927, 13314
|
13336, 14897
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,766
| 127,757
|
45977
|
Discharge summary
|
report
|
Admission Date: [**2141-4-18**] Discharge Date: [**2141-4-23**]
Date of Birth: [**2090-10-6**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Ascites, hypotension
Major Surgical or Invasive Procedure:
Intubation, central [**Doctor First Name **] placement
History of Present Illness:
50 year old female s/p gastric bypass (20 years ago) with
chronic pancreatitis and ETOH abuse who presented to the ED with
3-4 weeks of abdominal pain, ascites and decreased po intake.
The patient is a poor historian. The pain has been
progressively worsening. She has had chills but has not taken
her temperature. She had one episode of emesis 3-4 days PTA.
She has had oily stools for several months but denies diarrhea.
She also endorses a fall, but cannot elaborate on when it was
and on any details including whether she had LOC.
In the ED, VS were T = 99.2, HR = 107, BP = 91/76, RR = 16, O2
sat = 97% on RA. She was given 2L NS but her SBP remained
90s-100s. Lactate was drawn and found to be elevated at 3.7.
Blood cultures were drawn. She was given levofloxacin 500 mg po,
flagyl 500 mg IV and KCl 89 meq. Diagnostic paracentesis was
performed and the peritoneal fluid demonstrated 2605 WBC (87%
polys). Gram stain negative for organisms, culture pending. BP
dropped to 86/60, HR = 98. Sepsis line was placed in the R IJ,
CVP = 4 after 3L IVF and SVO2 = 80. She was started on levophed
at 2:15 am and BP improved to 98-114/90s-70s with HR = 70s. She
was given Zosyn 4.5 mg IV. Surgery was consulted given history
of gastric bypass. CT abd/pelvis demonstrated massive ascites
and cirrhosis as the only bowel pathology. She was seen by
surgery in the ED who felt that she had no primary cause for her
peritonitis. Repeat CVP = 6 and SVo2 = 70. She was admitted to
MICU for further management.
.
Currently she states that she does not feel like talking. She
reports improvemnent in her abdominal pain after the diagnositc
paracentesis. She denies light headedness and shortness of
breath.
.
Past Medical History:
Gastric bypass surgery- 20 years ago
Chronic pancreatitis
Depression
Alcohol Abuse
Chronic Diarrhea
Hypothyroidism
GERD
Social History:
Lives with 2 daughters. Does not work. Drinks about 12 pack beer
and 1 bottle of whiskey per week. Last drink 8 weeks ago. Does
not know if she has a h/o withdrawal. 2 pack tobacco per week.
No IVDU. Currently not sexually active. 10 lifetime partners. [**Name (NI) **]
high risk sexual behavior.
Family History:
M with DM and HTN. F with HTN. no FH of liver disease.
Physical Exam:
97.7, 100, 92/36, 100% on 3LNC, CVP =5
General: cachetic, chronically appearing woman, lying in bed.
NAD. Flat affect.
HEENT: NCAT, sclearae anicteric, proptosis bilaterally, dry MM,
poor oral hygeine.
Neck: RIJ TLC
Pulm: CTAB anteriorly
Abd: Distended abdomen, hypoactive BS, + percussive tenderness,
moderate diffuse TTP, no rebound or guarding.
Extrem: Trace pitting pretibial edema, DP pulses 1+ b/l, mild
asterixis
Neuro: pt will not comply with full neuro exam, A&o x 3,
?inattention, PERRL, proptosis, uvula/palate midline, plantar
flexion [**6-17**], b/l dorsiflexion [**5-18**] b/l.
Pertinent Results:
[**2141-4-18**] 09:19PM TYPE-MIX TEMP-37.2 PO2-43* PCO2-42 PH-7.44
TOTAL CO2-29 BASE XS-3 INTUBATED-NOT INTUBA
[**2141-4-18**] 09:19PM LACTATE-2.3*
[**2141-4-18**] 09:19PM O2 SAT-72
[**2141-4-18**] 09:03PM POTASSIUM-3.6
[**2141-4-18**] 09:03PM MAGNESIUM-2.3
[**2141-4-18**] 09:03PM WBC-5.4 RBC-2.30* HGB-7.8* HCT-21.6*# MCV-94#
MCH-33.9* MCHC-36.2* RDW-21.4*
[**2141-4-18**] 09:03PM PLT SMR-VERY LOW PLT COUNT-64*
[**2141-4-18**] 02:59PM POTASSIUM-3.3
[**2141-4-18**] 02:59PM MAGNESIUM-2.4
[**2141-4-18**] 02:59PM HCT-29.7*#
[**2141-4-18**] 11:26AM CORTISOL-29.0*
[**2141-4-18**] 11:06AM CORTISOL-26.1*
[**2141-4-18**] 07:46AM TYPE-MIX
[**2141-4-18**] 07:46AM O2 SAT-72
[**2141-4-18**] 05:31AM COMMENTS-GREEN TOP
[**2141-4-18**] 05:31AM COMMENTS-GREEN TOP
[**2141-4-18**] 05:20AM NEUTS-67 BANDS-9* LYMPHS-18 MONOS-3 EOS-0
BASOS-0 ATYPS-2* METAS-1* MYELOS-0
[**2141-4-18**] 05:20AM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-NORMAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-1+ SCHISTOCY-1+
TEARDROP-1+
[**2141-4-18**] 05:20AM PLT SMR-LOW PLT COUNT-114*
[**2141-4-18**] 04:31AM COMMENTS-GREEN TOP
[**2141-4-18**] 04:31AM LACTATE-2.9*
*
[**2141-4-18**] 02:47AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2141-4-18**] 02:47AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-8* PH-6.5 LEUK-TR
[**2141-4-18**] 02:47AM URINE RBC-[**4-17**]* WBC-[**7-23**]* BACTERIA-MANY
YEAST-NONE EPI-[**4-17**]
[**2141-4-18**] 02:45AM COMMENTS-GREEN TOP
[**2141-4-18**] 02:45AM LACTATE-3.1*
[**2141-4-18**] 01:50AM COMMENTS-GREEN TOP
[**2141-4-18**] 01:50AM LACTATE-3.2*
[**2141-4-18**] 12:30AM ASCITES WBC-2605* RBC-690* POLYS-87* LYMPHS-4*
MONOS-9*
[**2141-4-18**] 12:18AM COMMENTS-GREEN TOP
[**2141-4-18**] 12:18AM LACTATE-3.7* K+-2.8*
[**2141-4-17**] 10:49PM PT-20.1* PTT-54.0* INR(PT)-1.9*
[**2141-4-17**] 07:10PM GLUCOSE-115* UREA N-8 CREAT-0.9 SODIUM-134
POTASSIUM-2.3* CHLORIDE-96 TOTAL CO2-29 ANION GAP-11
[**2141-4-17**] 07:10PM CRP-68.4*
[**2141-4-17**] 07:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-4-17**] 07:10PM WBC-7.8# RBC-2.74* HGB-9.1* HCT-27.5*
MCV-100* MCH-33.2* MCHC-33.1 RDW-21.7*
[**2141-4-17**] 07:10PM NEUTS-63 BANDS-19* LYMPHS-12* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2141-4-17**] 07:10PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2141-4-17**] 07:10PM PLT SMR-LOW PLT COUNT-131*
*
Admission CTA/P:
RADIOLOGY Final Report
CT PELVIS W/O CONTRAST [**2141-4-18**] 11:23 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: ASCITES, WITH HCT DROP.
Field of view: 38
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with ascites now with 8 point hct drop in
setting of recent paracentesis.
REASON FOR THIS EXAMINATION:
r/o RP bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 50-year-old female with ascites and 8-point
hematocrit drop status post recent paracentesis.
COMPARISON: [**2141-4-18**] at 0403 hours.
TECHNIQUE: MDCT axial images from the lung bases through the
pubic symphysis were obtained without intravenous contrast.
Multiplanar reconstructions were performed.
CT ABDOMEN WITHOUT IV CONTRAST: Again identified is dense
consolidation with air bronchograms at the lung bases. Tip of a
venous catheter is seen in the right atrium. Evaluation of the
visceral organs is limited secondary to lack of intravenous
contrast. Allowing for this factor, no free air is identified in
the abdomen. There is massive ascites throughout all four
abdominal quadrants. The ascitic fluid demonstrates sligltly
increased attenuation ([**Doctor Last Name **] 20-22) in comparison with the earlier
study ([**Doctor Last Name **] [**10-28**]) raising the possibility of internal hemorrhage.
No sentinal clot identified. The opacified liver is shrunken and
nodular consistent with cirrhosis. Extensive coarse
calcifications are seen throughout the pancreas suggesting
chronic pancreatitis. The spleen is not enlarged. The kidneys
demonstrate cortical enhancement and excretion from the contrast
enhanced scan of 8 hours prior. There is no free intraperitoneal
air. Proximal loops of large and small bowel are grossly
unremarkable. There is no evidence of small-bowel obstruction.
Diffuse anasarca is noted within the soft tissues.
There is a new, large right flank hematoma.
CT PELVIS WITH IV CONTRAST: There is uniform diffuse wall
thickening of the distal descending colon and sigmoid colon,
which may reflect third spacing. A rectal tube and Foley
catheter are seen in place. The uterus contains a calcified
fibroid. Large amount of high attenuation fluid is present
within the cul-de-sac ([**Doctor Last Name **] 32). There are no pathologically
enlarged inguinal or pelvic lymph nodes.
No osseous findings suspicious for malignancy are identified.
There are moderate degenerative changes in the lower lumbar
spine.
IMPRESSION:
1. New large right flank hematoma. Slight short interval
increase in the attenuation of ascitic fluid raising the
possibility of internal hemorrhage versus enhancement from
previously administered contrast. No sentinal clot sign
identified.
2. Dense consolidation at the lung bases likely atelectasis,
although evolving infection or aspiration cannot be entirely
excluded.
3. Central venous line terminating in the right atrium.
4. Massive ascites and cirrhosis.
5. Pancreatic calcification suggesting chronic pancreatitis.
6. Uniform wall thickening of the distal descending colon and
sigmoid colon, likely edema from third spacing. Underlying
colitis cannot be entirely excluded. Clinical correlation is
recommended.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and the surgical
staff caring for the patient at the time of dictation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: WED [**2141-4-19**] 5:43 PM
*
Echo:
PATIENT/TEST INFORMATION:
Indication: Endocarditis.
Height: (in) 63
Weight (lb): 138
BSA (m2): 1.65 m2
BP (mm Hg): 114/89
HR (bpm): 105
Status: Inpatient
Date/Time: [**2141-4-19**] at 14:31
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W013-0:56
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: 0.39 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 65% to 70% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aorta - Arch: 2.8 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.43
TR Gradient (+ RA = PASP): *27 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.9 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2140-10-27**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is >2.5cm in diameter
with no change
with respiration (estimated RAP >20 mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Normal regional LV systolic function. [Intrinsic LV
systolic
function likely depressed given the severity of valvular
regurgitation.] No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Abnormal
diastolic septal motion/position consistent with RV volume
overload.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. No 2D or Doppler evidence
of distal
arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or
vegetations on aortic valve. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
mass or
vegetation on mitral valve. Moderate to severe (3+) MR.
TRICUSPID VALVE: Moderately thickened tricuspid valve leaflets.
No mass or
vegetation on tricuspid valve. Severe [4+] TR. Moderate PA
systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is >20
mmHg. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal. [Intrinsic
left ventricular systolic function is likely more depressed
given the severity
of valvular regurgitation.] There is no ventricular septal
defect. Right
ventricular chamber size and free wall motion are normal. There
is abnormal
diastolic septal motion/position consistent with right
ventricular volume
overload. The aortic valve leaflets (3) are mildly thickened but
aortic
stenosis is not present. No masses or vegetations are seen on
the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on
the mitral valve. Moderate to severe (3+) mitral regurgitation
is seen. The
tricuspid valve leaflets are moderately thickened. Severe [4+]
tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic
hypertension.
Compared with the prior study (images reviewed) of [**2140-10-27**],
the severity of
mitral regurgitation is similar. The degree of tricupsid
regurgitation has
significantly increased.
IMPRESSION: Signficant mitral and tricuspid regurgitation. At
least moderate
pulmonary hypertension. If clinically indicated, a TEE may be
better to
exclude any valvular vegetations.
Brief Hospital Course:
50 year old female with h/o gastric bypass surgery, heavy
alcohol abuse presents with abdominal pain, ascities,
hypotension and elevated lactate.
.
Sepsis hypotension:
The patient was pan cultured and 4/4blood cultures grew
coagulase negative staph. [**2-16**] blood cultures grew MSSA. Her
urine also grew pan senstivie Ecoli. She was started on
vancomycin and zosyn. She required intermittend pressors. An
echo was negative for vegetation.
.
Respiratory distress:
While in the MICU the patient developed respiratory distress
which was thought to be secondary to sepsis, gross fluid
overload and a hypoabuminemic state. She was eventually
intubated.
.
EtoH cirrhosis:
RUQ US demonstrated patent hepatic vasculature with hepatopetal
flow along with a large amount ascites. She was seen by the
liver consult service who did not think that she was a liver
transplant candidate.
.
Goals of care:
Throughout her stay in the ICU multiple family meetings were
held given her grim prognosis. Many of members of family flew in
from [**State 3908**] and [**State 5170**]. Eventaully they agreed that she
would not want her life prolonged in this way. Her family
agreed to pursue comfort care. She was terminally extubated and
passed away on [**2141-4-23**]
.
Medications on Admission:
Wellbutrin
Prilosec
Vitamin B12
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary
Sepsis
Alcoholic Cirrhosis
Hepatic Failure
Respiratory Failure
Secondary:
Alcohol Abuse
Chronic diarrhea
Hypothyroidism
GERD
Chronic pancreatitis
Depression
Discharge Condition:
Poor- dead
Discharge Instructions:
None
Followup Instructions:
None
|
[
"571.2",
"507.0",
"789.5",
"038.11",
"276.8",
"995.92",
"571.1",
"287.5",
"785.52",
"305.01",
"305.1",
"572.2",
"577.1",
"V45.86",
"286.6",
"518.81",
"567.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.05",
"99.07",
"99.04",
"96.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
15062, 15071
|
13694, 14950
|
295, 351
|
15280, 15292
|
3240, 5970
|
15346, 15353
|
2556, 2612
|
15033, 15039
|
6007, 6099
|
15092, 15259
|
14976, 15010
|
15316, 15323
|
9472, 13671
|
2627, 3221
|
235, 257
|
6128, 9446
|
379, 2082
|
2104, 2225
|
2241, 2540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,320
| 140,887
|
29563
|
Discharge summary
|
report
|
Admission Date: [**2131-1-14**] Discharge Date: [**2131-1-31**]
Date of Birth: [**2073-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 70884**] is a 57 yo male with h/o MS who presented to OSH
today with respiratory distress. Per friend and notes patient
was fine last night. Today he was coughing for several hours and
at ~ 5 pm he was found vomiting, coughing and aspirating emesis.
He was SOB, RR was 36-40 and O2 sat was 84 % on RA. He was
suctioned and treated with O2.
.
He was transferred to [**Hospital1 **] [**Location (un) 620**] where HR was 160, BP 140/90,RR
36 and O2 sat was 84% on RA. He was given metronidazole,
levofloxacin and ativan. He was paralyzed (etomidate 20 mg IV,
succinyl choline 125 mg IV) and intubated. He was given fentanyl
50 IV x2. OG tube was placed and brownish material came back.
Peripheral neosynephrine was started after a failed line attempt
for systolics in the 80s. He was transferred to the [**Hospital1 18**] for
further w/u.
.
In the ER here temp was 102, HR 150s (?afib), BP was in the 80s
systolic. Lactate was 7.4, WBC 1.3 with 58% bands. A central
line was placed and patient was started on levophed. His abdomen
appeared distended so abd/pelvis CT was done. It showed
evidence of bowel obstruction. Surgery was consulted and did
not see a need for surgical intervention. Additionally CXR was
done and showed a multifocal pneumonia. CT c-spine did not show
an acute fracture.
Past Medical History:
Multiple sclerosis
neurogenic bladder
UTIs
anxiety
hypercholesterolemia
Social History:
Per family he does not drink, smoke or do drugs. He is
divorced. His daughter and a friend are the HCPs.
Family History:
Non-contributory
Physical Exam:
VS: T 100.2 HR 130 BP 110/63 RR 33 O2 sat 99%
PCV: FiO2 0.8 PEEP 15 Inspiratory pressure 28 RR 24
Gen: intubated, sedated male in NAD
HEENT: intubated, anicteric sclera
Neck: supple, RIJ in place
Cardio: tachy with regular rhythms
Pulm: CTA b/l ant
Abd: soft, distended, hypoactive BS, NT
Ext: trace peripheral edema, 2+ DP pulses
Neuro: sedated, opens eyes to voice, does not respond to
commands
Pupils equal, round, slightly reactive to light
Pertinent Results:
EKG: appears to be sinus tachycardia vs. aflutter at a rate of
153
ST, q waves in 2, 3
<[**Street Address(2) 4793**] depressions in V2-v3
.
CT head [**1-14**]: No acute intracranial pathology including no
evidence of intracranial hemorrhage. Mild-to-moderate amount of
chronic periventricular microvascular ischemic changes with mild
prominence of the ventricles and sulci. Paranasal sinuses show
a minimal amount of mucosal thickening in the medial left
maxillary sinus and ethmoid air cells.
.
CXR [**1-14**]: Bilateral asymmetric opacities representing either
multifocal pneumonia vs asymmetric pulmonary edema with
infection more likely given lack of widening of the vascular
pedicle.
.
Abd/pelvis CT [**1-14**]:
Bilateral parenchymal consolidations in both lower lobes
posteriorly, and there are multiple nodular densities in the
right middle lobe.
The abdomen contains multiple dilated small bowel loops with
air-fluid levels and a transition point in the right lower
quadrant, consistent with small bowel obstruction. The colon is
relatively decompressed, containing residual air at several
locations. There is no ascites or free intra-abdominal air.
.
C-spine film (prelim): Limited exam due to patient motion. No
obvious fractures or malalignment.
.
RUQ U/S [**2130-1-20**]: No evidence for gallstones. No son[**Name (NI) 493**]
signs of acute cholecystitis. Sludge within gallbladder.
.
.
speech and swallow evaluation [**2131-1-29**]:
RECOMMENDATIONS:
1. Advance diet to ground solids & thin liquids by single
cup sip only, NO STRAWS!! No Mixed consistencies like
cold cereal w/milk or chicken soup w/liquid and solids
together.
2. Medications crushed in puree
3. Strict Aspiration Precautions:
A. PT MUST BE FED BY STAFF!
B. Remind him to eat & drink SLOWLY and
C. No Talking w/food/liquid in his mouth
D. Single cup sips of thin liquid, NO STRAWS
E. Hold liquid in mouth & keep head level
(don't look up or throw head back when drinking)
F. Alternate between bites and sips
4. If he coughs while drinking, downgrade his diet to Nectar-
Thick liquids. If he has any signs of coughing or choking
on ground solids, downgrade to Pureed foods. If he
does well w/ground solids, consider upgrading to soft
solids while carefully alternating between bites and sips
5. Repeat the videoswallow if his mental status or medical
status worsens to be sure this diet is still safe
PROGNOSIS:
Prognosis for safe swallowing without aspiration is good if he
is
supervised to take single sips of liquid and alternate between
bites and sips. However, if he drinks from a straw or feeds
himself, he tends to "gulp & shovel" liquid/food into his mouth,
placing him at significant risk to aspirate. Also, his level of
alertness/attention vary throughout the day. Please don't feed
him when he is not alert, attentive and appropirately following
commands.
.
.
[**2131-1-29**]: TTE with bubble study:
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. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). 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.
Brief Hospital Course:
A/P: 57 yo male with h/o MS who presents with hypoxia,
hypotension, neutropenia, fevers, ileus with likely PNA and UTI,
intubated for respiratory failure & sepsis.
.
# pulmonary: On arrival to the MICU, Mr. [**Known lastname 70884**] was hypoxic,
hypotensive, neutropenic, febrile and was intubated for hypoxic
respiratory failure. Source of his respiratory failure was
likely aspiration in the setting of sepsis. He was initially
treated with treated with meropenem x 7 days given concern for
aspiration pneumonia in this man who is chronic resident of an
extended care facility. A BAL was performed which showed 1+ gm
pos cocci in pairs and negative cultures. On [**1-19**], a SBT was
performed and patient was successfully extubated. Following
extubation, he continued to have copious secretions with
diminished gag, requiring vigorous chest PT. On [**1-23**], CXR
appeared markedly worsened consolidation representing
aspiration. Patient has weak gag and is not completely clearing
copious secretions. Due to leukocytosis, ? consolidation, pt
was started on Zosyn as empiric therapy for hospital acquired vs
recurrent aspiration pneumonia.
.
Pt was called out to medical floor on [**2131-1-28**]. A CTA was
obtained [**2-9**] persistent tachycardia and oxygen requirement
(2-3L), which revealed bilateral PE. Pt was started on heparin,
then transitioned to lovenox and coumadin. He was weaned off of
oxygen, and breathing comfortably on RA on [**1-29**]. Pt discharged
on [**1-31**] with instructions to continue coumadin, and lovenox
injections twice daily, and to have daily INRs checked and faxed
to his PCP ([**Doctor First Name **] [**Doctor Last Name **] [**Telephone/Fax (1) **], fax [**Telephone/Fax (1) 70885**]) with
goal INR [**2-10**]. He may discontinue his lovenox injections once
his INR is therapeutic (INR [**2-10**]) or as instructed by his PCP.
[**Name10 (NameIs) **] his pneumonia, pt will complete a 14 day course of
zosyn and vancomycin (via PICC) for hospital acquired pneumonia
(day 1 [**2131-1-23**], last day [**2131-2-5**]). Pt may benefit from ongoing
chest PT to help mobilize his secretions.
.
.
# altered mental status: pt with h/o multiple sclerosis. at
times, pt noted to be talking out loud with no one in room but
was easily redirectable. In the ICU, this was attributed to ICU
delirium after intubation/sedation, acute illness, lack of sleep
vs. MS [**First Name (Titles) 10942**] [**Last Name (Titles) **]. thiamine deficiency. Of note, per
family, patient's MS has been known to flare in the setting of
infection and has caused paralysis. Pt's mental status improved
gradually at time of callout to medical service, and per
disucssion on [**1-29**] with pt's PCP and with his daughter [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**1-30**], pt's mental status appeared close to baseline
(he was a&ox3, mumbling, and somewhat distractable, but aware of
current events, and of his recent medical history). While in
the ICU, pt developed acute onset of weakeness in hiw upper
extremities, whichw as felt [**2-9**] to his MS. [**Name13 (STitle) **] demonstrated
marked improvement over the course of his stay on the medical
floor, and had [**4-12**] bilateral strength of biceps, triceps, and
delts at the time of discharge. pt does not currently have a
neurologist, discussion with pt's previous neurologist (dr.
[**First Name (STitle) **], [**Hospital1 **], last saw pt [**9-12**]), suggest that pt lacks some
insight at baseline, but is generally a&ox3, and understands
some current events and some of his PMH.
.
.
# hypotension/sepsis: Sources of infection considered included
pneumonia (aspiration) and UTI. Hypotension could also be [**2-9**]
fluid losses in the setting of pancreatitis, cardiac causes such
as AMI or inadequate CO in the setting of rapid heart rate. Pt
had a history of urosepsis, with MRSA and multidrug resistant
proteus. He was initially maintained on single pressor titrated
to goal MAP 70. His basal cortisol level was 35.3 and did not
elevate with cosyntropin stimulation; he was treated with a
course of hydrocort and fludrocort. In the setting of profound
septic shock, he was initially started on Meropenem & Linezolid
given concern for aspiration pna and h/o VRE in urine. He
completed a 7-day course of meropenem; Linezolid was d/c'd on
day 6 as it may have been trigger for pancreatitis. Pt
subsequently started treatment for a hospital acquired pneumonia
on [**1-23**] given +BAL for GPCs, worsening sputum producing, and new
leukocytosis. Surveillance blood cultures on [**1-17**] have shown
NGTD. Surveillance urine cultures on [**1-15**] showed NGTD.
.
.
# cardiac: no cardiac history, pt denies chest pain or shortness
of breath upon admission to the medical service. mild elevation
in trop during ICU admission felt [**2-9**] demand in setting of
hypotension and sepsis. trop/ck trending down at time of
transfer to medical floor, repeat cardiac enzymes unremarkable.
TTE showed EF>55%, E/A 0.75 on [**1-29**]. regarding rythym, pt with
increased ventricular ectopy starting [**1-29**], and noted to have
transient self-limited episodes of bradycardia to the 30's. TTE
performed which was unremarkable, sinus tachycardia was
attributed to pt's PEs, and EP consult was obtained to evaluate
bradycardia, which were felt to be vagal (gradual slowing
observed on telemetry), and not requiring intervention as they
were asymptomatic. regarding pump function, pt initially
frankly volume overloaded, however he autodiuresed without
intervention, and was felt to be euvolemic upon discharge. pt
discharged on aspirin and zocor for hyperlipidemia.
.
.
# HTN: pt without history of HTN, but intermittently noted to
have elevated SBPs (150's) after extubation, possibly related to
mobilization of fluid. Upon arrival to the medical floor, his
SBPs were well controlled without initiation of antihypertensive
meds.
.
.
# Ileus vs SBO: On admission, CT Abd showed large amt of stool
in colon. Surgery was consulted but no surgical intervention
indicated. Pt arrived on the medical service without abdominal
complants, and +BM, with normoactive bowel sounds.
.
.
# ARF/UTI: pt presented with cre 2.2 on admission, felt likely
to be pre-renal in the setting of hypotension. pt with h/o
recurrent urosepsis, s/p course of cefepime which would have
covered enterococcus UTI, surveillance culture ngtd. Creatinine
stable s/p CTA (1.2->1.0, pt received mucomyst and hydration).
Pt was aggressively autodiuresing s/p CTA, likely mobilizing
fluid given during initial resuscitation, and on [**1-31**] was felt
to be euvolemic. He was encouraged to remain well hydrated upon
discharge and to match his urinary losses with oral hydration.
Pt has a chronic indwelling foley catheter which was last
changed 1 month earlier per NH, as such, his foley was replaced
on [**2131-1-31**].
.
.
# FEN: Given pt's acute presentation s/p aspiration event,
there was considerable concern regarding his ability to eat
unsupervised upon discharge. pt initially fed via post-pyloric
feeding tube which pt removed on [**1-29**]. pt evaluated by the
speech & swallow service who recommended: "ground solids & thin
liquids diet by single cup sip only, NO STRAWS!! No Mixed
consistencies like cold cereal w/milk or chicken soup w/liquid
and solids together. Medications crushed in puree. Strict
Aspiration Precautions. PT MUST BE FED BY STAFF. Remind him to
eat & drink SLOWLY and no Talking w/food/liquid in his mouth.
Single cup sips of thin liquid, NO STRAWS. Hold liquid in mouth
& keep head level (don't look up or throw head back when
drinking) Alternate between bites and sips. If he coughs while
drinking, downgrade his diet to Nectar-Thick liquids. If he has
any signs of coughing or choking on ground solids, downgrade to
Pureed foods. If he does well w/ground solids, consider
upgrading to soft solids while carefully alternating between
bites and sips." Pt discharged home with instructions to
follow above instructions. Should he develop recurrent coughing
with meals, he will follow-up with his PCP.
.
.
# DISPO:
Pt discharged to his nursing home on [**2131-1-31**], with instructions
to complete a course of vanco/zosyn (last day [**2131-2-5**]) via PICC
line. On [**2131-2-5**], he will contact his PCP regarding removal of
PICC line. He was instructed to take lovenox injections twice
daily, and have his INR checked daily and sent to his PCP, [**Name10 (NameIs) 1023**]
will adjust his INR as appropriate. he was instructed to
discontinue lovenox injections once his INR was at goal (INR
[**2-10**]) or as instructed by his PCP. [**Name10 (NameIs) **] plan was discussed with
pt's PCP (dr. [**First Name (STitle) **] [**Doctor Last Name **]) who is aware and amenable to this
plan.
.
.
# Communcation: HCP is [**Name2 (NI) 70886**] daily ([**Telephone/Fax (1) 70887**]),
daughter is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (3) 70888**]). pt lives
at windgate NH, [**Location (un) **] ([**Telephone/Fax (1) **]), PCP is [**Name9 (PRE) **] [**Doctor Last Name **]
[**Telephone/Fax (1) **], neurologist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 **])
[**Telephone/Fax (1) **].
Medications on Admission:
Vitamin C 500 mg qd
Prilosec 20 mg qd
Citalopram 40 mg qd
Zocor 40 mg qd
Senna 2 tabs [**Hospital1 **]
cranberry cap 2 caps TID
colace 200 mg qhs
Baclofen 30 mg qhs
ASA 81 mg qd
MVI
ativan 0.5 mg qhs
tylenol prn
Discharge Medications:
1. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Colace 100 mg Capsule Sig: [**1-9**] Capsules PO at bedtime as
needed for constipation.
6. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO BID PRN as
needed for constipation.
9. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
11. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours) for 2 weeks: please take twice daily. please
also take coumadin daily, and have INR checked daily and sent to
your PCP [**Name9 (PRE) **] [**Doctor Last Name **] ([**Telephone/Fax (1) **]), you may discontinue
lovenox injections once INR= [**2-10**] or instructed by your primary
care physician. .
Disp:*qs * Refills:*0*
12. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 6 days: please take
total 14 day course (day 1 was [**2131-1-23**], last day [**2131-2-5**]).
Disp:*24 Recon Soln(s)* Refills:*0*
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please have your INR checked daily and sent to your primary care
physician (dr. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) **]), who will adjust
your coumadin dose accordingly. your goal INR is [**2-10**]. you will
likely be on coumadin for 3 months for PE, or as instructed by
your PCP> .
Disp:*30 Tablet(s)* Refills:*1*
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 6 days: please take total
of 14 day course (day 1 was [**2131-1-23**], last day [**2131-2-5**]).
Disp:*12 * Refills:*0*
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed for 6 days: please
flush PICC with 2ml's of solution once daily, and prn. .
Disp:*qs ML(s)* Refills:*0*
16. Outpatient Lab Work
Please have your INR drawn daily for until [**2-7**], and sent to
your primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) **],
fax [**Telephone/Fax (1) 70885**]), who will adjust your coumadin dosing
appropriately, and instruct you as to how to monitor your INR in
the future. Your goal INR is [**2-10**].
17. PICC LINE CARE
please provide PICC line care per protocol.
18. PICC removal
Please call pt's PCP (dr. [**First Name (STitle) **] [**Doctor Last Name **], [**Telephone/Fax (1) **], fax
[**Telephone/Fax (1) 70885**]) on [**2131-2-5**] regarding removal of PICC, once pt has
completed his course of antibiotics.
19. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
20. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
21. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
22. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Sepsis
UTI
Respiratory failure
Aspiration pneumonia
Altered mental status
Multiple sclerosis
Pancreatitis
Acute renal failure
Discharge Condition:
stable
Discharge Instructions:
please continue to take all of your medications as prescribed.
.
You were started on a 14 day course of antibiotics for pneumonia
(zosyn, vancomycin last day [**2131-2-5**]).
.
You were started on a 14 day course of lovenox injections for
you pulmonary embolism. You will be transitioned to coumadin
therapy while on lovenox. You should have your INR checked
daily for the next week (until [**2131-2-7**]) until you reach a stable
INR (goal INR [**2-10**]), at which time you will have your INR
monitored routinely as per your primary care physician, [**Name10 (NameIs) 1023**] is
aware of this plan. you should continue to take lovenox twice
daily until your INR is between [**2-10**], or until instructed to stop
by your primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
[**Telephone/Fax (1) **]).
.
You should be fed in a supervised fashion, with aspiration
precautions, given that you were admitted for aspiration
pneumonia, please see feeding instructions on page 1 sheet for
more details.
.
If you develop chest pain, shortness of breath, difficulty
breathing, worsening lower extremity swelling, fevers, chills,
or other worrisome symptoms please contact your primary care
physician or the emergency department.
Followup Instructions:
Upon arriving to rehab please contact your primary care
physician and arrange to be seen within 2-3 weeks.
|
[
"596.54",
"401.9",
"584.9",
"344.1",
"518.81",
"250.00",
"599.0",
"414.8",
"415.19",
"285.29",
"577.0",
"785.52",
"038.9",
"276.6",
"272.4",
"507.0",
"995.92",
"340",
"560.1",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"96.6",
"96.72",
"33.24",
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
18742, 18819
|
5880, 8034
|
336, 348
|
18988, 18997
|
2437, 5857
|
20311, 20421
|
1930, 1948
|
15442, 18719
|
18840, 18967
|
15205, 15419
|
19021, 20288
|
1963, 2418
|
276, 298
|
376, 1695
|
8049, 15179
|
1717, 1790
|
1806, 1914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,223
| 199,191
|
52745+59461
|
Discharge summary
|
report+addendum
|
Admission Date: [**2172-8-18**] Discharge Date: [**2172-9-1**]
Date of Birth: [**2105-4-12**] Sex: M
Service: VSURG
Allergies:
Penicillins / Meperidine
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
AAA resection with ABF graft
History of Present Illness:
67/y/o male with history of lteft leg claudication and known
abdominal aortic aneurysm which has increased in size. Now
admitted for surgical repair
Past Medical History:
HTN
s/p L CEA [**6-5**]
AAA 5.3cm x 5.6cm
Thoracic descending AA
DM-diet controlled
Depression
Anxiety
Laryngeal cancer s/p resection and xrt
Compression fracture
Osteomyelitis of right jaw s/p bone graft
Social History:
Lives with sister and nephew. +tobacco 50 pack-years. no IVDU.
former ETOH. sober 25 years.
Family History:
Mother--ICH at 72yo
Pertinent Results:
[**2172-8-18**] 08:15PM WBC-6.7 RBC-2.96* HGB-9.5* HCT-26.8* MCV-91
MCH-32.1* MCHC-35.5* RDW-15.3
[**2172-8-18**] 08:15PM PLT COUNT-177
[**2172-8-18**] 08:15PM PT-14.2* PTT-30.3 INR(PT)-1.3
[**2172-8-18**] 03:00PM TYPE-ART PO2-462* PCO2-51* PH-7.33* TOTAL
CO2-28 BASE XS-0
[**2172-8-18**] 02:48PM GLUCOSE-151* UREA N-13 CREAT-0.6 SODIUM-139
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11
[**2172-8-18**] 02:48PM CALCIUM-9.5 PHOSPHATE-4.9* MAGNESIUM-1.1*
Brief Hospital Course:
Patient admitted to preoperative holding area [**2172-8-13**]
[**2172-8-18**] AAA repair with aortobifemoral bypass graft with intra
operative epidural catheter placement.Transfered to PACU
extubated and stable.Post operative Hct. 26.8
transfused two units of PRBC's. Patient in PACU developed new
onset of left arm and legnumbness .Blood pressure controlled
with improvement of left sided symptoms. Epidural also held and
solution changed and neurological symptoms rsolved. Patient
stablized and was transfered to VICU for continued care.Patient
continued to required high doses of Iv nitro which was converted
to Niprid with improvement of blood pressure.
[**2172-8-19**] POD#1 episode of confusion after recieving benadryl for
"itching". Also pulled out arterial line and epidural catheter.
This required haldol of total dose of 8mgm to manage confusion
and agitation.Lopressor was began for hypertension. nasogastric
tube clamping trial was began.
8/19-20/04 POD #[**2-4**] remained in VIcu. Requiring lasix for
moblization of fluids.
[**2172-8-22**] POD #4 Tolerating nasogastric tube clamping. TPN
insutued. Swan catheter converted to triple lumen subclavian
line.Antihypertensive s continued to require dosing adjustment.
Patient remained in VICU.
[**2172-8-23**] POD# 5 ambulation to chair began. Physical thearphy
evaluation recommended continued physical thearphy on daily
basis should be able to be discharged to home.
If gastric drainage residual less 200cc plan discontinue
nasogastric tube.Remained in VICU.
[**2172-8-24**] POD#6 clear liquids began and TPN rate of infusion
decreased.
[**2172-8-25**] POD#7 TPN dicontinued. Tolerating oral intake.
Perioperative clindamycin discontinued.Transfered to nursing
floor for continued care.
[**2172-8-26**] POD#8 Evaluated by physical thearphy. Would require
continued following prior to discharge on a daily basis by
physical therphy.
[**2172-8-27**] POD#9 Noted right foot to be cooler than left on am exam
during attending
rounds. Arterial PVR's demonstrated signficant flow
defecit.reutrned to surgery.
s/p right fmoral thromboembolectomy, endartectomy,right femoral
-popiteal by pass graft with PTFE, right lower extremity
introperative angiogram.He was transfered to PACU with palpable
graft pulse and Dp pulse.
[**2172-8-28**] POD# [**10-2**] Patient was seen by psyhciarty. Patient
refusing his antipsychotic medications.sequol discontinued since
patient not taking on a regular basis but nardal continued.Will
followup with his Phsyhiatric when discharged. Psychiatry did
not find any contraindiactions to dicharge to home when
mediacally stable.
[**2097-8-28**] POD# 11/12/2/3 continued to progress with stable
[**Month/Day/Year 1106**] exam. Foley discontinued, centeral ine discontinued and
abdominal stable were discontinued.
[**2172-8-31**] POD# 13/4 discharged to home stable condition.
Medications on Admission:
same as D/c medications
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Quetiapine Fumarate 25 mg Tablet Sig: Five (5) Tablet PO QD
(once a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
10. Phenelzine Sulfate 15 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
11. Phenelzine Sulfate 15 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
12. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
13. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay [**Hospital **] Nursing and Rehab Center
Discharge Diagnosis:
abdominal aortic aneurysm
right femoral thromobembolism s/p right femoral thromboelectomy
wit right fem-[**Doctor Last Name **] bypass graft with PTFE
adverse reaction to benadryl
Discharge Condition:
stable
Discharge Instructions:
continue all medicatiions as instructed
may shower, no tub baths
no driving until seen followup with Dr. [**Last Name (STitle) 1391**].
[**Name8 (MD) 138**] Md [**First Name (Titles) **] [**Last Name (Titles) 26520**] redness,swelling or drainage from groin or
leg wounds.
[**Name8 (MD) 138**] Md [**First Name (Titles) **] [**Last Name (Titles) 26520**] fever
Followup Instructions:
2 weeks with Dr. [**Last Name (STitle) **]. Call for appointment [**Telephone/Fax (1) 1393**]
followup with Dr. [**Last Name (STitle) 1007**] post discharge
followup with Dr.[**First Name (STitle) **] post discharge
Completed by:[**2172-8-31**] Name: [**Known lastname 400**],[**Known firstname 133**] Unit No: [**Numeric Identifier 17816**]
Admission Date: [**2172-8-18**] Discharge Date: [**2172-9-1**]
Date of Birth: [**2105-4-12**] Sex: M
Service: VSURG
Allergies:
Penicillins / Meperidine
Attending:[**First Name3 (LF) 231**]
Chief Complaint:
aaa
Major Surgical or Invasive Procedure:
AAA resection with ABF graft
s/p right femoral endartectomy and thromboembolectomy with right
femoral -[**Doctor Last Name **] bypass graft with PTFE, intraoperative angiogram
History of Present Illness:
Patient with known abdominal aortic aneurysm with increasing in
size . Now admitted for elective aortic surgery.
Past Medical History:
HTN
s/p L CEA [**6-5**]
AAA 5.3cm x 5.6cm
Thoracic descending AA
DM-diet controlled
Depression
Anxiety
Laryngeal cancer s/p resection and xrt
Compression fracture
Osteomyelitis of right jaw s/p bone graft
Social History:
Lives alone
Family History:
Mother--ICH at 72yo
Physical Exam:
unremarkable.
Pertinent Results:
[**2172-8-18**] 08:15PM WBC-6.7 RBC-2.96* HGB-9.5* HCT-26.8* MCV-91
MCH-32.1* MCHC-35.5* RDW-15.3
[**2172-8-18**] 08:15PM PLT COUNT-177
[**2172-8-18**] 08:15PM PT-14.2* PTT-30.3 INR(PT)-1.3
[**2172-8-18**] 03:00PM TYPE-ART PO2-462* PCO2-51* PH-7.33* TOTAL
CO2-28 BASE XS-0
[**2172-8-18**] 02:48PM GLUCOSE-151* UREA N-13 CREAT-0.6 SODIUM-139
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11
[**2172-8-18**] 02:48PM CALCIUM-9.5 PHOSPHATE-4.9* MAGNESIUM-1.1*
Brief Hospital Course:
patient's discharge was defered after talking with family who
felt patient would require extensive care and would be better to
be at rehabilitation. Rehabilitation screeing weas began.
Patient's PET scan for history of laryngeal cancer would need to
be done on an out patient basis. Patient should followup with
his ENT specialist after discharge to home for this evaluation.
We spoke to patient primary care physcial Dr. [**Last Name (STitle) 85**] [**Name (STitle) 17817**]
workup of patient's chronic loose stools and need for
colonoscopy. He felt it was not necessary at this time to do and
if need would be done on an out patient basis.
[**2172-9-1**] Patient was discharged to rehabilitation in stable
contition.
Medications on Admission:
see discharge medications
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Quetiapine Fumarate 25 mg Tablet Sig: Five (5) Tablet PO QD
(once a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
10. Phenelzine Sulfate 15 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
11. Phenelzine Sulfate 15 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
12. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
13. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 1726**] Bay [**Hospital 4824**] Nursing and Rehab Center
Discharge Diagnosis:
abdominal aortic aneurysm, s/p aortio-bifemoral bypass graft
Right leg thromboembolism , s/p right femoral endartectomy,
thrombolectomy and right femoral to popteial bypass with
PTFE,intra operative angio
Discharge Condition:
stable
Discharge Instructions:
none
Followup Instructions:
2 weeks with Dr. [**Last Name (STitle) **]. Call for appointment [**Telephone/Fax (1) 236**]
f/up with Dr. [**Last Name (STitle) 85**] upon d/c
f/up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17818**] d/;c
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2172-9-1**]
|
[
"996.74",
"441.4",
"E878.2",
"292.81",
"997.09",
"444.89",
"250.00",
"276.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"38.44",
"39.29",
"88.48",
"88.72",
"38.18"
] |
icd9pcs
|
[
[
[]
]
] |
10069, 10173
|
8089, 8809
|
6927, 7106
|
10422, 10430
|
7593, 8066
|
10483, 10875
|
7523, 7544
|
8885, 10046
|
10194, 10401
|
8835, 8862
|
10454, 10460
|
7559, 7574
|
6884, 6889
|
7134, 7248
|
7270, 7477
|
7493, 7507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,011
| 104,948
|
32756
|
Discharge summary
|
report
|
Admission Date: [**2154-12-14**] Discharge Date: [**2155-1-4**]
Date of Birth: [**2074-11-21**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Delta MS, respiratory distress
Major Surgical or Invasive Procedure:
R chest tube place
Intubation and mechanical ventilation
R IJ central line placed
L SC central line placed
PICC line placed
History of Present Illness:
80yo M with h/o hyperlipidemia, RA, new diagnosis of
glioblastoma multiforme (grade 4) p/w altered mental status and
respiratory distress. He was diagnosed in [**Month (only) 1096**] with GBM (by
biopsy) in the setting of increasing confusion, memory loss. He
was started in [**Month (only) 1096**] on high dose radiation therapy at which
time he was also started on high dose decadron w/ q3day taper
(most recently on 3mg); last radiation session was late
[**Month (only) 1096**]. He also recently had a port placed through which he
was receiving avastin (last 2 weeks ago). His family reports
mildly productive cough (cold sx) beginning approximately 1 week
ago; he had a CXR 3-4 days ago which reportedly was negative for
pneumonia and took atovaquone.
.
After the onset of these pulmonary symptoms, he later developed
left knee "bursitis" last week for which he received injection
most recently yesterday by PCP (presumably steroid injection).
He had largely been bed bound over the last few days [**1-4**] to left
knee pain. Beginning this morning, he was very exhausted. He
took a nap this morning and when he awoke, he was confused,
somnolent, lethargic. His wife called EMS and he was
transferred to [**Hospital1 18**] ED. En route to the ED, he was noted to be
in a.fib with RVR for which he received diltiazem.
.
In the ED initial vitals were T 96.7 HR 112 BP 105/67 RR 28 O2
sat 85% RA. CXR showed multifocal PNA at RUL, RLL, LLL. He was
placed on NRB and shortly thereafter O2 sats again dropped to
the 80s, thus he was intubated 4:30 pm. Blood cultures were
drawn and he received levofloxacin 750g IV x1, vancomycin 1g IV
x1, ceftriaxone 1g IV x1, and azithromycin 500mg x1. He also
received 10mg IV decadron. He was initially normotensive, but
dropped pressure at 6:30 pm into 70s requiring initiation of
phenylephrine gtt. Over his entire ED course, received total 5L
NS.
.
Head CT demonstrated "no new findings" and was reportedly
reviewed by [**Hospital1 18**] neurosurgery however there is no note in
chart/OMR. Additionally he was seen by his neurologist who
follows him at [**Hospital1 2025**], however there is no documentation of this.
Past Medical History:
# Grade 4 glioblastoma multiforme left temporal lobe; s/p high
dose radiotherapy, previously on high dose steroids, recently
tapered. Recently placed Portacath with steristrips still
present.
# Rheumatoid arthritis; on remicade until recently
# L knee bursitis
# Hyperlipidemia
Social History:
Lives at home with wife. [**Name (NI) **] and daughter-in-law (who is [**Name8 (MD) **] MD)
live locally. Smoking, Etoh history unknown.
Family History:
nc
Physical Exam:
S: Temp: 97.2 BP: 99/69 HR: 138 a. fib RR: 22 O2sat 92% AC
500/19 PEEP 14 FiO2 1.0
GEN: Intubated, unresponsive on minimal sedation
HEENT: Pupils pinpoint, symmetric, unresponsive to light,
scleral mildy icteric, dry MM, Multiple pinpoint white plaques
on roof of mouth
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
CHEST: Portacath site right anterior chest with steri strips in
place, mildly erythematous, no significant increase
warmth/induration/fluctuance
RESP: Clear anteriorly, decrease BS right laterally, no
wheezing/rales
CV: irreg irreg, no mrg appreciated
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ pedal edema b/l, right foot cooler than left 1+ DP on
right, 2+ DP on left, palpable PT pulses b/l, left knee with
small effusion, increased warmth without significant increased
erythema
SKIN: appears mildly jaundiced
NEURO: Downgoing toes b/l. DTRs [**Name (NI) 20772**] throughout
including biceps, patellar, achilles.
Pertinent Results:
ADMISSION LABS
[**2154-12-14**] 04:45PM BLOOD WBC-6.0 RBC-3.78* Hgb-11.7* Hct-34.3*
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.6 Plt Ct-74*
[**2154-12-14**] 04:45PM BLOOD Neuts-80* Bands-6* Lymphs-9* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2154-12-14**] 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2155-1-2**] 02:38AM BLOOD Plt Ct-179
[**2155-1-2**] 02:38AM BLOOD PT-14.6* PTT-35.5* INR(PT)-1.3*
[**2154-12-14**] 04:45PM BLOOD PT-13.3 PTT-31.5 INR(PT)-1.1
[**2154-12-14**] 04:45PM BLOOD Plt Smr-VERY LOW Plt Ct-74*
[**2154-12-14**] 04:45PM BLOOD Glucose-98 UreaN-44* Creat-1.1 Na-138
K-5.3* Cl-105 HCO3-23 AnGap-15
[**2154-12-14**] 04:45PM BLOOD CK(CPK)-52
[**2154-12-14**] 04:45PM BLOOD CK-MB-NotDone
[**2154-12-14**] 04:45PM BLOOD Calcium-8.0* Phos-3.7 Mg-2.7* UricAcd-3.4
[**2154-12-14**] 10:47PM BLOOD calTIBC-146* VitB12-1418* Folate-3.5
Ferritn-1409* TRF-112*
[**2154-12-14**] 10:47PM BLOOD TSH-0.69
[**2154-12-15**] 06:26AM BLOOD Cortsol-26.9*
[**2154-12-14**] 06:50PM BLOOD Type-ART pO2-60* pCO2-50* pH-7.30*
calTCO2-26 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2154-12-14**] 07:15PM BLOOD Lactate-2.2*
[**2154-12-15**] 12:25AM BLOOD O2 Sat-98
[**2154-12-15**] 12:25AM BLOOD freeCa-1.10*
Brief Hospital Course:
Note: the majority of this hospital course refers to the
patient's ICU course. He was on the medical floor for 16 hours
prior to discharge and was stable during this time.
.
# Septic Shock: Met criteria for septic shock. On presentation
had clear pulmonary source of infection. Initial sputums grew
out pneumococci. Patient relatively immunocompromised due both
to cancer diagnosis and chronic steroid use secondary to brain
tumor.
On admission patient had central line placed, CVPs maintained
[**7-15**]. Patient needed pressors to maintain BP initially. On
levophed, but developed some tachyarrhythmnias (Afib with RVR)
so was switched to neo. Initially covered with Zosyn, levoflox
and vanco. Patient was continued on atovaquone for PCP
[**Name Initial (PRE) 6187**]. Patient was also intubated on presentation, and
maintained on AC. Patient had EKGs without signs of ischemia,
and multiple sets of normal cardiac enzymes. Pressors were
largely weaned by HD #3. He did rarely require brief periods of
neosynepherine, due to too-rapid diuresis.
The patient had a normal cortisol stim test.
Historically, it was noted that the patient had a red left
knee a few days prior to admission. This knee was tapped by
ortho and found to be floridly septic. He was taken to the OR
and washed out by Ortho (please see seperate op note for full
accounting of this procedure). This infection was found to be
MSSA, which also grew out of his blood and eventually out of his
R chest chemo-port, which was removed by surgery. He was
maintained on a 6week course of Nafcillin for this staph
infection. A TEE demonstrated no signs of endocarditis.
Infectious disease was consulted and assisted with his
antibiotic regimen.
The patient completed a full 14d course of Levoflox for
pneumonia. The patient also had a full course of Clinda for a
question of toxic shock syndrome or aspiration pneumonia. His
Vanco was d/c'd after 5d due to only MSSA growing out. On [**12-20**]
his pre-existing R chest chemo port was noted to be purulent and
was removed by surgery. This grew out MSSA. Once more, the
nafcillin was continued for 6week total course.
A [**12-21**] culture grew out yeast and he was started on a course
of fluconisol as per ID. He recieved a full Ophtho eval which
demonstrated no ocular involvment.
Planned course of treatment is for nafcillin for total of 6
weeks to end [**1-30**], fluconazole for 2 weeks total to end [**1-9**], and
ceftriaxone to end [**1-10**].
.
# Afib c RvR: New-onset afib in the face of sepsis,
hypotension, infection. Patient initially controlled with
boluses of Diltiazem or Lopressor. Often returned into Afib
during times of increased activity or stress. Used
neosynepharine which seemed less arrhythmagenic. Amiodarone was
tried initially for control, but the patient became to
bradycardic on this [**Doctor Last Name 360**]. As patient was weaned from pressors
he was begun on a regimen of metoprolol which seemed to control
his rate well. He did ocassionally return to RVR, which was
treated with boluses of dilt or lopressor with good effect. He
was then restarted on amiodarone [**1-1**] and responded to it well.
Due to his brain tumor he was note anticoagulated during his
time in the ICU. The risks and benefits were discussed. It was
felt that the risks of ICH outweighed the benefits of stroke
prevention at this time. Plans were made to readdress this issue
once the patient's mental status improved.
.
# Septic Arthritis: As above, had septic arthritis of L knee
treated via washout by ortho on [**12-17**]. Nafcillin x6weeks per ID
started on [**12-19**]. Nafcillin is scheduled to finish on [**1-30**].
Patient did have a swollen L wrist later in his course, but this
was tapped by Ortho and never grew out any bacteria.
Plastics-hand was consulted and felt clinically that this was
not a septic joint, instead just a manifestation of his chronic
RA.
Ortho also felt it was not prudent to washout his R knee, which
was clinically asymptomatic during his ICU course. His L knee
healed well and the staples and drain were removed without
incidence. He has been signed off from direct ortho care, and
is weight-bearing as tolerated at time of ICU discharge.
.
#Respiratory status: Patient was maintained on ARDS-style
ventilation while on the ventilator. He has a bronchoscopy on
[**12-18**] which showed diffuse thick bloody sputum greatest in the R
LL. By [**12-19**] the patient was changed to pressure support
ventilation. The patient was activily diuresed at this time,
with good effect and improving respiratory status. The patient
tested negative for legionella and influenza. The patient was
quickly weaned to CPAP+PS of [**4-7**], but was difficult to wean
fully from the vent due mainly to his mental status. He was
extubated on [**12-24**] with great success.
On [**12-25**] the patient was noted to have an increasing o2
requirement and a CXR demonstrated a moderate-sized R
pneumothorax. Thoracic surgery was consulted and placed a chest
tube. This tube was intermittantly to wall-suction, water-seal
or clamped. On [**1-2**] it was d/c'd, with the pneumothoax smaller
in size.
.
#GBM: Head CTs compared to his baseline [**Hospital1 2025**] scans showed no
interval change. He was maintained on his baseline 3mg of
Dexamethasone while inpatient here. It appears that neurooncs
original plans were to taper the dexamethasone. We were unable
to contact primary neuro-oncoligist to discuss steroid taper but
this should be discussed with Dr. [**Last Name (STitle) **] when he becomes
available.
.
#Anemia/thrombocytopenia: Had anemia of chronic disease,
admitted with thrombocytopenia attributed to Avastin and
timador. His thrombocytopenia was asymptomatic during his
hospital course, and steadily improved. His anemia was mild,
and did require occasional transfusion.
.
# Hyperglycemia: Intitally hyperglycemic in face of sepsis,
controlled with SS insulin and resolved on its own.
.
#R Chest wound: Con't to drain purulent material s/p removal of
port. Surgery recommended QID dilute([**12-6**]) Dakin's solution and
close f/u. Any fluctuant areas must be debrided.
.
#Mental Status: The patient presented with altered mental
status felt to be due to sepsis. He did take some days to
awaken from his intubated and sedated state. He continued to be
Aox1-2 in the MICU, with symptoms consistent with delerium. A
repeat head CT showed no change; his delerium was felt to be
mainly post-septic and ICU related and appeared to be slowly
intervally improving each day.
.
#Prophylaxis: Patient was initially on pneumoboots and then
Heparin SC, a bowel regmimen and a Gi prophlyaxsis throughout
his hospital course.
.
# Electrolytes: The patient required extensive repletion of his
potassium during his ICU course, often requiring q6hr lyte
checks and 100-200meq of K+ per day. This was felt to be mostly
due to a diarrhea and thus GI loss, and was resolving at the end
of his hospital course as diarrhea resolved.
.
# Nutrition: The patient was maintained on TF while intubated,
and also s/p intubation as he failed his initial speech and
swallow exams. On [**1-3**] he passed his speech and swallow bedside
test.
.
#LFTs: Patient had elevated LFTs on presentation which were
attributed to sepsis. This abnormality resolved as the
patient's clinical picture improved. He should continue on
weekly LFT checks due to his continuing nafcillin.
.
# PT/OT: after extubation the patient was followed actively by
PT and OT.
Medications on Admission:
# Naproxen prn
# Mepron (prophylaxis)
# Hydrocodone
# Dexamethasone 3mg
# Avastin (last received 2wks ago, due on Monday [**2154-12-16**])
# Lipid lowering [**Doctor Last Name 360**] (wife unsure of name)
# Timador (was previously on this, but was stopped [**1-4**] to
thrombocytopenia)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
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: Five (5) ml PO BID (2
times a day).
4. Atovaquone 750 mg/5 mL Suspension Sig: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for cough.
9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 2 weeks: last day [**1-9**].
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for HR<50 and SBP<100.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): [**Hospital1 **] until [**1-7**] then 400mg daily.
12. Famotidine 10 mg/mL Solution Sig: Twenty (20) mg Intravenous
Q12H (every 12 hours).
13. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours).
14. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q6H (every 6 hours) for 6 weeks: last day
[**1-30**].
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5)
units Subcutaneous twice a day.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous four times a day: sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Septic Shock
Community Aquired Pneumonia
Respiratory Failure
Acute Renal Failure
Septic Arthritis (L Knee)
Bacteremia
Infected R Chest Catheter
Afib with RVR
Delerium
Anemia
Thrombocytopenia
Hyperglycemia
Pneumothorax (R)
Hypokalemia
Transaminitis
Secondary:
# Grade 4 glioblastoma multiforme left temporal lobe; s/p high
dose radiotherapy, previously on high dose steroids, recently
tapered. Recently placed Portacath with steristrips still
present.
# Rheumatoid arthritis; on remicade until recently
# L knee bursitis
# Hyperlipidemia
Discharge Condition:
fair - multifactorial delirium with waxing and [**Doctor Last Name 688**] mental
status A+Ox1-2
Discharge Instructions:
You were admitted for pneumonia and multiple infections
including of your knee and blood stream. you were treated with
several antibiotics and had a stay in the intensive care unit
which required intubation. Currently you are being treated for
these infections and are on tube feedings and slowly eating
again.
Regarding your brain tumor, we felt that this issue, while
serious, was stable during your stay here. It is very important
that you followup with your neuro-oncologist Dr. [**Last Name (STitle) **] at
[**Hospital1 2025**]. You need to discuss with him whether you should be on
blood thinners.
.
Followup Instructions:
f/u with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 1005**] of orthopedic surgery at ([**Telephone/Fax (1) 15940**] to schedule a followup appointment in 1 month.
f/u with your outpatient rheumatologist in [**1-6**] weeks.
f/u with your outpatient neurooncologist Dr. [**Last Name (STitle) **] on Monday
by phone - he should be involved in deciding steroid taper and
deciding about anticoagulation.
Some of your labs will be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of infectious
disease at ([**Telephone/Fax (1) 1353**] (phone ([**Telephone/Fax (1) 17490**]), she will
contact you regarding followup.
|
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icd9cm
|
[
[
[]
]
] |
[
"81.91",
"86.05",
"38.93",
"96.04",
"33.24",
"96.72",
"88.72",
"96.6",
"86.28",
"80.76",
"38.91",
"80.16",
"34.04",
"97.89"
] |
icd9pcs
|
[
[
[]
]
] |
15059, 15138
|
5468, 11659
|
313, 439
|
15730, 15828
|
4180, 5445
|
16491, 17189
|
3116, 3120
|
13349, 15036
|
15159, 15709
|
13038, 13326
|
15854, 16468
|
3135, 4161
|
243, 275
|
467, 2642
|
11675, 13012
|
2664, 2944
|
2960, 3100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,293
| 176,525
|
2289
|
Discharge summary
|
report
|
Admission Date: [**2111-5-26**] Discharge Date: [**2111-6-12**]
Date of Birth: [**2035-5-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
s/p pulling out PEG tube and inability to pass foley
Major Surgical or Invasive Procedure:
PICC line placement
PEG tube insertion
EGD with cauterization
PICC line insertion
History of Present Illness:
Pt is a 76 yo [**Location 7972**] Creole speaking male with HTN,
essential thrombocytopenia, s/p right craniotomy for subdural
hematoma, additional admission in [**Month (only) 547**] for management of SDH,
PCA stroke, and c. diff colitis, who presents because he pulled
out his PEG tube and inability to pass foley. Pt was started on
ritalin last week for being sluggish. He was noted to be
delirium over the weekend and ritalin was d/cd on saturday. Day
of admission, pt was delirius, and pulled out his PEG tube.
Reportedly, pt also with low back pain over the past week and
adominal pain which is chronic.
Past Medical History:
Subdural hematoma
Hypertension
Hypercholesterolemia
Essential thrombocytopenia
s/p placement of GJ tube
infected GJ tube insertion site
h/o C diff infection (diagnosed in [**Month (only) **] admit)
Social History:
Pt is haitian Creole speaking. He is married with a son and a
daughter.
Family History:
Non-contributory
Physical Exam:
VS: T: 96.1; BP: 197/70; HR: 50; RR: 16; O2: 98 RA
Gen: Confused laying in bed in NAD
HEENT: PERRLA; Sclera anicteric
CV: RRR S1S2. No M/R/G
Lungs: CTA b/l anteriorly.
Abd: +BS. Diffuse tenderness without rebound or guarding >er LLQ
and suprapubic areas. G-tube removed. Site is not erythematous.
Ext: No edema. DP 2+
Neuro: Did not know where he was, or day, or month. MS: [**4-23**]
upper extremities b/l. LE: left flexion [**3-24**], all else [**4-23**].
Pertinent Results:
Labs on admission:
[**2111-5-26**] 05:15PM BLOOD WBC-12.2*# RBC-3.74* Hgb-11.5* Hct-34.6*
MCV-93 MCH-30.9 MCHC-33.3 RDW-15.3 Plt Ct-746*
[**2111-5-26**] 05:15PM BLOOD Neuts-69.9 Lymphs-21.1 Monos-8.4 Eos-0.3
Baso-0.2
[**2111-5-26**] 05:15PM BLOOD Glucose-100 UreaN-15 Creat-1.0 Na-140
K-5.0 Cl-104 HCO3-27 AnGap-14
[**2111-5-26**] 05:15PM BLOOD ALT-21 AST-26 AlkPhos-140* Amylase-69
[**2111-5-26**] 05:15PM BLOOD Calcium-9.9 Phos-3.6 Mg-1.7
__________________________
Other:
[**2111-5-26**] 05:15PM BLOOD ALT-21 AST-26 AlkPhos-140* Amylase-69
[**2111-5-27**] 09:05AM BLOOD VitB12-690 Folate-19.4
[**2111-5-27**] 09:05AM BLOOD TSH-2.8
[**2111-6-3**] 06:13PM BLOOD Lactate-1.1
[**2111-6-8**] 08:37AM BLOOD Lactate-1.0
__________________________
Labs on discharge:
[**2111-6-11**] Hct: 33.0*
[**2111-6-10**] Hct: 33.1*
[**2111-6-9**] Hct: 32.2*
[**2111-6-8**] Hct: 32.5*
___________________________
Micro:
[**2111-5-26**]- UCx- no growth
[**2111-5-27**] 12:18 pm URINE
**FINAL REPORT [**2111-5-29**]**
URINE CULTURE (Final [**2111-5-29**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
IMIPENEM-------------- 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
[**2111-5-27**] RPR -negative
[**2111-5-21**], [**2111-5-31**], [**2111-6-9**]- C. diff no growth
[**2111-6-2**]- UCx- no growth
_____________________________________
Radiology:
[**2111-5-26**] CT ab/pelvis with and without contrast-1. Improved
appearance of previously described colitis.
2. No acute abnormality.
[**2111-5-27**]- CT head without contrast-CT OF THE BRAIN WITHOUT
INTRAVENOUS CONTRAST: There is again seen an area of linear
density adjacent to the inner table at the location of the
right-sided craniotomy, which is unchanged in appearance since
[**2111-5-19**], likely post- surgical in origin. No acute
intracranial hemorrhage is identified. There is no new mass
effect or shift of normally midline structures. The lateral
ventricles are symmetric and unchanged in size. The basilar
cisterns are patent. Stable appearance of old infarct in the
right posterior cerebral artery distribution is noted. Stable
periventricular white matter hypodensity consistent with small
vessel ischemic change is seen. Elsewhere within the brain, the
[**Doctor Last Name 352**]-white differentiation is preserved.
[**2111-5-28**]-EEG-: Abnormal EEG due to the slow and disorganized
background
rhythm. This indicates a widespread encephalopathy. Medications,
metabolic disturbances, and infection are among the most common
causes.
There were no epileptiform features.
[**2111-6-4**]-EEG-This is an abnormal routine EEG due to the presence
of a
slow and disorganized background rhythm in the theta frequency
range
with occasional intermixed, generalized delta frequency slowing.
These
findings suggest deep, midline subcortical dysfunction and are
consistent with an encephalopathy. Common causes include
infections,
medication effects, and metabolic disturbances. No lateralizing
or
epileptiform abnormalities were identified. If clinical concern
for
seizures persists, a repeat study after the patient's mental
status
improves, may be of benefit to better discriminate focal
abnormality
that can be obscured by an encephalopathic pattern. Sinus
bradycardia
was noted.
[**2111-6-8**] MRA/MRI head-1. New focus of increased susceptibility in
the peripheral right cerebellar hemisphere, which may be
artifactual, but could represent a small area of hemorrhage.
Please note that this finding was not seen on the previous
examination, but the difference may be due to the present study
obtained at 3T, as opposed to the 1.5T study earlier. The higher
field strength of the present study could increase the
visibility of magnetic susceptibility.
2. No evidence of acute ischemia.
3. Stable MRA of the circle of [**Location (un) 431**] compared to [**2107-10-20**].
[**2111-6-10**] MRI gadolidium-1. Enhancement of the pachymeninges along
the entire right convexity, likely related to previous subdural
hemorrhage.
2. Developmental venous anomaly in the right frontal lobe, a
benign finding.
3. No evidence of acute ischemia.
4. No cerebral masses.
Brief Hospital Course:
On [**2111-5-28**], pt was noted to be tachycardic, then had decreased in
BP from 120's from 150-180's. That same day patient had 2 large
melenic stools. ~ 10 point Hct drop from 32 on [**5-27**] am to 23 on
[**5-28**]. He was given 2 units of pRBC and then was transferred to
the MICU.
MICU course: Patient had an episode on bloody emesis ~300 cc but
Hct remained stable. EGD was initially attempted but could
unsuccessful to visualize bleeding b/o old clot. EGD repeated on
[**2111-5-29**] and showed small ulcer w/ signs of recent bleeding at
gastrostomy site. This was injected wtih epinephrine and
cauterized. Additionally, pt was found to have a pseudomonal UTI
and mental status improved. Then pt had two unresponsive
episodes on the floor. The following is by problem of the above:
1. Altered mental status/unresponsive- Pt was initially pulling
at his foley and IVs pulling them out when he was initially
hospitalized. He eventually was found to have a pseudomonal UTI
and was fully treated with Zosyn (see below). His mental status
cleared to baseline per family where at times he was oriented x
3. Thus, his altered mental status when he was in the hospital
was attributable to his UTI and has now resolved to his previous
mental status.
Pt also had with two episodes of unresponsiveness on [**2111-6-3**] and
[**2111-6-7**]. MRI/MRA showed ? small amount of hemorhage in right
cerebellar hemishphere which could be artifact. MRA was fine.
Repeat MRI with gadolidium showed no acute stroke. EEG was
repeated and was only consistent with encephalopathy. Neurology
was consulted on pt who thought that pt may have seizures but it
was unclear. [**Name2 (NI) **] was stable for the rest of his hospitalization.
B12 was checked (pt with history of b12 deficiency) and it was
normal. Pt would pull at his tubes/lines frequently but this
decreased towards the end of his hospital stay. HE was on 1:1
sitters and restraints during hospitalization having the
restraints taken off within a few days. The 1:1 sitter was taken
off a few days before discharge and pt did well, with no
agitation.
We held pt's provigil and paxil during altered mental status and
avoided sedating medications.
2. GI Bleed-Pt had a GIB secondary to ulceration at PEG tube
from pulling it out. He had an EGD which showed this and the
ulceration was cauterized.
He required blood transfusion x 2 initially and then 2 units of
pRBC when he came back on the floor to bump him up. We initially
were checking Hct q12 when pt arrived back on the floor and then
when Hct was stable for a few days qday. We started with
protonix [**Hospital1 **] and switched to prevacid [**Hospital1 **] once G tube was
placed. He will get this for one month in total and then to
qday.
3. [**Name (NI) 12007**] Pt grew pseudomonas in his urine which was sensitive to
Zosyn. He completed a 14 day course of Zosyn while in-house. He
had negative U/A, UCx after that. His initial delirium was
likely due to this, and has now resolved to baseline. FOley
placement was difficult therefore no voiding trials were done.
4. G-tube displacement- As above. Replaced [**2111-5-28**]. Receiving
tube feeds through it. Needs speech and swallow evaluation for
safety of po intake in setting of baseline delerium.
5. Foley placement/[**Name (NI) 12008**] Pt had inability to place foley
initially and then had a 22 caude placed in the ED. GU saw pt
when he was out of the MICU and replaced a 22 caude catheter.
Flomax was started for urinary retention. However, we d/cd it as
that was the only change in medications prior to initial
unresponsiveness. Inability to pass foley is likely [**1-21**] foley
trauma/acute edema. He will need a voiding trial in rehab and
outpt follow up with urology.
6. Essential [**Name (NI) 12009**] Pt was not on his hydroxyurea upon
coming in, stopping in in his surgery admission. We restarted
hydroxyurea after discussing this with his hematologist, Dr.
[**Last Name (STitle) **]. Plavix on hold [**1-21**] bleed. Pt will need follow up with Dr.
[**Last Name (STitle) **] as an outpatient. Please continue to hold plavix (for at
least 6 weeks) ; follow outpt hematolgy recommendations.
7. Depression- we d/cd paxil in setting of altered mental
status. This should be restarted when pt follows up with his
PCP.
8. HTN- BP meds were initially being held in the setting of
acute bleed. We restarted his clonidine and metoprolol at outpt
doses.
9. Hyperlipidemia- Cholestyramine was on hold. We restarted it
prior to discharge.
10. C. diff- Pt with c. diff positive on prior hospitalizations
with persistant diarrhea. We treated him with vancomycin while
on zosyn, and have now d/c'd vancomycin.
11. PPx- Subcutaneous heparin restarted after GIB stable.
Prevacid.
12. [**Name (NI) 12010**] Pt had a Right fem line in the MICU which was d/cd.
He had a right arm PICC placed by IR which was d/cd when the
antibiotic course was finished. He had peripheral IVs otherwise.
13. F/E/[**Name (NI) **] Pt was on tube feeds. Nutrition consulted for help.
Electrolytes were checked and repleted prn. Speech and Swallow
evaluation needed for safety of po intake.
14. Code Status-Pt was Full Code.
Medications on Admission:
1. Modafinil 50 mg qday
2. Celecoxib 100 [**Hospital1 **]
3. Metoprolol 25 tid
4. Lansoprazole 30 qhs
5. Cholestyramine 4 g [**Hospital1 **]
6. Paroxetine 30 mg qday
7. Clonidine 0.1 mg q8 hours
8. Paroxetine 30 mg qday
9. Cholestyramine 4 g [**Hospital1 **]
10. Dalteparin 2500 units qday
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO twice a
day.
2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
SC Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day) for 2 weeks: After 2 weeks stop [**Hospital1 **]
dosing and switch to daily dosing.
9. Cholestyramine-Sucrose 4 g Powder Sig: One (1) PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis:
Delirium
Gastrointestinal bleed
Urinary Tract Infection
Inability to pass foley
Clostridium difficile
Secondary diagnosis:
Hypertension
Essential thrombocytosis
Hyperlipidemia
Discharge Condition:
Pt is doing significantly better. His Hct is stable and his
mental status has returned to baseline per family. They note
that he has had intermittant delerium since SDH in spring, now
baseline, does not require inpatient care.
Discharge Instructions:
Call your doctor or go to the ED if you have change in your
mental status, bright red blood per rectum, black stools, have
fever >101, chills, nausea, vomiting, chest pain, problems
breathing, shortness of breath, or any other health concern.
Take your medications as prescribed.
Go to your appointments below.
1.Call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 7976**] within the next
7-10 days for follow up.
2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 742**] NEUROSURGERY WEST Where:
LM [**Hospital Unit Name 12011**] Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2111-6-18**] 2:15
-HEMATOLOGY: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- call for appointment [**Telephone/Fax (1) 9645**]
-UROLOGY: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] call for appointment: [**Telephone/Fax (1) 6445**]
Take your medications as prescribed.
Followup Instructions:
1.Call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 7976**] within the next
7-10 days for follow up.
2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 742**] NEUROSURGERY WEST Where:
LM [**Hospital Unit Name 12011**] Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2111-6-18**] 2:15
-DR. [**Last Name (STitle) **]- [**Telephone/Fax (1) 9645**]
-UROLOGY: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] call for appointment: [**Telephone/Fax (1) 6445**]
Completed by:[**2111-6-12**]
|
[
"599.0",
"008.45",
"788.20",
"348.30",
"578.1",
"536.49",
"041.7",
"287.3",
"707.8",
"427.31",
"536.42",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.13",
"38.93",
"99.04",
"97.02",
"57.94",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
12819, 12892
|
6472, 11644
|
368, 452
|
13132, 13360
|
1929, 1934
|
14405, 15009
|
1418, 1436
|
11984, 12796
|
12913, 12913
|
11670, 11961
|
13384, 14382
|
1451, 1910
|
276, 330
|
2691, 6449
|
480, 1091
|
13056, 13111
|
12932, 13035
|
1948, 2672
|
1113, 1313
|
1329, 1402
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,311
| 173,113
|
34919
|
Discharge summary
|
report
|
Admission Date: [**2136-7-15**] Discharge Date: [**2136-7-20**]
Date of Birth: [**2102-8-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
nausea/vomiting, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33F with metastatic melanoma with leptomeningeal disease, most
recently recieved XRT four days prior to current admission to
T11-L2 for BLE weakness and loss of sensation now presents with
frontal headache and nausea/vomiting. Of note, she was recently
admitted [**Date range (1) 45401**] with new onset BLE weakness and urinary
retention, and T11-L2 and conus mets on MRI at OSH. Her
dexamethasone was increased during last hospitalization to 8mg
TID but decreased over the weekend because of insomnia. This
morning, patient woke up with left sided frontal/temporal
headache not releived by Tylenol She felt nauseaous and had
several episodes of vomitting, no blood. She vomited the
steroids and was only able to keep down a few peaches and
fluids. The BLE weakness/loss of sensation has not progressed,
she is unable to stand. She doesn not have any new focal
weakness. Urinary retention has worsened. She is able to void
with straining but not able to fully evacuate her bladder. She
has required stool softeners for the last few days which is new
for her. She denies fevers/chills, SOB, chest pain, abdominal
pain, no change in mental status. Fatigue has worsened over the
past 5-6 days. Referred in for admission to OMED and brain MR
w/ contrast.
.
In the ED, initial vs were: T 98.8 HR 88 BP 139/87 RR 16 O2 100%
Patient was given morphine for pain and zofran for nausea, which
were effective. CT Head showed hemorrhagic transformation of
known brain metastases with no midline shift or hydrocephalus.
She was seen by neurosurgery who stated that no intervention is
needed at this time and recommended q1 hour neur checks. Neuro
onc saw her and recommended Decadron IV q6hr. Rad/onc fellow
was called who said that no further imaging is needed urgently
and that she will be seen tomorrow morning for probable whole
brain radiation.
Past Medical History:
Melanoma stage IV
-[**1-7**] Excisional biopsy revealed a 3.75 mm thick, [**Doctor Last Name 10834**] level
IV melanoma on her lower back. She underwent wide local
excision
and bilateral inguinal node sentinel lymph node biopsy which
revealed no melanoma.
-[**6-5**] adjuvant peptide vaccine clinical trial at the NCI for 1
year.
-[**8-9**] Resection of soft tissue recurrence in apparent lymph node
beneath right twelfth rib.
-[**10-9**]. Enrolled in a vaccine trial at the [**State 79908**], but reoccurred in right back soft tissue and an
additional
supraclavicular nodule. Restaging PET scan showed
retroperitoneal disease which was biopsied on [**2134-2-18**] and proven
to be melanoma.
-[**3-10**] HD IL-2 with 13/14 doses week 1 and [**11-14**] doses week 2
with
disease progression noted [**9-9**].
-Enrolled in clinical trial PLX/RO5185426 on [**2134-10-5**]. She
underwent pre treatment biopsy on [**2134-10-6**] on the left breast
taillesion. Treatment began on [**2134-10-19**].
-On [**2136-6-2**], she had restaging Ct of head for routine follow up
as well as torso CT. Her torso CT revealed to be stable with
further reduction of her disease however, on head CT two
suspicious lesion 1.0 cm in L frontal lobe and in the
periventricular white matter on the left note is made of a small
hyperdense focus which also enhances on post-contrast imaging,
measuring in total 4 x 3 mm. She
underwent head MRI for confirmation and was found to have at
least [**6-8**] small lesions and well as the L frontal lesion. She
was seen by
Dr. [**Last Name (STitle) 3929**], our radiation oncologist who felt she also had
leptomeningeal involvement given the location of the lesions are
in the suface of the CNS. Also she has one lesion on the
brainstem. She began ipilimumab off protocol on [**2136-6-19**].
Social History:
Denies tob. Endorses a few beers/night. Denies
recreational/illicit drug use.
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: T:98.1 BP:134/83 P:53 R:11 O2: 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no cyanosis or edema
Neuro: CN II-XII intact, UE: [**4-5**] b/l in proximal/distal/hands,
LE: 1+/5 with proximal flexion b/l, 0/5 in distal extremities,
sensation intact in UEs, no sensation in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l from upper
patella and below
.
Discharge Physical Exam:
Vitals: T:97.6 BP:124/86 P:67 R:14 O2: 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no cyanosis or edema
Neuro: CN II-XII intact, UE: [**4-5**] b/l in proximal/distal/hands,
LE: 1+/5 with proximal flexion b/l, 0/5 in distal extremities,
sensation intact in UEs, no sensation in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l from upper
patella and below
Pertinent Results:
Admission Labs:
[**2136-7-15**] 02:35PM WBC-11.7* RBC-4.70 HGB-14.5 HCT-41.0 MCV-87
MCH-30.7 MCHC-35.3* RDW-12.7
[**2136-7-15**] 02:35PM NEUTS-93.1* LYMPHS-3.3* MONOS-3.3 EOS-0.3
BASOS-0
[**2136-7-15**] 02:35PM PLT COUNT-366
[**2136-7-15**] 02:35PM GLUCOSE-113* UREA N-15 CREAT-0.6 SODIUM-137
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2136-7-15**] 08:03PM PT-12.1 PTT-22.3 INR(PT)-1.0
[**2136-7-15**] 02:42PM LACTATE-1.0
[**2136-7-15**] 02:35PM URINE UCG-NEGATIVE
[**2136-7-15**] 02:35PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2136-7-15**] 02:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
.
Discharge Labs:
.
[**2136-7-20**] 08:15AM BLOOD WBC-8.6 RBC-4.08* Hgb-12.9 Hct-36.0
MCV-88 MCH-31.6 MCHC-35.8* RDW-12.4 Plt Ct-316
[**2136-7-20**] 08:15AM BLOOD PT-11.6 PTT-21.0* INR(PT)-1.0
[**2136-7-20**] 08:15AM BLOOD Plt Ct-316
[**2136-7-20**] 08:15AM BLOOD Glucose-97 UreaN-12 Creat-0.6 Na-134
K-4.2 Cl-97 HCO3-28 AnGap-13
[**2136-7-20**] 08:15AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.3
.
Microbiology:
Urine culture ([**7-15**]): Negative
.
Imaging:
CT head without contrast ([**7-15**]): IMPRESSION:
1. Interval hemorrhage into two known metastatic lesions in the
left anterior frontal lobe and left periventricular white matter
with surrounding vasogenic edema.
2. Local mass effect upon the left lateral ventricle and sulcal
effacement. No shift of the midline structures or evidence of
transtenorial herniation.
3. Incompletely characterized additional known metastatic
lesions. If there is clinical concern for new metastasis, MRI of
the brain is recommended.
.
CT torso with contrast ([**7-16**]): IMPRESSION:
Hypodensity/melanoma lesion in the caudate lobe appears slightly
increased in size on the current study compared to the prior
examination. Otherhypodensities in the liver too small to
characterize but unchanged since [**2135-1-3**].
.
MR head with contrast ([**7-17**]): IMPRESSION:
1. Hemorrhage within the lesions in left frontal and left
frontoparietal
periventricular white matter with increase in the size of these
lesions and increased mass effect.
2. Increase in the size of the lesions in right temporal, left
temporal, left frontal lobes, and in right periaqueductal
region.
3. No new lesion.
Brief Hospital Course:
33F with metastatic melanoma with leptomeningeal disease, BLE
weakness and loss of sensation now presents with frontal
headache, nausea, and vomiting, found to have likely
hemorrhagic transformation of 2 known brain metastases on CT
head.
.
ACTIVE DIAGNOSES:
.
#Hemorrhagic Transformatin of known brain mets: Pt presented
with severe headaches, nausea, and vomiting with findings on CT
demonstrating hemmorrhagic conversion confirmed on MRI brain.
The patient was seen by neurosurgery in the ED, who recommended
no immediate surgical intervention. Her dexamethasone dose was
increased to retard swelling and she was admitted to the ICU for
regular neuro checks and monitoring. She remained neurologically
stable overnight and was transferred to the OMED service. CT
Chest/Abd was performed for staging and showed no new mets.
Radiation Oncology recommended whole brain radiation to address
the growth of brain mets in addition to the planned spinal
radiation course. The patient refused WBR in favor of other
therapeutic options. She was started on vamurefanib (study
medication) and monitored for neurological changes over the next
2 days. She remained nearly completely paralyzed from the waist
down with full neurological function above the waist. She
tolerated the study medication well and required only occasional
PRN doses of morphine for headaches and ativan for
steroid-induced anxiety and muscle tension. She was converted to
PO morphine liquid (as she preferred it to her home oxycodone)
and was discharged on a regimen of oxycontin 10mg [**Hospital1 **] for basal
pain control and morphine liquid 5mg PO Q4hrs PRN for
breakthrough (pt also continued on oxycodone by family request
but warned against using both PRN oxycodone and PRN morphine for
concern of increased risk of sedation and respiratory
depression).
.
# Cauda Equina Syndrome [**1-4**] to Leptomeningeal Involvement of
Melanoma: She remained neurologically stable with known BLE
weakness with motor function limited to 1+/5 strength in
proximal BLEs and with complete loss of sensation below her
knees. Since her prior admission she had developed worsening of
her urinary and bowel retention. A foley was placed and she was
continued on her bowel regimen of senna and colace with daily PR
dulcolax (she had concerns about straining for urination and
bowel movements as a cause of increased intracranial pressure).
She continued a short course of radiation treatments to her
spine which was discontinued on initiation of vamurefanib
therapy. She was discharged home with services and a foley in
place.
.
CHRONIC DIAGNOSES: None
.
TRANSITIONAL ISSUES: Her decadron dose was converted to PO and
continued at 4mg PO QID. Neuro-oncology recommended a taper down
from 4mg QID to 4mg TID over a week and then to 4mg [**Hospital1 **] over
another week. We held off on initiating a taper until she was
followed by neuro-oncology in Dr.[**Name (NI) 6767**] clinic.
.
Medications on Admission:
dexamethasone 8 mg PO tid
docusate sodium 100 mg PO bid prn constipation
senna 8.6 mg PO bid
ativan 1 mg PO bid prn anxiety
ZOFRAN ODT 8 mg PO q8h prn nausea
OxyContin 10 mg PO bid
MVI 1 tab PO qd
gabapentin 100 mg PO tid
ibuprofen 800 mg PO tid prn pain
naproxen 500 mg PO bid
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
4. morphine 10 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every 4
hours) as needed for pain.
Disp:*30 doses* Refills:*0*
5. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*30 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:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Vemurafenib Sig: Four (4) [**Hospital1 **] (2 times a day).
8. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
9. OxyContin 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
Metastatic melanoma
Cauda Equina Syndrome
Secondary:
None
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 Mrs. [**Known lastname 22056**],
.
It was a pleasure taking care of you. You were admitted to [**Hospital1 18**]
for evaluation of severe headaches and found to have hemorrhagic
conversion of known tumor metastasis in your brain. You were
monitored in the ICU but were found to be neurologically stable.
You were started on vamurafenib and tolerated the medication
well. You remained neurologically stable on the new treatment
and are being discharged home.
.
The following changes have been made to your medications:
-START Vamurefanib 4 tabs by mouth twice daily per Oncologist
Orders
-START Morphine oral solution 10mg/5ml, one-half of a dose every
4 hours as needed for pain
-CHANGE dexamethasone to 4mg by mouth every six hours
-STOP Ibuprofen and Naproxen and Gabapentin
.
It was a pleasure taking care of you. Please be sure to
follow-up with the appointments below. Please continue on your
current steroid dosage until you see Dr [**Last Name (STitle) 724**] in clinic (make an
appointment for within 1 week if possible).
Followup Instructions:
Please call to make a follow-up appointment with Dr. [**Last Name (STitle) 724**] in
clinic ([**Telephone/Fax (1) 1844**]) for management of your steroid taper
within a week
.
Department: BMT/ONCOLOGY UNIT
When: TUESDAY [**2136-7-31**] at 2:00 PM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
.
Department: BMT/ONCOLOGY UNIT
When: TUESDAY [**2136-8-21**] at 2:00 PM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
.
Department: DERMATOLOGY
When: WEDNESDAY [**2136-9-12**] at 9:30 AM
With: [**Doctor First Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8476**], MD, PHD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
Completed by:[**2136-7-20**]
|
[
"788.65",
"338.3",
"196.8",
"198.81",
"198.4",
"198.3",
"787.01",
"344.60",
"197.6",
"431",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94",
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
12539, 12622
|
8149, 8391
|
332, 338
|
12733, 12733
|
5790, 5790
|
13969, 15206
|
4165, 4182
|
11414, 12516
|
12643, 12712
|
11111, 11391
|
12909, 13946
|
6522, 8126
|
4222, 4984
|
10777, 11085
|
266, 294
|
366, 2221
|
5806, 6506
|
12748, 12885
|
8409, 10756
|
2243, 4053
|
4069, 4149
|
5009, 5771
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,461
| 136,001
|
15958+15959+15960
|
Discharge summary
|
report+report+report
|
Admission Date: [**2127-2-2**] Discharge Date: [**2127-2-14**]
Date of Birth: [**2074-2-24**] Sex: M
Service:
ADDENDUM:
5. Renal: Patient with worsening acute renal failure felt
secondary to prerenal versus AmBisome. He was continued on
AmBisome but felt if he continued to worsen, consider
changing antifungal [**Doctor Last Name 360**]. Medications were renally dosed.
6. GI: Transaminases were elevated so INH and Rifampin were
discontinued. They resolved off of INR and Rifampin.
7. Fluids, electrolytes and nutrition: He was started on
tube feeds but didn't tolerate due to high residuals despite
Lactulose and Reglan. Electrolytes were repleted as needed.
8. Access: For access a right internal jugular line was
placed. A line was continued from the outside hospital.
9. Code status: DNR not DNI.
10. Prophylaxis: Heparin subcutaneous, Pneumoboots, proton
pump inhibitor and bowel regimen.
DISPOSITION: The patient received tracheostomy on [**2127-2-14**]
then was transferred east for radiation therapy.
The rest of the hospital course will be dictated by a
resident in the intensive care unit.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2127-2-26**] 12:24
T: [**2127-2-26**] 12:40
JOB#: [**Job Number 45726**]
Admission Date: [**2127-2-2**] Discharge Date: [**2127-2-26**]
Date of Birth: [**2074-2-24**] Sex: M
Service:
NOTE: This is a dictation of the Hospital Course from
[**2127-2-2**] to [**2127-2-15**] when he was transferred
to the [**Hospital Ward Name 516**] Intensive Care Unit.
CHIEF COMPLAINT: Critical tracheal narrowing from
mediastinal mass; transferred from [**Hospital6 **] for
rigid bronchoscopy and stents.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
Caper Verdean male with hypertension, asthma, many pack year
smoking history, asbestos exposure, and positive purified
protein derivative with known right apical cavitary lesion
(being treated since [**2126-10-1**]) who was admitted to
[**Hospital6 **] on [**2127-1-29**] with a productive
cough, increased shortness of breath, and bilateral neck
swelling.
He originally had a positive purified protein derivative in
[**2126-9-1**] with an initial negative chest x-ray. He
was started on INH. Then, in [**2126-10-1**], he had scant
hemoptysis and weight loss. An x-ray revealed a new 5-cm
mass with lucency suggestive of cavitation in the right apex
with hilar retraction and fullness in the paratracheal area.
He was started on quadruple drug therapy. He then had one
set negative acid-fast bacillus smears in [**2126-10-1**] as
well as culture negative, and then another negative set times
three acid-fast bacillus in [**2126-11-1**].
He went to [**Country 3587**] to visit in [**2126-11-1**] to
[**2126-12-1**]. He was seen back in the [**Hospital 45727**]
Clinic on [**1-13**], and the chest x-ray showed no change in
the cavitation.
Then, on [**1-29**], the patient presented to [**Hospital6 14430**] complaining of a persistent productive cough times
three months with greenish white/yellow sputum with
occasional scant blood mixed in, increased shortness of
breath, and increased dyspnea for two weeks, dysphagia times
three months, and bilateral neck swelling times a few weeks.
He also complained of chest pain with left arm radiation. He
ruled out for a myocardial infarction with serial cardiac
enzymes and was started on levofloxacin for "bronchitis."
REVIEW OF SYSTEMS: On review of systems, he complained of a
50-pound to 60-pound weight loss over a two to three month
period, a persistent productive cough, neck swelling,
dysphagia, shortness of breath, dyspnea on exertion, nausea,
and vomiting.
He hospital course at [**Hospital6 **] was notable for
ruled out for a myocardial infarction by enzymes. He then
had an exercise tolerance test on the treadmill which was
negative. Then, several hours after his exercise treadmill
test, he had increasing shortness of breath and respiratory
distress with "signs of seizure activity." He was intubated
with an initial arterial blood gas of 6.99, PCO2 of 105, and
PO2 of 25. Intubation was very difficult. After intubation,
150 cc of blood came out of the patient's left naris and 100
cc of bright red blood per endotracheal tube. An emergent
bronchoscopy revealed distorted tracheal anatomy at the level
the carina, and no visualization of the right main stem
bronchus due to mass compression and clot covering the area.
The trachea at that level revealed friable mucosa. Brushings
for cytology were sent which ultimately revealed large-cell
carcinoma of the lung.
Of note, with labile blood pressures with a systolic blood
pressure of 200/110 and was started on a Nipride drip. Of
note, sputum culture at [**Hospital6 **] was positive
for aspergillosis; so he was also given one dose of
amphotericin. He was transferred to [**Hospital1 190**] for a rigid bronchoscopy and stents.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Asthma.
3. Tobacco use.
4. Asbestos exposure.
5. Purified protein derivative positive (see History of
Present Illness).
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Home medications included
albuterol, Advair diskus, rifampin, INH, Combivent, and
levofloxacin.
MEDICATIONS ON TRANSFER:
1. INH 300 mg intravenously q.d.
2. Rifampin 600 mg intravenously q.d.
3. Ceftriaxone 1 g intravenously q.8h.
4. Flagyl 500 mg intravenously q.8h.
5. Decadron 10 mg intravenously q.8h.
6. Atrovent 10 puffs q.i.d.
7. Versed drip.
8. Nipride drip.
9. Ranitidine 50 mg intravenously q.8h.
10. Vecuronium 4 mg to 8 mg per hour drip.
11. Colace.
12. Amphotericin 400 mg intravenously q.d.
13. Benadryl 500 mg intravenously q.d. (premedication for
amphotericin).
14. Lasix 20 mg intravenously q.d.
15. Lopressor 25 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 101.2, heart rate was 110, blood
pressure was 126/90, assist-control 600 X 20, positive
end-airway pressure 10, FIO2 was 50%, peak inspiratory flow
34, plateau of 23. Arterial blood gas was 7.37, PCO2 of 45,
PO2 of 97. The patient was intubated and sedated. Pupils
were equal, round, and reactive to light at 5 mm to 4 mm
bilaterally. No lymphadenopathy. Lungs with rhonchi
diffusely. Heart revealed tachycardic. No murmurs, rubs, or
gallops. The abdomen was soft, nontender, and nondistended.
Normal active bowel sounds. No hepatosplenomegaly
appreciated. Upper extremity edema of 2+, trace lower
extremity edema. Neurologic examination revealed
unresponsive.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 17.7, hematocrit was 44,
and platelets were 251. INR was 1.6. Differential with 81%
neutrophils, 0% bands, and 12% lymphocytes. Chemistry-7
revealed sodium was 143, potassium was 4.5, chloride was 108,
bicarbonate was 24, blood urea nitrogen was 19, creatinine
was 0.9, and blood glucose was 162. Calcium was 9.1,
magnesium was 2.2, phosphorous was 3.1. Lactate was 2.4.
Total bilirubin was 0.6, albumin was 3.7, AST was 192, ALT
was 166, alkaline phosphatase was 75, LDH was 360, amylase
was 104, and lipase was 144.
PERTINENT RADIOLOGY/IMAGING: [**Hospital6 **] chest
x-ray on [**1-28**] revealed persistent increased opacity of
the right apex with linear densities and apparent cavitary
lesions, a soft tissue nodule, within this cavity, and a
meniscus sign.
A computed tomography at [**Hospital6 **] on [**1-29**]
revealed a 2.7-cm X 1.8-cm thick wall cavitary lesion within
the right apex, several stellate fibrotic bands radiated from
this lesion inferiorly. There was an irregular 3.5-cm X
1.5-cm lesion in the posterior portion of the right upper
lobe in surround ground-glass opacity in the right upper
lobe, and a 7-mm nodule in the posterior right base. No
pleural effusions. No pericardial effusions. Positive
lymphadenopathy in the paratracheal, prevascular, precarinal,
and subcarinal spaces.
A exercise treadmill stress test on [**1-31**] revealed
positive chest pain. No electrocardiogram changes.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted
to [**Hospital1 69**] for a rigid
bronchoscopy and stents.
1. PULMONARY ISSUES: The patient was initially kept on
assist-control; however, on the morning of [**2127-2-4**],
he self-extubated, and intubation with prolonged arterial
blood gas empty time was 2.23, PCO2 was 54, PO2 was 127. He
was reintubated due to inadequate sedation resulting in
self-extubation with a difficult airway.
A computed tomography tracheostomy was performed for planning
of rigid bronchoscopy with stents; which revealed a large
speculated mass in the right upper lobe with cavitations and
extensions to pleural surface, hilar lymphadenopathy. Masses
posterior to right carina and main stem bronchi, and two
necrotic lymph nodes in right upper and mediastinal left
supraclavicular, two bibasilar atelectasis with scarring
containing nodular components, and three scattered tiny
nodules in the lunch parenchyma.
A flexible bronchoscopy was performed which revealed possible
communication between the right upper lobe lesion and
trachea, severe narrowing of the right main stem bronchus.
Bronchial washings were sent.
First staging computed tomography was obtained which showed
no hemorrhage, and no enhancing lesions, and normal
[**Doctor Last Name 352**]/white differentiation.
A computed tomography of the abdomen showed no metastases.
Because of concern over infection control, given that the
patient traveled to [**Country 3587**] since the last time he ruled
out for tuberculosis, acid-fast bacillus times three were
obtained; which were negative.
The patient underwent a rigid bronchoscopy with stents on
[**2127-2-6**] which revealed large amounts of paratracheal
edema. Stents were placed times two in the trachea and right
main stem bronchus. It was felt that he was unlikely an
extubation candidate given severe paratracheal edema without
tracheostomy placed.
Ultimately, a tracheostomy was placed on [**2127-2-14**],
and the patient remained ventilated.
2. INFECTIOUS DISEASE ISSUES: The differential diagnosis
for the right upper lobe cavitary mass included malignancy
alone, tuberculosis, and aspergillosis.
Tuberculosis was unlikely given the negative acid-fast
bacillus smears and negative cultures; however, that he was
always on anti-tuberculosis medications during this time
complicated matters as well as recent travel to [**Country 3587**].
Therefore, in conjunction with infection control, it was
decided that the patient should be ruled out with acid-fast
bacillus smears times three. He was initially continued on
INH and rifampin therapy per outpatient medications (he had
already received quadruple therapy times 10 weeks and was to
continue double therapy with INH and rifampin to complete a
6-month course). Due to the rising AST and ALT and low
likelihood for tuberculosis given negative acid-fast bacillus
smears, his INH and rifampin were discontinued.
The patient was initially placed on levofloxacin and Flagyl
for postobstructive pneumonia; however, he continued to spike
fevers and was changed to AmBisome on [**2127-2-6**] due to
aspergillus growing out of bronchial washings from sample
taken here at [**Hospital1 69**] as well as
a computed tomography cavitary lesion highly suspicious for
aspergilloma. The patient also with heavy amounts of sinus
discharge, which were negative for aspergillosis. He was
continued on AmBisome per Infectious Disease recommendations
and continued to spike temperatures to 103.8. He was started
on vancomycin and Zosyn.
3. HEMATOLOGY/ONCOLOGY ISSUES: An Oncology consultation was
obtained. The patient likely with stage III-B large-cell
carcinoma of the lung given bilateral subcarinal lymph node
involvement.
A Radiology/Oncology consultation was obtained, and the plan
was to begin radiation therapy. Therefore, the patient had
to be transferred to the [**Hospital Ward Name 516**] Intensive Care Unit for
daily radiation therapy.
4. CARDIOVASCULAR SYSTEM: The patient continued with
hypotension which responded to fluids. A cardiac
echocardiogram was performed which revealed findings
consistent with infiltrative cardiomyopathy. However, no
further workup was done at this time. A cosyntropin
stimulation test was performed which revealed no evidence of
renal insufficiency.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2127-2-26**] 14:21
T: [**2127-2-26**] 12:27
JOB#: [**Job Number 45728**]
Admission Date: [**2127-2-8**] Discharge Date: [**2127-3-2**]
Date of Birth: [**2074-2-24**] Sex: M
Service: ICU
ADDENDUM: This dictation is a summary of the hospital course
from [**2-16**] to the day of discharge. Mr. [**Known lastname 13983**] had
been transferred to the [**Hospital Ward Name 516**] intensive care unit to
undergo XRT for his lung cancer which was causing an SVC
syndrome. He initiated treatment on [**2-17**] with a
mapping procedure and since then has completed his course on
[**2-27**]. Otherwise Mr. [**Known lastname 13983**] has continued to wean
slowly from his ventilator. He underwent tracheostomy
placement prior to transfer. He completed a 14-day course of
Zosyn for a presumed ventilator-associated pneumonia. He
also remained on AmBisome for treatment of possible
aspergilloma. Given our assessment that Mr. [**Known lastname 13983**] would
most likely take several weeks to be weaned from his
ventilator, efforts were made to prepare Mr. [**Known lastname 13983**] for
transfer to a chronic vent wean facility. A percutaneous
gastrojejunostomy feeding tube was placed as well as a PICC
line for access and intravenous fluids if necessary. A
family meeting was held with a Portuguese translator as well
as multiple members of Mr. [**Known lastname **] family to discuss his
prognosis as well as eventual disposition. The family
appeared to express understanding that Mr. [**Known lastname 13983**] may only
have several weeks left to live due to the prognosis of his
lung cancer. It was their decision that they wished to
proceed with placement to a rehabilitation facility in an
effort to wean Mr. [**Known lastname 13983**] off a ventilator. He does remain
DNR at this time.
Otherwise over the last week the patient's fentanyl drip and
Versed drip have been weaned off. He is now continuing
aggressive diuresis in an effort to mobilize fluid and if
diuresing well without any evidence of prerenal state or
intravascular volume depletion. He is felt to be currently
stable to discharge to a chronic vent facility which is
believed to be [**Hospital6 13846**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Expected to be to [**Hospital6 18042**].
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. q. day.
2. Morphine sulfate immediate relief 15-30 mg p.o./ng, q. 4-6
hours p.r.n.
3. Potassium chloride 20 mEq p.o. q. day.
4. Risperidone 1 mg p.o. q. day, 2 mg p.o. q.h.s.
5. Acetaminophen 325 mg to 650 mg p.o. q. 6 hours p.r.n.
6. Albuterol metered dose inhaler two puffs q. 6 via
tracheostomy.
7. Ipratropium bromide 2 puffs metered dose inhaler q. 6 via
tracheostomy.
8. Fentanyl patch at 75 mcg topical q. 72 hours.
9. Haldol 1-5 mg intravenous q. 6 hours p.r.n. for agitation.
10. Sliding scale insulin.
11. Heparin 5,000 units subcutaneous t.i.d.
12. Dulcolax 10 mg p.r. q.d. p.r.n.
13. Colace 100 mg p.o. b.i.d.
14. Lansoprazole 30 mg p.o. q. day.
DISCHARGE PLAN: The patient is to be discharged to the
[**Hospital6 **] facility for a wean from his
ventilator. He will follow up with hematology and oncology
for further management of his lung cancer. At this time no
chemotherapy is planned and the patient should be evaluated
by the palliative care services at the [**Hospital6 **] facility.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 22406**]
MEDQUIST36
D: [**2127-2-28**] 10:22
T: [**2127-2-28**] 11:28
JOB#: [**Job Number 45729**]
|
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icd9cm
|
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] |
icd9pcs
|
[
[
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14991, 15061
|
15084, 15763
|
5299, 5396
|
8287, 14969
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3596, 5066
|
1722, 1843
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1872, 3575
|
15780, 16359
|
5422, 8252
|
5088, 5272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,380
| 124,616
|
14122
|
Discharge summary
|
report
|
Admission Date: [**2189-7-16**] Discharge Date: [**2189-8-1**]
Date of Birth: [**2112-9-9**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of breath, increased oxygen requirement
Major Surgical or Invasive Procedure:
Endotracheal tube placement
Central venous line
Arterial line
History of Present Illness:
Mr. [**Known lastname **] is a 76 male admitted to MICU with acute worsening
of baseline shortness of breath since this morning. He is a 76
year old male with pulmonary fibrosis on 2L of oxygen at night
and with exertion, CAD recently admitted [**Date range (3) 42083**] with
presumed idiopathic pulmonary fibrosis exacerbation started on
steroid taper and discharged to pulmonary rehab now transferred
from OSH ED with acute onset of air hunger and feeling of
suffocation since this morning which prompted him to increase
his usual supplemental oxygen to 4LNC. Reports he had been
feeling much improved until awakening this morning with acute
onset of SOB. Also reports cough productive of yellow blood
tinged sputum and subjective fevers and chills with temp to 102
at OSH and post-tussive emesis x 3. At OSH, VS 104/57 HR 130
RR35 85%RA->100% NRB. ABG on 100% 7.47/32/73/23. WBC 18. He
received Ceftriaxone, Azithro, Solumedrol 125mg IV, Protonix
40mg, Compazine 10mg and Tylenol 1g with subsequent improvement
in symptoms.
.
This presentation similar to previous admission 1 month ago
except SOB much more severe. Denies current leg pain but did
have right calf cramping this am when at OSH ED x 2 hours now
resolved. Denies chest pain, palpitations, myalgias, sick
contacts, N/V/D, abdominal pain, dysuria.
.
In our ED, initial vs were: 98.4 70 98/58 20 95%NRB with desats
to 88% on 6L. Patient was given Vancomycin 1g IV and 1L NS for
tachycardia, prerenal azotemia. CXR consistent with new RML/RUL
infiltrate and he was admitted to MICU. WBC 14.7 and Lactate
1.1.
.
On the floor, he feels much better, is requesting diet and
reports SOB back to baseline but is unsure which intervention
has helped him.
Past Medical History:
CAD angioplasty and stenting of the distal LCX [**2187**]
Spinal Stenosis
Idiopathic Pulmonary Fibrosis
Colonic Adenomas
Inguinal Hernia
Hyperlipidemia
Diverticulosis
GERD
Meralgia Paresthetica
Hypertension
BPH
Social History:
Patient lives alone and has daughter who lives nearby.
Farsi-speaking, recently visited family in [**Country **] 2 months prior.
Patient has a 25 pack-year history and quit over 35 years ago.
No alcohol. No pets. No VNA services but daughter check on
patient and lives nearby. He is separated from his
wife. [**Name (NI) **] has four children and two grandchildren, with two of
his
children living in the [**Location (un) 86**] area. Formerly worked in iron
furniture factory.
Family History:
Non-contributory
Physical Exam:
On Admission
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented x 3 but does not recall details of
transfer, tachypneic but appears comfortable, using accessory
muscles, speaking in full sentences
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP 6cm, no LAD
Lungs: Bibasilar dry crackles with coarse wet crackles/rhonchi
with egophony right mid lug field. No wheezes
CV: Distant. 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, + clubbing. 2+ pulses, no cyanosis or
edema
On Discharge
General: Alert, oriented x 3, Farsi speaking
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, without JVP, no LAD
Lungs: Bibasilar dry crackles without crackles, rhonchi or
wheezes
CV: Distant. 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, + clubbing. 2+ pulses, no cyanosis or
edema
Pertinent Results:
Labs on Admission: [**2189-7-16**]
WBC-14.7* RBC-4.05* Hgb-13.4* Hct-39.0* MCV-96 RDW-16.3* Plt
Ct-175
Neuts-96.4* Lymphs-1.7* Monos-1.0* Eos-0.8 Baso-0.2
PT-13.3 PTT-21.9* INR(PT)-1.1
Glucose-145* UreaN-24* Creat-1.2 Na-132* K-4.0 Cl-98 HCO3-23
AnGap-15
ALT-19 AST-30 LD(LDH)-394* CK(CPK)-61 AlkPhos-69 TotBili-0.6
Albumin-3.1* Calcium-8.0* Phos-4.2 Mg-2.2
BLOOD Lactate-1.1
.
Labs throughout stay:
[**2189-7-31**] 02:14AM BLOOD WBC-7.6 RBC-2.88* Hgb-9.5* Hct-28.1*
MCV-98 MCH-33.2* MCHC-34.0 RDW-15.5 Plt Ct-167
[**2189-7-30**] 03:43AM BLOOD Glucose-132* UreaN-42* Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-28 AnGap-9
[**2189-7-27**] 03:12AM BLOOD Type-ART Temp-36.7 pO2-71* pCO2-36
pH-7.50* calTCO2-29 Base XS-4 Intubat-NOT INTUBA
.
Other labs:
[**2189-7-16**] 07:44PM BLOOD CK-MB-NotDone cTropnT-0.05* proBNP-146
[**2189-7-17**] 02:56AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2189-7-17**] 11:36AM BLOOD CK-MB-NotDone cTropnT-0.02*
.
Micro:
[**2189-7-16**] Urine culture negative
[**2189-7-16**] Urine legionella antigen negative
[**2189-7-16**] Blood culture x 2: no growth to date
[**2189-7-29**] 4:02 pm URINE No growth
[**2189-7-19**] 10:50 am Mini-BAL
GRAM STAIN (Final [**2189-7-20**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
.
Other Studies:
[**2189-7-16**] CXR: Ill-defined areas of opacity in the right upper and
right mid
lung zones which could represent developing pneumonia or
alternatively
represent atelectasis from lower lung volumes compared to
previous studies. Clinical correlation is recommended.
[**2189-7-17**] BLE U/S: No evidence of deep vein thrombosis in either
leg.
Brief Hospital Course:
This is a 76M with IPF recently admitted with presumed IPF
exacerbation now a/w acute worsening SOB, hypoxemia, fever,
possible right infiltrate consistent with health care pneumonia
vs exacerbation of IPF.
.
# Respiratory failure: The likely cause was due to IPF
exacerbation vs pneumonia. The patient presented with SOB,
increased oxygen requirement associated with fever, chills and
leukocytosis. The patient had a CXR which was concerning for
pneumonia or worsening of fibrotic lung disease. The patient was
treated for health care associated pneumonia with cefepime,
ciprofloxacin and vancomycin for an 8 day course. He was also
given steroids and oral NAC for his interstitial pulmonary
fibrosis. The patient subsequently desaturated while ambulating
and required intubation for hypoxemic respiratory failure. He
was intubated for 7 days and extubated after diuresis. Post
extubation the patient was maintained on high flow oxygen mask
with continued diuresis, however, he was not able to tolerate
significant weaning of his oxygen. Post extubation the patient
developed leukocytosis and sputum production which was again
suspicious for pneumonia. The patient was empirically treated
with zosyn and ciprofloxacin for a 14 day course which started
[**2189-7-30**].
.
# Sedation: At the time of intubation, the patient was
maintained on propofol, versed, and fentanyl with daily
wakenings. The patient required paralytics due to dysynchrony
from the ventilation. These were quickly discontinued. Sedation
was easily weaned prior to extubation.
.
# Leukocytosis: The patient had leukocytosis on admission which
was either secondary to steroids or infection. The patient's
fevers resolved early in his admission and cultures were not
revealing of an etiology. The patient was treated multiple
courses of antibiotics for possible health care associated
pneumonia. No cultures were positive during his stay.
Leukocytosis resolved during his admission.
.
# Hypotension: The patient became hypotensive with SBPs to 80's
with a HR in the 50's and low uring output. The patient was
given IVF and the hypotension resolved.
.
# Bradycardia: The developed bradycardia to HR 30s while he was
sedated. The likely cause of the bradycardia was fentanyl.
Following weaning of fentanyl the bradycardia resolved. He
maintained good urine output with warm extremities during his
episodes of bradycardia.
.
# Normocytic anemia: Hct was 39 atthe time of admission. This
decreased to the low 30's. The likely etiology was
hemoconcentration from dehydration with underlying anemia of
chronic disease from IPF. There was no signs of acute bleed
throughout his stay, all stool was guaiac negative. Labs for
hemolysis are pending, B12 and folate were within normal limits.
.
# HTN: Initially the patient was hypotensive and his imdur was
held. After extubation the patient became hypertensive. He was
restarted on his home medications.
.
# High tube feed residuals and constipation: The patient had
high tube feeds during his stay. A KUB was done which was
negative for obstruction. The patient was given a bowel regimen
with resolution of his residuals.
.
# Anxiety/agitation: The patient has a history of anxiety. He
was treated with Lorazepam 0.5 mg Q6H PRN with good effect.
.
# IPF: Methylprednisolone was started at 180 mg IV daily and
tapered to 40mg IV daily for IPF exacerbation. The patient had
improvement of his clinical picture, however, without complete
return to his prior baseline. He was started on Bactrim
prophylaxis and continued on his PO NAC regimen.
.
# Hematuria: The patient had blood in multiple UA, with negative
leukocyte esterase and nitrite. Multiple urine cultures were
sent, all of which were negative. The likely etiology was
mechanical injury in the setting of a foley.
.
# Hyponatremia: At the time of admission, his hyponatremia was
likely hypovolemic hyponatremia given dry appearance on exam. He
was given IVF NS, with improvement of sodium to normal range.
.
# CAD: Continued ASA, Plavix, and Imdur with holding parameters.
.
# GERD: Changed home PPI to H2 blocker.
.
# FEN: Following intubation, he was maintained with tube feeds.
After extubation, his diet was advanced to a thickened liquids,
medications crushed in puree, which he has tolerated well. A
swallow re-evaluation is recommended before advancing diet.
Hyperglycemia was managed with insulin sliding scale.
.
# Prophylaxis: Subcutaneous heparin, H2 blocker as per above.
.
# Social: A family meeting was held with the patient and his
children through Farsi interpreter to describe that his IPF had
likely progressed and it was unclear if his functional status
would significantly improve. The family did not wish to
reconsider full code status at that time.
.
Medications on Admission:
1. Aspirin 325 mg daily.
2. Atorvastatin 40 mg.
3. Plavix 75 mg daily.
4. Isosorbide mononitrate 60 mg daily in the morning.
5. NAC 600mg PO TID
6. Currently prednisone 10mg PO BID.
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.
Disp:*QS Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*QS Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*QS Tablet(s)* Refills:*2*
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): take if no Bowel Movement for 1 day.
Disp:*QS * Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*QS Tablet(s)* Refills:*0*
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for if no BM in 1 day: Take if no
bowel movement for 1 day.
Disp:*QS ML(s)* Refills:*0*
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*QS Tablet(s)* Refills:*2*
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*QS ML(s)* Refills:*0*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*QS Tablet(s)* Refills:*2*
10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*QS Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) as needed for cough.
Disp:*QS Tablet(s)* Refills:*0*
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
Disp:*QS ML(s)* Refills:*0*
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheeze.
Disp:*QS * Refills:*0*
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze.
Disp:*QS * Refills:*0*
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ml
Miscellaneous Q8H (every 8 hours).
Disp:*QS ml* Refills:*2*
16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*QS Tablet(s)* Refills:*0*
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Ondansetron 4 mg IV Q8H:PRN nausea
20. MethylPREDNISolone Sodium Succ 20 mg IV BID Start: [**2189-7-29**]
21. Piperacillin-Tazobactam 4.5 g IV Q8H
22. Ciprofloxacin 400 mg IV Q12H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Hypoxemic Respiratory failure
Idiopathic pulmonary fibrosis
Hypotension
Leukocytosis
Constipation
Bradycardia
Anxiety
Hypertension
Bradycardia
Hematuria
Hyponatremia
Secondary:
Normocytic anemia
CAD
GERD
Discharge Condition:
Fair. Interval increase in oxygen requirement from 2 L nasal
cannula to high flow oxygen, with stable oxygen saturation.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for shortness of breath and fevers.
You developed low levels of oxygen in your blood and you were
placed on a ventilator to support your breathing. It is likely
that your difficulty of breathing was from a worsening of your
idiopathic pulmonary fibrosis or an infection. You were treated
with antibiotics and steroids and were able to be taken off the
ventilator. You are still requiring an oxygen mask to get enough
oxygen into your blood. You are being transferred to [**Hospital3 **]
ICU for continued care of your respiratory distress.
.
After discharge, you should continue solumedrol as directed by
your pulmonologist, Dr. [**Last Name (STitle) 575**]. You were started on
antibiotics named cefepime and ciprofloxacin. You will take
these for 12 more days. You should continue taking your bactrim
as well. All other discharge medications should be taken as
directed.
.
Please attend your follow up appointments as listed.
.
After discharge from [**Hospital3 2568**], please contact your
pulmonologist or present to an emergency department if you
develop worsening shortness of breath, fevers, increasing sputum
production, chest pain or any other symptoms that you find
concerning.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2189-9-14**] 1:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2189-9-22**] 1:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-10-21**] 11:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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|
4804, 5711
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63,489
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41637
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Discharge summary
|
report
|
Admission Date: [**2185-11-13**] Discharge Date: [**2185-11-18**]
Date of Birth: [**2166-9-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 19 year-old Indian with no significant PMH but a
recent diagnosis of idiopathic dilated cardiomyopathy (EF 15%,
2D-Echo [**2185-11-15**]), presenting with acute-onset of shortness of
breath for 2-days.
.
Of note, the patient was recently admitted to the
[**Hospital1 1516**]-Cardiology service on [**2185-10-17**] when he presented with
palpitations, dyspnea, some URI symptoms, which was associated
with substernal chest pain, found to have evidence of volume
overload and peripheral edema consistent with decompensated
dilated cardiomyopathy. A 2D-Echo was performed and showed 3+
mitral regurgitation with an LVEF of 15-20%. He was started on a
Nitro gtt and aggressively diuresed, requiring a Lasix gtt with
conversion to PO Torsemide prior to discharge. His weight on
admission was 97 kg (dry weight estimated at 90 kg) and this
improved to 89.8 kg at discharge. In terms of cardiomyopathy
investigation - his HIV, Lyme antibody, CMV, EBV, hepatitis
serologies, TSH and [**Location (un) **] virus testing were all negative.
Of note, the patient has a strong family history of dilated
cardiomyopathy, with two uncles who expired in their 30s from
heart failure. Additions to his medication list at that time
included an ACEI, beta-blocker and spironolactone. He was also
loaded with Digoxin and was uptitrated to 375 mcg PO daily. He
was discharged on [**2185-10-26**]. The patient's 2D-Echo was repeated on
[**2185-10-31**] showed similar findings after initiation medical
therapies.
.
He now presented with shortness of breath while at his
rehabilitation facility the day prior to admission, [**2185-11-12**],
which was occurring at rest and worst with exertion. This was
associated with substernal chest pain that radiated to the right
scalp, worse with deep inspiration and relieved by leaning
forward. He has noted no unintentional weight gain, leg
swelling. He also denied fevers or chills, nausea, palpitations
and diaphoresis. He denies URI symptoms or productive cough or
abdominal pain.
.
In the ED, initial VS 98.1 105 137/79 15 100%RA. His exam was
notable for tachypnea, tachycardia, but no leg swelling or JVP
elevation. His WBC was 21.1 (N 82.9%, L 10.3%), pro-BNP 2968,
Troponin < 0.01. In the ED, his tachypnea progressed and he
required RSI (etomidate, succinylcholine) for airway protection
and increased work of breathing. Cardiology was consulted.
Cardiac U/S in the ED showed no evidence of pericardial
effusion, poor squeeze and a dilated left ventricle. CTA chest
showed small, LLL subsegmental pulmonary embolus with possible
right lung base PNA. Prior to transfer, VS 97.7 100 99/72 22
100% intubated (500/22/5/1.0).
.
In the MICU, patient was started on heparin gtt following bolus
for small, LLL subsegmental pulmonary embolus. They continued
Vancomycin, Cefepime and Levofloxacin for presumed
healthcare-associated pneumonia given CT findings of right lung
base consolidation. Cardiology recommended discontinuing
anti-hypertensives and continuing anticoagulation. He was
extubated on [**11-13**] and his heparin gtt was bridged to Coumadin
with some mild hemoptysis. He spiked a temperature to 101.5F,
developed tachycardia to the 120s and had a repeat 2D-Echo on
[**11-14**] showing right ventricular systolic function that was more
severely impaired when compared to the [**10-31**] study. He developed
intermittent abdominal pain with hyperbilirubinemia and a
moderate transaminitis concerning for cardiogenic hepatic
congestion. A RUQ ultrasound showed prominent hepatic veins,
mild distention of the gallbladder with mild wall thickening and
no gallstones. At this point, his outpatient Cardiologist, Dr.
[**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**], recommended transfer to the CCU for IV Lasix and
Milrinone therapy given his biventricular cardiac failure.
.
On arrival to CCU, has some nausea and on-going small volume
hemoptysis but he is without lightheadedness or dizziness. He
denies chest pain or trouble breathing.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, black stools or
red stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative; see HPI for details.
.
Cardiac review of systems is notable for absence of chest pain.
It is notable for dyspnea on exertion, but no paroxysmal
nocturnal dyspnea. He did notes some orthopnea, but was without
ankle edema, palpitations, syncope or pre-syncope.
Past Medical History:
PAST MEDICAL HISTORY:
* CARDIAC RISK FACTORS: No dyslipidemia, hypertension or
diabetes
* CARDIAC HISTORY: Recently diagnosed with dilated
cardiomyopathy with 2D-Echo showing 3+ mitral regurgitation with
an LVEF of 15-20%
* CABG: None
* PERCUTANEOUS CORONARY INTERVENTIONS: None
* PACING/ICD: None
.
PAST MEDICAL & SURGICAL HISTORY:
1. Dilated cardiomyopathy (3+ mitral regurgitation with an LVEF
of 15-20%)
Social History:
Patient is a never-smoker. He notes drinking [**2-21**] alcoholic
beverages weekly, ocassionally up to 7-beers in one sitting (4
drinks on the Friday prior to presentation). Notes ocassional
marijuana use with no IVDU. He is student studying international
relations and economics; he has a girlfriend, and he is sexually
active with her monogamously. He denies history of SITs
(although never tested prior to presentation). Has traveled to
wooded areas within [**Location (un) 8447**], but does not recall ticks or
insect bites. Prior travel to both cities and rural areas of
[**Country 63412**], [**Country 11150**], [**Country 12602**]; was born in [**Country **], [**Country **], traveled to
the UK, UAE, and USA. Has not traveled to Latin or South
America.
Family History:
Mother's brother developed cardiomyopathy s/p and is cardiac
transplant. Father's brother died of cardiomyopathy around age
30 years; both of these cases were caused by an infectious
etiology. No other family history of heart disease, sudden
cardiac death, or dysrrhythmias.
Physical Exam:
PHYSICAL EXAM (on admission to CCU):
VITALS: 98.8 104 108/73 81 33 96%RA
GENERAL: Appears in no acute distress. Alert and interactive.
Robust-appearing male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry with dry-blood at mouth edges. No
xanthalesma.
NECK: supple without lymphadenopathy. JVD 2-3 cm above the
clavile at 30-degrees.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Sinus tachycardia with normal rhythm, with 2/6
holosystolic murmur, without rubs or gallops. S1 and S2 normal.
No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Decreased
breath sounds bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft, mildly tender diffusely, non-distended, with
normoactive bowel sounds. No palpable masses or peritoneal
signs. Abdominal aorta not enlarged to palpation, no bruit. No
hepatomegaly noted.
EXTR: no cyanosis, clubbing; [**12-19**]+ non-pitting edema, 2+
peripheral pulses
DERM: No stasis dermatitis, ulcers, scars.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2185-11-12**] 10:15PM BLOOD WBC-21.1*# RBC-5.03 Hgb-14.1 Hct-42.3
MCV-84 MCH-27.9 MCHC-33.2 RDW-13.7 Plt Ct-245
.
[**2185-11-17**] 06:45AM BLOOD WBC-9.2 RBC-4.25* Hgb-11.7* Hct-35.7*
MCV-84 MCH-27.4 MCHC-32.7 RDW-13.4 Plt Ct-245
.
[**2185-11-12**] 10:15PM BLOOD Neuts-82.9* Lymphs-10.3* Monos-5.7
Eos-0.7 Baso-0.4
.
[**2185-11-17**] 06:45AM BLOOD PT-33.8* PTT-33.5 INR(PT)-3.3*
.
[**2185-11-14**] 03:22AM BLOOD PT-16.9* PTT-74.5* INR(PT)-1.5*
.
[**2185-11-12**] 10:15PM BLOOD PT-16.1* PTT-26.9 INR(PT)-1.4*
.
[**2185-11-17**] 06:45AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-132*
K-4.1 Cl-93* HCO3-32 AnGap-11
.
[**2185-11-12**] 10:15PM BLOOD Glucose-142* UreaN-15 Creat-0.9 Na-134
K-4.6 Cl-101 HCO3-22 AnGap-16
.
[**2185-11-17**] 06:45AM BLOOD ALT-160* AST-59* AlkPhos-59 TotBili-1.7*
.
[**2185-11-15**] 03:21PM BLOOD ALT-226* AST-244* AlkPhos-55 TotBili-2.0*
.
[**2185-11-13**] 05:20AM BLOOD ALT-24 AST-21 AlkPhos-50 TotBili-1.7*
.
[**2185-11-14**] 10:32AM BLOOD Lipase-62*
.
[**2185-11-13**] 05:20AM BLOOD cTropnT-<0.01
.
[**2185-11-12**] 10:15PM BLOOD cTropnT-<0.01 proBNP-2968*
.
[**2185-11-17**] 06:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.2
.
[**2185-11-16**] 04:55AM BLOOD Albumin-2.9* Calcium-8.1* Phos-2.0*
Mg-1.7 Iron-23*
.
[**2185-11-12**] 10:15PM BLOOD Calcium-9.3 Phos-3.0 Mg-2.1
.
[**2185-11-16**] 04:55AM BLOOD calTIBC-243* Ferritn-573* TRF-187*
.
[**2185-11-17**] 06:45AM BLOOD Vanco-12.2
.
[**2185-11-12**] 10:15PM BLOOD Digoxin-0.8*
.
CARDIAC CATH: None
.
MICROBIOLOGY DATA:
[**2185-11-12**] Urine culture - negative
[**2185-11-13**] Blood culture (x 2) - pending
[**2185-11-13**] MRSA screen - negative
[**2185-11-13**] Urine Legionella antigen - negative
[**2185-11-13**] Sputum culture - contaminated specimen
[**2185-11-14**] Sputum culture - contaminated specimen
[**2185-11-15**] Urine culture - pending
.
2D-ECHO ([**2185-10-31**]) - The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. There is severe global left
ventricular hypokinesis (LVEF = 15 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with depressed
free wall contractility. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Significant augmentation of
contractile function of the left ventricle is seen during
postextrasystolic beats.
.
2D-ECHO ([**2185-11-15**]) - The left atrium is dilated. The right
atrium is markedly dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
with severe global free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. Mild to moderate ([**12-19**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. There is a trivial/physiologic
pericardial effusion. Compared with the prior study (images
reviewed) of [**2185-10-31**], right ventricular systolic function is
now more severely impaired. The left ventricle is now more
dilated. Mitral regurgitation is now slightly less prominent.
.
[**2185-10-19**] CARDIAC MR IMAGING - Severely increased left ventricular
cavity size with severe global dysfunction. The LVEF was
severely decreased at 12%. The effective forward LVEF was
severely decreased at 8%. No CMR evidence of prior myocardial
scarring/infarction. These findings areconsistent with a
nonischemic cardiomyopathy. Mildly increased right ventricular
cavity size and severe global dysfunction. The RVEF was severely
decreased at 15%. No thrombus seen in the left ventricular
cavity. Moderate-to-severe mitral regurgitation. Mild pulmonic
regurgitation. The indexed diameters of the ascending and
descending thoracic aorta were normal. The main pulmonary artery
diameter index was normal. Mild biatrial enlargement. Normal
coronary artery origins with no evidence of anomalous coronary
arteries, and normal signal characteristics of all visualized
vessel segments. There is mild to moderate pulmonary edema.
Moderate bilateral simple pleural effusions (right greater than
left) and bibasilar consolidations, likely representing
atelectasis.
.
[**2185-11-12**] CTA CHEST W&W/O C&RECON - Pulmonary emboli within
subsegmental branches of the left and right lower lobe pulmonary
arteries. Small right pleural effusion, decreased from prior.
Non-enhancing consolidation in the right lung base which may
reflect pneumonia or aspiration in the appropriate clinical
circumstance. Stable mediastinal and right hilar
lymphadenopathy. Stable moderate cardiomegaly. No pericardial
effusion. Standard position of lines and tubes.
.
[**2185-11-15**] LIVER OR GALLBLADDER US - Right pleural effusion.
Prominent hepatic veins. Mild distension of the gallbladder
along with mild thickening of its wall, no stones identified.
Trace amount of pericholecystic fluid.
Brief Hospital Course:
19M with no significant PMH presents with likely famlial dilated
cardiomyopathy with recent hospitalization for acute failure who
responded to diuresis who now returns with shortness of breath
found to have pneumonia and subsegmental pulmonary embolus with
evidence of biventricular failure and volume overload.
.
# IDIOPATHIC DILATED CARDIOMYOPATHY - The patient presented on
[**2185-10-17**] in overt volume overload with evidence of congestive
heart failure. He was noted to have decompensated dilated
cardiomyopathy with a 2D-Echo showing 3+ mitral regurgitation
with an LVEF of 15-20%. He responded to aggressive Lasix gtt
with conversion to PO Torsemide with improvement in symptoms at
that time. Etiologies for his cardiomyopathy included: ischemic
(unlikely given age and no risk factors; no cardiac cath data)
vs. infectious (HIV, Lyme, viral, Chagas - last admission his
HIV, Lyme antibody, CMV, EBV, hepatitis serologies, TSH and
[**Location (un) **] virus testing were all negative) vs. toxic (alcohol,
cocaine, medications - unlikely given no prior medication; prior
toxicology screens negative, although moderate alcohol intake
was noted) vs. familial (most likely possibility given strong
family history noted above; genetic vs. autoimmunity-related).
He now returned with dyspnea on exertion and at while at rest
without overt volume overload symptoms, but was found to have a
subsegmental LLL pulmonary embolus requiring heparinization. A
repeat 2D-Echo ([**11-15**]) showed right ventricular systolic
dysfunction that was now more severely impaired. The left
ventricle was also more dilated. Overall it appeared to be
consistent with right ventricular failure and right atrial
dilatation occurring in the setting of subsegmental LLL
pulmonary embolus and infection (pneumonia) that had
precipitated [**Hospital1 **]-ventricular failure (his admission pro-BNP was
2968). He also had significant abdominal pain and transaminitis
which was attributed to cardiogenic-hepatic congestion or
congestive hepatopathy. He was admitted to the CCU after
transfer from the medical ICU, and was initiated on a Milrinone
infusion of 0.25 mcg/kg/min following an initial loading dose of
50 mcg/kg over 15-minutes. This was titrated to 0.375 mcg/kg/min
at one point, but he developed tachycardia, and this was
decreased to the 0.25 mcg/kg/min dosing with good tolerance.
Simultaneously, he was started on a continuous IV Lasix infusion
at 5-7 mg/hr and together with the inotropic effect of
Milrinone, he diuresed roughly 6-8L of fluid to a weight of 90.2
kg (95 kg on admission; dry weight 89.8 kg). He will continue on
Milrinone therapy and will be transferred to [**Hospital3 90505**] Center for Cardiac Transplant Surgery evaluation. We
trended his transaminitis and monitored his abdominal pain,
which both steadily improved with diuresis. His ACEI
(Lisinopril) and Spironolactone therapy were held in the setting
of acute heart failure, but his Metoprolol was titrated back at
12.5 mg by mouth twice daily; we also continued his Digoxin
therapy. We strictly monitored his in's and out's and optimized
his electrolytes; he was monitored via telemetry.
.
# PULMONARY EMBOLUS - The patient was found to have pulmonary
embolism in a segmental branch of the left lower lobe of the
pulmonary artery - initially presenting with worsening dyspnea.
He received heparin gtt and he was bridged to Coumadin. A
2D-Echo showed right ventricular failure and right atrial
dilatation with acute [**Hospital1 **]-ventricular failure; but it is unlikely
that a distal, subsegmental PE induced right ventricular
failure, but this should be considered. EKG was without evidence
of poor R-wave progression; and he maintained his oxygen
saturations. In light of his recent hospitalization, the risk of
thromboembolic disease should be noted. He was started on
Coumadin 5 mg PO daily and his dose was titrated to an INR of
[**1-20**].
.
# HEALTHCARE-ASSOCIATED PNEUMONIA - The patient presented with
right sided chest pain with tachypnea. He was found to have
right lower lobe consolidation on CT imaging. The patient was
recently discharged from the hospital and was in a rehab
facility. This was all associated with leukocytosis with a left
shift. The patient was afebrile in the ED. Nonetheless, he was
given IV Vancomycin, Cefepime, and Levofloxacin (started [**11-13**])
for healthcare associated pneumonia coverage. The patient was
initially intubated in the ED for airway protection and
increased work of breathing, but he was swiftly extubated
without desturations. He did have some evidence of hemoptysis,
likely from his infectious alveolar process and anticoagulation
needs. This steadily improved and he remained hemodynamically
stable without evidence of large volume bleeding. His U/A was
reassuring and blood, urine cultures were negative. He remained
afebrile and his leukocytosis improved. He will continue on
healthcare associated PNA coverage with Vancomycin, Cefepime,
Levofloxacin for a total of [**9-30**] days.
.
# CORONARIES - He has no evidence of ischemic cardiomyopathy or
coronary disease; no prior cardiac catheterizations; no HTN,
smoking history or strong atherosclerotic family history (only
familial NICM history) - presented with some atypical chest pain
symptoms - but now pain free - Troponin < 0.01 x 2-sets with
reassuring EKG showing only sinus tachycardia and no ST-changes
on admission. He has no indication for Aspirin - [**Location (un) 47**] risk
score calculates to 10-year risk of 1% - given HDL 44,
cholesterol 167, age < 20, male, no smoking history and no
indication for statin at this time. He was monitored with serial
EKGs.
.
# RHYTHM - No evidence of arrhythmia or history of dysrrhythmia.
.
TRANSITION OF CARE ISSUES:
1. The patient is being transferred to [**Hospital6 **]
Center for management of his acute biventricular heart failure
and will be evaluated by the Cardiac Transplantation Service.
2. Continue Lasix gtt at 5 mg/hr and titrate to adequate
diuresis.
3. Continue Vancomycin, Levaquin and Cefepime for 10-14 days for
coverage of healthcare-associated pneumonia; start date of
[**2185-11-13**].
4. Morphine IV for pain control.
5. His ACEI and Spironolactone were held while his acute
biventricular failure was managed.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Lisinopril 25 mg PO daily
2. Metoprolol succinate 25 mg XL PO daily
3. Spirinolactone 12.5 mg PO daily
4. Digoxin 325 mcg PO daily
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. 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.
4. Milrinone 0.25 mcg/kg/min IV INFUSION
Maximum dose: 0.5 mcg/min
5. furosemide 10 mg/mL Solution Sig: Five (5) mg/hour Injection
INFUSION (continuous infusion): titrate to UOP 100cc/hour.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. morphine 5 mg/mL Solution Sig: 2-4 mg Injection Q3H (every 3
hours) as needed for pain.
8. levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q24H (every 24 hours): day
1=[**11-14**].
9. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 8H (Every 8 Hours): day 1 [**11-13**].
10. cefepime 2 gram Recon Soln Sig: Two (2) g Injection Q8H
(every 8 hours): day 1=[**11-13**].
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3278**] Medical Center
Discharge Diagnosis:
Primary Diagnoses:
1. Acute biventricular heart failure
2. Dilated cardiomyopathy
3. Pulmonary embolism
4. Healthcare-associated pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Cardiac Intensive Care Unit (CCU) at
[**Hospital1 69**] on CC7 regarding management
of your severe heart failure and pulmonary embolism with
pneumonia. You were treated with an IV inotropic (promotes heart
contractility) [**Doctor Last Name 360**] with IV diuretics to promote better heart
function with promotion of fluid removal. You tolerated this
therapy in the ICU well and diuresed to near-baseline weight.
You were also anticoagulated for your pulmonary clot. You were
treated with IV antibiotics for presumed healthcare associated
pneumonia. Your abdominal pain, volume status and shortness of
breath improved prior to your transfer to [**Hospital3 90505**] Center. The cardiac transplant team will continue your
management and care.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
You are being TRANSFERRED ON: Milrinone 0.25 mcg/kg/min IV
continuous infusion (maximum dosing 0.5 mcg/min); lasix drip
titrated to urine output 100cc/hour; cefepime, vancomycin and
levofloxacin.
Monitor your INR and restart warfarin when your INR is no longer
supratherapeutic at 3.3 (ideal range is [**1-20**]).
We CHANGED: Metoprolol succiante 25 mg XL daily to Metoprolol
tartrate 12.5 mg by mouth twice daily.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Spironolactone
DISCONTINUE: Lisinopril
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2185-12-5**] at 2:00 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2185-12-5**] at 3:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"415.19",
"790.4",
"276.7",
"428.0",
"518.81",
"486",
"425.4",
"428.23",
"787.01",
"782.4",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20968, 21029
|
13339, 19610
|
334, 362
|
21212, 21212
|
7840, 13316
|
23838, 24406
|
6214, 6490
|
19836, 20945
|
21050, 21191
|
19636, 19813
|
21395, 23815
|
6505, 7821
|
275, 296
|
390, 4989
|
21227, 21339
|
5033, 5420
|
5436, 6198
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,504
| 178,374
|
19533
|
Discharge summary
|
report
|
Admission Date: [**2157-12-21**] Discharge Date: [**2157-12-29**]
Date of Birth: [**2087-2-5**] Sex: M
Service: Cardiothoracic Service
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: Patient is a 70-year-old man
with a history of hypertension and hypercholesterolemia, who
presented to primary care provider with [**Name Initial (PRE) **] [**2-16**] week history of
burning in his chest while exercising. He was treated with
GERD without relief of symptoms. He returned to his primary
care provider, [**Name10 (NameIs) **] was referred to cardiologist, who
recommended a cardiac catheterization.
Catheterization was done on [**2157-12-20**] at [**Hospital6 **], and showed LAD with a 90% occlusion, proximal
circumflex occlusion of 60%, OM-2 70-80%, RCA 90% and an EF
of 50-55%. Patient was transferred following catheterization
to [**Hospital1 69**] for coronary artery
bypass grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Tinnitus.
4. Anxiety.
5. Benign prostatic hypertrophy.
6. Open cholecystectomy in [**2131**].
7. Polio as a child.
SOCIAL HISTORY: Retired postal carrier. Lives with his
wife. Social alcohol use. Tobacco one pack per day x7
years, quit 47 years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS AT TIME OF ADMISSION:
1. Toprol XL 50 q.d.
2. Hyzaar 50 q.d.
3. Cardura 4 q.d.
4. Aspirin 81 q.d.
5. Isordil 30 q.d.
6. Nexium 40 q.d.
7. Xanax 0.5 q.h.s. prn.
REVIEW OF SYMPTOMS: No visual changes, no dysphagia.
Positive shortness of breath with exertion. Positive
palpitations with exertion. No GERD, no melena, no
hematochezia, no CVA, no TIA, no diabetes, no vein stripping.
PHYSICAL EXAMINATION: General: Pleasant man in no acute
distress. HEENT: Pupils are equal, round, and reactive to
light. Extraocular movements are intact. Pharynx is clear.
Neck is supple, no JVD, no bruits. Chest: Diffuse macular
rash with dry skin at edges. Lungs are clear to auscultation
bilaterally. Heart: Regular rate and rhythm, S1, S2 with no
murmur. Abdomen is soft, nontender, nondistended with
positive bowel sounds and a well-healed right subcostal
incision. Extremities: No clubbing, cyanosis, or edema.
Right lower extremity with posterior varicosities. Dorsalis
pedis and posterior tibial pulses are 2+ bilaterally. Radial
pulses are 2+ bilaterally. Neurological exam: Alert and
oriented times three, nonfocal examination.
Patient was admitted to the Cardiothoracic Service. On
[**12-23**], he was brought to the operating room at which
time he underwent coronary artery bypass grafting x3. Please
see the OR report for full details. In summary, the patient
had a CABG x3 with a LIMA to the LAD, saphenous vein graft to
OM, and saphenous vein graft to RCA. His bypass time was 74
minutes with a cross-clamp time of 42 minutes. He tolerated
the operation well, and was transferred from the operating
room to the Cardiothoracic Intensive Care Unit.
At time of transfer, the patient's mean arterial pressure was
80. CVP was 12. She was A paced at a rate of 88 beats per
minute. She only had propofol running at the time of
transfer.
Patient did well in the immediate postoperative period as
anesthesia was reversed. Was successfully weaned from the
ventilator and extubated. On postoperative day one, the
patient remained hemodynamically stable, although he did
require Neo-Synephrine infusion to maintain adequate blood
pressure.
On postoperative day two, the patient continued to do well.
He was weaned off his Neo-Synephrine infusion. His chest
tubes were removed. His central venous catheters were
removed, and he was transferred from the Cardiothoracic
Intensive Care Unit to [**Hospital Ward Name 121**] 2 for continuing postoperative
care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful
postoperative course. With the assistance of the nursing
staff and Physical Therapy staff, his activity level was
gradually increased until on postoperative day five, it was
decided that the patient would be ready for discharge to home
on postoperative day #6.
At that time patient's physical exam is as follows: Vital
signs: Temperature 98.3, heart rate 70 sinus rhythm, blood
pressure 100/61, respiratory rate 20, and O2 saturation 98%
on room air.
LABORATORY DATA: White count 7.5, hematocrit 29.6, platelets
281. Sodium 139, potassium 4.1, chloride 104, CO2 25, BUN
14, creatinine 0.9, glucose 99, magnesium 1.9.
General: Alert in no acute distress. Neurologic: Alert and
oriented times three, moves all extremities, and follows
commands. Cardiovascular: Regular rate and rhythm, S1, S2.
Sternum is stable. Incision with Steri-Strips open to air,
clean and dry. Lungs are clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended. Extremities are
warm and well perfused with no edema. Left lower leg
incision with Steri-Strips open to air clean and dry.
DISCHARGE MEDICATIONS:
1. Percocet 1-2 tablets p.o. q.6h. prn.
2. Enteric coated aspirin 325 q.d.
3. Colace 100 mg b.i.d.
4. Metoprolol 25 mg b.i.d.
5. Doxazosin 4 mg q.d.
6. Patient is also to resume his Nexium 40 mg q.d and Xanax
0.5 q.h.s. prn following discharge to home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x3 with a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to obtuse
margin, and saphenous vein graft to right coronary artery.
2. Hypertension.
3. Hypercholesterolemia.
4. Tinnitus.
5. Anxiety.
6. Benign prostatic hypertrophy.
7. Status post open cholecystectomy.
8. Polio as a child.
DISCHARGE STATUS: The patient is to be discharged to home
with visiting nurses.
FO[**Last Name (STitle) **]P INSTRUCTIONS: He is to have followup with Dr.
[**Last Name (STitle) **] in [**12-16**] weeks. Follow up with Dr. [**Last Name (STitle) **] in [**1-17**] weeks
and follow up with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2157-12-29**] 10:03
T: [**2157-12-29**] 10:18
JOB#: [**Job Number 52991**]
|
[
"272.0",
"600.00",
"530.81",
"138",
"300.00",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5291, 6279
|
4984, 5238
|
1719, 2379
|
2399, 4961
|
174, 200
|
229, 939
|
961, 1122
|
1139, 1696
|
5263, 5270
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,880
| 132,241
|
1465
|
Discharge summary
|
report
|
Admission Date: [**2153-11-29**] Discharge Date: [**2153-11-30**]
Date of Birth: [**2113-9-16**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Anaphylactic reaction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
: Pt is a 40y/o male with a h/o HIV diagnosed in [**2146**],
nephrolithiais, and Crohn's disease who was recently seen in the
[**Hospital 18**] clinic to establish care. He has been fairly non-compliant
with HAART regimens in the past and had been off any regimen for
2-3yrs, with his most recent labs HIV viral load greater than
100,000 and CD4 of 164; he has had no opportunistic infections
in the past. His PCP and ID doctors decided to [**Name5 (PTitle) 8691**] off on
initiating HAART, but did decide to initiate bactrim
prophylaxis, a medication he'd not previously taken. On this
medications, he first developed a pruritic rash and was advised
to stop the medication but took an additional dose and began to
develop nausea, myalgias, palpitations, and a headache, and came
into the ED for evaluation.
In the ED, he was given bendaryl, ranitidine, steroids, and
fluids. He was hypotensive into the 80's and was started on
phenylephrine with a good response, but was able to be weaned
off over the course of an hour. Once in the [**Hospital Unit Name 153**], he reported
feeling much better with the resolution of the majority of [**Last Name (un) 8692**]
symptoms.
Past Medical History:
1.)HIV, dx [**2146**], last CD4 164, viral load >100,000, no h/o OI's
2.)Nephrolithiasis
3.)Crohn's
Social History:
Male partner-[**Name (NI) **]; smokes cigars occasionally, social ETOH use,
uses crystal meth--last time a few months ago. Married to a
woman [**2134**]-[**2141**]. Also admits to ketamine, cocaine use. Long
history of IVDU.
Family History:
NC
Physical Exam:
G: AAOx3
HEENT: No nuchal rigidity, MMM, no photophobia
CV: RRR S1,S2 No MRG
Lungs: R sided bronchial crackles
Abd: BS+, soft, NT, ND No CVAT
Ext: No edema, erythematous rash around face, ext onto chest
Neuro: grossly intact
Pertinent Results:
[**2153-11-30**] 04:59AM BLOOD WBC-5.1# RBC-4.15* Hgb-11.6* Hct-33.6*
MCV-81* MCH-28.0 MCHC-34.5 RDW-16.1* Plt Ct-144*
[**2153-11-29**] 10:55AM BLOOD WBC-10.6# RBC-4.98 Hgb-13.9* Hct-39.5*
MCV-79* MCH-27.9 MCHC-35.2* RDW-15.4 Plt Ct-198
[**2153-11-29**] 10:55AM BLOOD Neuts-74* Bands-7* Lymphs-9* Monos-4
Eos-4 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2153-11-29**] 10:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
Ellipto-OCCASIONAL
[**2153-11-30**] 04:59AM BLOOD Plt Ct-144*
[**2153-11-29**] 10:55AM BLOOD Plt Ct-198
[**2153-11-29**] 10:55AM BLOOD WBC-PND Lymph-PND Abs [**Last Name (un) **]-PND CD3%-PND
Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND
CD4/CD8-PND
[**2153-11-30**] 04:59AM BLOOD Glucose-134* UreaN-15 Creat-0.7# Na-139
K-3.6 Cl-112* HCO3-20* AnGap-11
[**2153-11-29**] 10:55AM BLOOD Glucose-92 UreaN-37* Creat-1.8* Na-131*
K-4.2 Cl-97 HCO3-20* AnGap-18
[**2153-11-30**] 04:59AM BLOOD Calcium-7.2* Phos-2.1* Mg-1.5*
[**2153-11-29**] 10:55AM BLOOD TSH-0.75
[**2153-11-30**] 01:21AM BLOOD Cortsol-24.4*
[**2153-11-29**] 11:30PM BLOOD Cortsol-6.4
[**2153-11-30**] 12:52AM BLOOD Cortsol-19.6
[**2153-11-29**] 10:55AM BLOOD HCV Ab-PND
[**2153-11-29**] 12:52PM BLOOD Lactate-0.9
[**2153-11-29**] 11:15AM BLOOD Glucose-97 Lactate-2.8* Na-132* K-4.2
Cl-98* calHCO3-21
Brief Hospital Course:
Pt started on H2 blocker, benedryl, hydrocortisone. [**Last Name (un) **] stim
test performed, revealed appropriate response. BP improved
through night and patient looked well in the AM. No wheezes on
lung exam. Discharged home on 5 day steroid taper, with PRN
epinephrine pen and benadryl. Also started on Dapsone for PCP
[**Name Initial (PRE) **].
Medications on Admission:
Bactrim
Aspirin PRN
Discharge Medications:
1. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every six (6) hours as needed for rash or shortness of breath.
Disp:*20 Capsule(s)* Refills:*0*
2. Epinephrine HCl 0.1 mg/mL Syringe Sig: One (1) injection
Injection once as needed for shortness of breath or wheezing.
Disp:*1 epi-pen* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Taper PO See taper for 5 days:
Taper: Take 50mg for 1 day, then 25mg for 2 days, then 10mg for
2 days, then stop.
Disp:*24 Tablet(s)* Refills:*0*
4. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bactrim anaphylaxis
Secondary:
HIV
Crohn's disease
History of nephrolithiasis
Discharge Condition:
Stable
Discharge Instructions:
Continue prednisone taper as written.
If rash returns, or you experience acute shortness of breath,
take benadryl and use epinephrine pen, and call your primary
care physician or go directly to the Emergency Dept.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] within 1 week. Please call [**Telephone/Fax (1) 8693**] to make an appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2153-12-20**] 2:00
Provider: [**First Name4 (NamePattern1) 8694**] [**Last Name (NamePattern1) 8695**], MD Where: [**Hospital6 29**]
Date/Time:[**2153-12-21**] 1:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2154-1-3**] 3:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"584.9",
"276.1",
"995.0",
"042",
"E931.0",
"276.5",
"555.9",
"V13.01",
"271.3",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4550, 4556
|
3520, 3875
|
299, 306
|
4678, 4686
|
2155, 3497
|
4948, 5749
|
1890, 1894
|
3945, 4527
|
4577, 4657
|
3901, 3922
|
4710, 4925
|
1909, 2136
|
238, 261
|
335, 1507
|
1529, 1632
|
1648, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,943
| 154,112
|
27164
|
Discharge summary
|
report
|
Admission Date: [**2133-12-14**] Discharge Date: [**2133-12-19**]
Date of Birth: [**2084-7-16**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Vancomycin / Penicillins / Naprosyn / Shellfish / Adhesive Tape
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Posterior removal of instrumentation/ revision laminectomies
History of Present Illness:
Patient is s/p previous L1 Burst fracture and kyphosis with
acute conus compression
Past Medical History:
As above with prior narcotic dependence
Social History:
Lives with daughter/ smokes 1 ppd
Family History:
Non-contributory
Physical Exam:
Kyphosis s/p L1 fracture- moderate weakness right lower
extremity
Pertinent Results:
[**2133-12-14**] 01:40PM freeCa-1.12
[**2133-12-14**] 01:40PM HGB-11.6* calcHCT-35
[**2133-12-14**] 01:40PM GLUCOSE-79 LACTATE-1.1 NA+-140 K+-4.0 CL--98*
TCO2-33*
[**2133-12-14**] 01:40PM TYPE-[**Last Name (un) **] PH-7.36
[**2133-12-14**] 03:18PM freeCa-1.00*
[**2133-12-14**] 03:18PM HGB-10.1* calcHCT-30
[**2133-12-14**] 03:18PM TYPE-ART PO2-237* PCO2-41 PH-7.45 TOTAL
CO2-29 BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2133-12-14**] 05:15PM freeCa-1.18
[**2133-12-14**] 05:15PM HGB-10.3* calcHCT-31
[**2133-12-14**] 05:15PM HGB-10.3* calcHCT-31
[**2133-12-14**] 05:15PM TYPE-ART PO2-250* PCO2-39 PH-7.48* TOTAL
CO2-30 BASE XS-6 INTUBATED-INTUBATED VENT-CONTROLLED
[**2133-12-14**] 05:15PM GLUCOSE-110* LACTATE-1.0 NA+-137 K+-3.6
CL--102 TCO2-29
[**2133-12-14**] 05:15PM HGB-10.3* calcHCT-31
Brief Hospital Course:
Patient was admitted for planned staged posterior
decompression/anterior vertebrectomy/ and then revision
osteotomy with re-instrumentation. She underwent a revision
decompression and beginning of re-instrumentation without
complication. She developed acute post-op blood loss anemia
post-op but was found to have a rare blood type and was not able
to adequately cross-matched. A delay in the second stage was
determined to be the safest course of action for her. She was
able to be mobilized on oral pain meds with a walker. Her
posterior incision is healing well with no signs of infection.
Medications on Admission:
Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). 5. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours). 7. Oxycodone-Acetaminophen 5-325 mg Tablet
Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*60 Cap(s)* Refills:*2*
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
MWF (Monday-Wednesday-Friday).
Disp:*60 * Refills:*2*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
10. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Thoracolumbar kyphosis
Discharge Condition:
Stable
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.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
|
[
"285.1",
"724.02",
"737.12",
"518.7",
"724.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"81.35",
"81.63",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
3904, 3910
|
1623, 2217
|
348, 411
|
3977, 3986
|
773, 1600
|
4241, 4328
|
654, 672
|
2695, 3881
|
3931, 3956
|
2244, 2672
|
4010, 4218
|
687, 754
|
291, 310
|
439, 524
|
546, 587
|
603, 638
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,519
| 172,077
|
14071
|
Discharge summary
|
report
|
Admission Date: [**2135-9-20**] Discharge Date: [**2135-10-19**]
Date of Birth: [**2062-1-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Lower back pain
Major Surgical or Invasive Procedure:
T4-L5 laminectomies with epidural abcess drainage
Right first toe amputation
PEG tube placement
PICC line placement
PICC line change (to double-lumen from single lumen)
History of Present Illness:
Patient is a 73 year old gentleman with a history of CAD s/p
CABG [**2110**] and [**2125**], chronic atrial fibrillation on coumadin, and
PVD. He presented to [**Hospital 1562**] Hospital on [**9-19**] with 3 day hx of
back pain, which came on gradually, until pt was not able to get
out of bed [**1-19**] pain. Pt was taken by ambulance and was found to
be febrile and in Afib w/ HR to the 150s. He was found to have
an infected right first toe, MRSA bacteremia ([**3-21**]+ blood cxs)
-started on Vanco q12hrs, and a TnT leak (1.78->4.77->5.45). Pt
was transfered to [**Hospital1 18**] for further care.
He was admitted to [**Hospital1 18**] ORTHO/SPINE service on [**9-20**], he grew
MRSA in 2 blood cxs, and was found to have an epidural abcess
from his sacrum to T5 that was evacuated by the spinal service
and required T4-L5 laminectomy. Started on IV Vanco q12hrs.
Blood cultures have been negative sinceadmission. Cards followed
pt for Troponin leak (0.48 x3)-> consistent w/demand ischemia
and medically manged pt.
Because he continued to be febrile and confused despite
evacaution and IV abxand because of an episode of Vtach on tele,
he was transferred to medicine from spinal service for further
w/up of fever and management of multiple medical issues.
ROS: Denies headache, visual changes, fevers, chills, sweats,
nausea, vomiting, shortness of breath, chest pain, dysuria,
abdominal pain, diarrhea.
Past Medical History:
1. Hyperlipidemia
2. CAD s/p MI s/p CABG in [**2110**] and [**2125**]. last stress was an
adenosine stress in [**8-22**] showing fixed mid-lateral wall defect
3. CHF with normal EF (last echo [**2135-8-30**])
4. Mild aortic stenosis
5. Mild mitral regurgitation
6. Hypertension
7. Chronic Atrial fibrillation/flutter since [**2128**] on Coumadin
8. Right foot cellulitis [**2133-9-24**]
9. Osteoarthritis
10. Does not have DMII (as all previous notes have said). This
was confirmed with the daughter
Past Surgical History:
1. CABG x2 in [**2110**] and [**2125**]
2. multiple toes right foot amputated from dry gangrene
following aneurysm rupture in right leg (unclear what caused
anyersum)
3. Right leg aneurysm repair
4. Tonsillectomy
5. Appy
Social History:
Social History: lives w/ wife. active @ [**Name2 (NI) 4222**]
Physical Exam:
O: VS:99.3 99.6 168/90 100 20 95%RA
Tele: 4 beat run of NSVT at 00:57 this am
Gen: Comfortable,Alert in NAD, lying in bed
HEENT: MMM, JVP flat
Lungs: Clear to auscultation bilaterally, without crackles
Heart: Irreg irreg rythm. no m/g/r
Abd: soft NT/ND, NABS, PEG tube in place without erythema or
edema
Ext: right toe amp with dressing C/D/I.
Skin: Warm and dry
Brief Hospital Course:
1.)Infectious Disease: The pt was transferred from [**Hospital 1562**]
Hospital on [**9-20**] where he was found have [**3-21**]+ bcx for MRSA +
where R 1st toe abcess culture grew MRSA. The pt was admitted
to Dr.[**Name (NI) 1392**] service where he was tx w/ Vanc 500mg PO tid,
Levo 250mg PO qD and [**Doctor Last Name **] 500mg PO tid. Bcx (10/4+[**9-21**]) grew
MRSA. The pt continued to complain of lower back pain and got a
head and spine MRI which showed a massive epidural abcess
extending from the beginning of the C-spine to the end of the
sacral spine. The pt was taken to the OR the next day by Dr.
[**Last Name (STitle) 363**] and underwent T4-L5 laminectomies w/ drainage of the
epidural abcess in the thoracic and lumbar spine but with
limited drainage of the abcess in the cervial spine. It was
decided that the remainder of abcess would be treated w/ abx and
followed clinically. Cultures from the epidural abcess grew
MRSA. After surgery [**Doctor Last Name **] + Levo were disontinued. On POD #2
the pt started spiking fevers and became more confused. His WBC
went up to 19.4. The pt was transferred to Medicine service and
a massive ID work-up was begun to identify possible sources of
infection. The pt was started empirically on Metronidazole to
cover for C. Diff and cefepime for pna. Pt's repeat bcxs + ua
w/cx came back negative. He was C. Diff neg x4. TEE was
negative for endocarditis or thrombi. Pt's AP CXR ([**9-27**]) showed
LLL opacity consistent w/pna, but torso CT ([**9-30**]) only revealed
small bilateral pleural effusions and bibasilar atelectasis and
no infectious collections were identified in the chest, abdomen
or pelvis. Repeat MRI of head and spine was attempted ([**9-28**]),
but due to the pt's confusion he couldn't tolerate it and the
study was limited in time and quality-> Thus the pt was sent
for cervical CT ([**9-30**]) which showed-> epidural abcess in the
cervical spine (C1-C5) The pt's white count went down on and
the pt was afebrile for 5 days althoough he continued to be
intermittently confused and disoriented. Cefepime and
Metronidazole were stopped per IDs recs since no other source of
infection was found except for the epidural abcess. The pt
continued to improve clinically and went for amputation of R
first toe. The pt tolerated the surgery well, but on POD#2 he
spiked a temp-> 101.3 and his WBC went up to 12.2. Bcx + UA
were resent and were negative. The pt also developed a
productive cough and started choking when eating. Repeat PA CXR
showed no evidence of pna or aspiration. The pt was sent for
repeat MRI to assess for change in epidural abcess, which showed
an interval improvement. He was [**Male First Name (un) 2083**] restarted empirically on
[**Doctor Last Name **] + Cefipime for possible aspiration PNA and was treated for
a 7 day course. He has remained afebrile since then. The plan is
to continue Vancomycin for an 8 week course and to have another
MRI in [**2-18**] weeks to assess for resolution of the epidural
abscess. He will follow up with Infectious Disease, Ortho/Spine
and vascular surgery as an outpatient.
2. )Delerium: The pt was highly functional @ baseline + had no
hx of dementia. Afer admission to OSH the pt became
intermittently disoriented and confused, which worsened s/p
T4-L5 laminectomy w/ epidural abcess drainage. The pt's delta MS
was likely the result of toxic metabolic encephalopathy due to
infection exacerbated by anesthesia since the pt wasn't in any
sedating or anticholinergic meds, and Head CT and MRI showed no
intracranial process. The pt's mental staus cleared after
starting triple abx therapy Vanco/[**Doctor Last Name **]/Cefapime upon transfer
to the Medicine service. Eventhough the pt continued to be
intermittently confused and disoriented, he was easilily
redirected and more alert. The pt underwent R 1st toe
amputation which he tolerated well.
3. )Dysphagia. On [**10-7**], the RN and wife noted increasing
dyspahgia, this was in the setting of his temp to 101.3.
initially it was felt to be due to toxic/metabolic effects of
worsening infeciton, however after he was treated for aspiration
PNA wtih cefepiome/flagyl and became afebrile, his dysphagia
remained. Speech swallow was consulted and recommended NPO. NG
tube was attempted, but the patient pulled it out and then
refused re-placement. Neurology service was consulted, and they
were concerned for possible brainstem CVA, but also thought that
Parkinsonism could be contribnuting and recommended Sinemet
trial. MRI head was performed that showed no CVA. GI was
consulted and placed a PEG tube on [**10-18**] without complications.
If still with ongoing dysphagia after addition of Sinemet, would
need ENT evaluation as an outpatient.
4. )Afib w/ RVR: On admission to OSH pt was found to be in Afib
w/ RVR to the 150s. The pt's rate was difficult to control w/
Metoprolol, Dig, + dilt drip. Coumadin was held since pt had to
undergo surgery. The cardiologist felt this was likely a result
of the infectious process and that the priority was to tx the
infection. The possibilty of cardoverting the pt while at TEE
was discussed w/ cardiology, which thought it could wait to be
done as outpt since he was hemodynamically stable. He was
staretd on heaprin drip and coumadin initally after okay iwth
ortho spine service, but then his coumadin was held due to NPO
status and in preparation for PEG tube placement. The pt was
continued on Metoprolol 200mg [**Hospital1 **] which achived some
control->pt's HR stayed btw the 90s-110s. The pt's HR became
harder to control when he was lost his inability to take po
medications and he was changed to lopressor 20mg iv q6hr. Once
the PEG tube was placed, he was resumed on metoprolol 200mg po
bID. Recommend f/u with cardiology to consider possible DC
cardioversion. Continue heparin gtt until INR therapuetic on
coumadin.
5. )NSVT: The pt started having asymptomatic runs of NSVT
around POD#2 (T4-L5 laminectomies). Cardiology thought this was
most likely the result of the infection,. They recommended a
TEE, since endocarditis could be a possible cause. The TEE was
negative for endocarditis. Cardiology thought the pt would
benefit from an outpt EP study for risk stratification (since hx
of CAD) for possible ICD implantation, but that it should wait
until the infection was under control. Pt's electrolyte were
monitored closely and repleated accordingly. Of note, he did
not have runs of NSVT for the last 7 days of hospitalization.
6.) CAD: The pt was found to have a troponin leak
(1.78->4.77->5.45) at OSH. On admission to the [**Hospital1 **] the pts
troponins were (0.44->0.44->0.40), which was most consistent w/
demand iscgemia per cardiology. There were no signs of acute MI
on ECG. The pt was started on Heparin, which was stopped when
the pt had to undergo epidural abcess drainage. The pt was
continued on ASA, atorvastatin, metoprolol and vasotec.
7. )FEN: After the dysphagia ([**Last Name 788**] problem 3 above) started, he
was made NPO. he was initially staretd on PPN and then TPN once
PICC line was changed to double lumen. PEG tube was placed on
[**10-18**] and tube feeds were initiated. His electrolytes were
agressively repleted given NSVT, to goal of K 4.5 and Mg 2.5 per
Cardiology recommendations.
8)Leucocytoclastic Vascultiis. Hd a small amount of purpura in
his left groin which resovled. Was seen by derm who perfmored bx
which showed leucocytoclastic vasculitis. Could be due to
cefepime which was discontinued, however dermatology is unsure
and recommends not labeling him as an "allergy" to cefepime.
9) Anemia. His Hct remained stable at 27-30. He remained guaiac
negative throughout hosptilazation.
Medications on Admission:
Home Medications:
Coumadin 2mg PO
Coumadin 1mg PO Tueday + Thursday
Lipitor 40mg PO qD
Toprol XL 50mg PO qD
Vasotec 5mg PO qD
.
Transfer medications:
Atorvastatin 40mg PO
MEtoprolol 150mg PO bid
ASA 325mg PO qD
Pantoprazole 40mg IV
Vanco 1500mg IV bid Day -
Ipratropium INH qhrs prn- SOB
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous every twelve (12) hours for 8 weeks.
2. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
units Subcutaneous four times a day: Per sliding scale.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
4. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day.
7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed.
8. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig:
as directed units Intravenous ASDIR (AS DIRECTED): See weight
based guideline. Until INR is therapeutic.
9. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Goal INR [**1-20**].
10. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Epidural abcess
First right toe abcess
MRSA bacteremia
Atrial Fibrillation
Asymptomatic Non Sustained Ventricular Tachycardias
Methicillin-Resistent Staph Aureus Bacteremia
Epidural Abscess
Right Big Toe Abscess
Dysphagia
Delirium
Non-Sustained Supraventricular Tachycardia
Rapid Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Follow up as below
Continue antibiotcs as below
Followup Instructions:
With your new PCP [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3649**] in [**12-19**] weeks after discharge
from rehab. [**Street Address(2) 8172**], [**Location (un) 620**], [**Numeric Identifier 3002**] ([**Telephone/Fax (1) 33387**]
With ID clnic Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 457**] in 8 weeks
With Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in vascular surgery clinic is 2 weeks
for removal of sutures( [**Telephone/Fax (1) 31602**]
With Dr. [**Last Name (STitle) 363**] (Orthopedics) in 4 weeks for MRI scan at ([**Telephone/Fax (1) 18552**]
With Dr. [**Last Name (STitle) **] (Neurology)in 4 weeks([**Telephone/Fax (1) 41967**]
With Electrophysiology (Cardiology) in 4 weeks ([**Telephone/Fax (1) 8793**]
|
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276, 293
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1972, 2473
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2751, 2798
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,955
| 197,607
|
31755
|
Discharge summary
|
report
|
Admission Date: [**2131-7-20**] Discharge Date: [**2131-8-10**]
Date of Birth: [**2071-2-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Bloody pleural effusion in OSH, SOB
Major Surgical or Invasive Procedure:
VATS (Video assisted thorascopic surgery) and lung biopsy
Insertion of hemodialysis catheter
Cardiac arrest requiring CPR and electric cardioversion.
History of Present Illness:
This pt is a 60 y/o F with history of CKD, HTN, without
treatment for either, who presents with 6 months of
unintentional wt loss, increasing SOB on exertion, and
increasing LE edema. She presented to a new PCP, [**Name10 (NameIs) 1023**] sent her to
[**Location (un) **] ED where a large loculated left pleural effusion was
found and 1L bloody effusion was removed ([**7-19**]). B/l LE dopplers
negative. CT scan from OSH showed no masses in abdomen or
pelvis, only effusion in left lower lung.
.
Since [**Month (only) **], the patient has had 85 pounds of unintentional
wt loss. She had shortness of breath on exertion after walking
about 40 feet. denies orthopnea. Denies PND. patient had
dependent edema at baseline, which she says has been worsenign
over the past 2-3 months. She also c/o fatigue, decreased
appetite.
.
Patient went to the doctor several years ago, and was noted to
have elevated creatinine, likely chronic renal failure from htn.
Pt says she has occassional elevated blood pressure, and does
not take medication for it. She did not follow up the chronic
kidney disease.
.
Patient has never had colonoscopy or mammogram. Does not see
doctor regularly.
.
In our ED, VS 95 174/80 95% RA. CXR w large left sided effusion.
K 5.4. No EKG changes. Kayexelate given. Hct 27, OB negative.
Creatinine 6.1.
.
On ROS: denies dysuria, hematuria, or noted sediment/discharge.
Denies any flank pain. No HA, vision changes, no LAD, no CP
palpitations, no abd pain, no const/diarrhea. no fevers, chills,
diaphorses.
Past Medical History:
nephrolithiasis 4yrs ago
HTN - Noted several times, but sometimes also normotensive, thus
never took meds for this.
CKD - noticed several years ago, never treated, never followed
up.
Osteoarthritis
Social History:
lives with mother. [**Name (NI) **] [**Name2 (NI) **]. Prior [**11-28**] ppd x 15yrs. No IVDU.
Social etoh. Many supportive family members. [**Name (NI) **]: case manager
at NH currently.
Family History:
Colon ca in [**Last Name (un) **] 52, GM 60
Lung ca in GF 65
Afib mom
TIA mom
DM sister and 2 [**Name2 (NI) **]
Celiac, sogrens sister
Physical Exam:
98, 166/92 HR 96 18 97% 2L
Gen: pleasant, appears older than stated age.
HEENT: anicteric, MMM, OP clear. no oral lesions.
Neck: no LAD, supple, postive JVD
breast; large 3x5 cm right breast mass reportedly unchanged for
over 20 years
CV: II/VI SEM LUSB, nl S1S2 Reg, tachy
Chest: decreased BS left base, +e->a egophany LLL, decreased
fremetus LLL. otherwise clear
Abd: no CVA tenderness. BS+ NT ND. no HSM. no rebound. no masses
Ext: mild edema. bilat very tender legs
Lymphs: full cervical, inguinal, and axillary neg
OB neg
NEURO: AAO x3
Pertinent Results:
[**2131-7-20**] 06:45PM WBC-10.7 RBC-2.97* HGB-8.5* HCT-27.0* MCV-91
MCH-28.6 MCHC-31.5 RDW-18.8*
[**2131-7-20**] 06:45PM NEUTS-71.6* LYMPHS-21.1 MONOS-4.1 EOS-2.7
BASOS-0.5
[**2131-7-20**] 06:45PM PLT COUNT-452*
[**2131-7-20**] 06:45PM PT-13.1 PTT-27.3 INR(PT)-1.1
[**2131-7-20**] 06:45PM GLUCOSE-80 UREA N-74* CREAT-6.1* SODIUM-136
POTASSIUM-5.4* CHLORIDE-110* TOTAL CO2-12* ANION GAP-19
.
[**2131-7-21**] Renal U/S
RENAL ULTRASOUND: The right kidney measures 8.6 cm. The left
kidney measures 7.2 cm. There is increased echogenicity of the
renal sinuses and thinning of the cortex bilaterally. There are
no stones or hydronephrosis. A 1.4 x 1.1 cm cyst is seen within
the lower pole of the right kidney. A partially full bladder is
unremarkable.
IMPRESSION:
Atrophic kidneys bilaterally consistent with chronic
medical-renal disease. No stones or hydronephrosis.
.
[**2131-7-21**] CT Abdomen/Pelvis with contrast
CT CHEST FINDINGS: Some subcentimeter mediastinal lymph nodes
are noted that are not pathological by size criteria. The main
pulmonary artery is prominent at 3.2 cm with a maximum diameter
of the right pulmonary artery measuring 2.8 cm. There is some
vascular calcification noted. There is volume loss in the left
hemithorax. There is a left pleural effusion which extends
circumferentially around the lateral side of the chest wall.
There is a slightly thickened rim of parietal pleura just
adjacent to the chest wall in relation to this pleural effusion.
There is associated atelectasis; superimposed consolidation
cannot be excluded. There are calcified pleural plaques noted
suggesting a history of asbestos exposure.
CT ABDOMEN FINDINGS: Given that this is a non-contrast CT, the
liver and
spleen are normal. The gallbladder is normal. There is
calcification of the splenic vasculature. The adrenals are
normal. The kidneys are reduced in size. Some areas of low
attenuation are seen in the right kidney which may be consistent
with cysts. Some tiny scattered punctate areas of high
attenuation are seen in relation to the kidneys bilaterally
which represent calculi that are nonobstructing.
The pancreas is normal. No significant retroperitoneal
lymphadenopathy. The bowel where visualized is normal.
CT PELVIS FINDINGS: Note is made of diverticulosis without
evidence of
diverticulitis especially in the sigmoid colon. The bladder is
normal. The uterus is unremarkable.
Bony windows reveal some degenerative changes at the L5-S1
level.
Multiplanar reconstructions were essential in depicting the
anatomy and
identifying the pathology.
IMPRESSION:
1. Volume loss in left hemithorax with moderate-sized left
pleural effusion and associated collapse and atelectasis but no
definite mass identified. No evidence of high attenuation in
pleural fluid to suggest recent hemorrhage.
2. Calcified pleural plaques suggesting asbestos exposure.
Thickening of the parietal pleura surrounding the left pleural
effusion.
3. Diverticulosis without evidence of diverticulitis.
4. Prominent pulmonary artery which may suggest pulmonary
hypertension.
5. Renal cysts and nonobstructing calculi.
.
[**2131-7-23**] Echocardiogram
Conclusions:
The left atrium is normal in size. 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%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function. Mild
mitral regurgitatio.
.
[**7-24**] Venous duplex
IMPRESSION: Right cephalic and basilic veins are patent. The
left basilic vein is patent and the left cephalic vein is
clotted at the level of the forearm.
.
[**2131-7-31**] Chest CT
IMPRESSION:
1. Persistent left loculated pneumothorax with air leaking
along the chest wall into the subcutaneous tissue.
Bronchopleural fistula cannot be excluded. Overall slight
decrease in the amount of the right pleural effusion.
2. Right pleural effusion, slightly increase in size,
accompanied by left
lower lobe atelectasis.
3. New multiple bilateral, right more than left consolidations,
which may
represent aspiration and/or pneumonia.
4. Improvement of aeration of the left upper lobe compared to
the most recent chest radiograph.
.
[**2131-8-9**] CXR
REASON FOR EXAMINATION: Followup of a patient with known
loculated
hydropneumothorax on the left.
PA and lateral upright chest radiograph compared to [**8-8**], [**2130**].
The loculated left hydropneumothorax is unchanged. The
cardiomediastinal
silhouette is stable. The right pleural effusion is
small-to-moderate,
unchanged. The right lung is unremarkable as well as the left
upper lung.
Subcutaneous emphysema within the left chest wall is stable.
IMPRESSION: No evidence of interval change.
Brief Hospital Course:
60 y/o F with history of HTN and CKD (untreated) who presented
with increasing SOB, bloody pleural effussion, and concern for
ARF. VATS for decortication and biopsy was attempted however
had to be aborted as patient went into cardiac arrest PEA v.
asystole v. fine vfib arrest she was resuscitated and
transferred to MICU for continued care. She had an elevation in
cardiac enzymes following this event felt most likely due to
cardiac defibrillation rather than ACS. Renal function was
worsened following this event and patient had to be started on
hemodialysis for treatment on volume overload and uremia. She
also had a chest tube in place to treat her persistent pleural
effusions. The chest tube was removed prior to discharge which
she tolerated well. Prior to discharge, outpatient hemodialysis
was arranged as well as contact for consideration of peritoneal
dialysis.
.
Brief Hospital Course by Problem:
.
#Persistent Bloody pleural effusion: On admission, VATS
attempted for biopsy and decortication however the procedure had
to be aborted due to cardiac arrest. Tissue sample and pleural
fluid was obtained and was negative for AFB, fungus, bacteria,
malignancy. She had a chest tube placed in the OR following
biopsy. This was left in place with considerable drainage of
bloody fluid. Chest tube was removed prior to discharge which
she tolerated without event. She continued to have bilateral
persistent pleural effusions and she was discharge on oxygen as
she desaturated on ambulation. She will follow up with Dr.
[**Last Name (STitle) **].
.
#. hospital/ventillator acquired pneumonia - during MICU stay
she was noted to have infiltrate felt most likely to be due to
hopital/ventillator acquired pneumonia. She was treated with 2
week course of cefepime and vancomycin with last dose on
[**2131-8-13**]. She was discharged on levofloxacin and vancomycin
dosed with dialysis to complete course of treatment.
.
#. Acute renal on end stage renal failure - on admission she had
end stage renal failure with likely hemodialysis in the near
future however her renal function was significantly worsened
following her cardiac arrest. She did not recover any
significant renal function in the days following the event and
she was started on hemodialysis for treatment of uremia and
volume overload. She tolerated dialysis well and was discharge
with outpatient hemodialysis and appointment to discuss option
of peritoneal dialysis. She was treated with epogen and iron
with dialysis for anemia. In addition she was started on
nephrocaps and renagel.
.
#s/p asystolic/VF arrest at time of lung bipsy with NSTEMI and
troponins up to 0.5- most likely [**12-29**] cardioversion with
resuscitation. She was started on metoprolol, ASA and
lisinopril prior to discharge. She opted not to have inpatient
stress test to further evaluate risk for cardiac ishemia however
agreed to have her primary care physician arrange this as an
outpatient. Echocardiogram showed low normal EF at 50% without
focal wall motion abnormalities.
.
#Left cephalic vein clot on prior UE u/s - likely related to
prior PICC on that side. She refused repeat ultrasound to asses
for extension or resolution of clot but agreed to have her
primary care doctor arrange as an outpatient.
.
#.Weight loss- significant unintentional weight loss prior to
admission. Pleural fluid without evidence of malignancy, no LAD
or fevers/sweats. No prior colonoscopy or mammogram. Concern for
lipoma vs. breast mass, per pt-breast mass on R side has not
grown, no bx done but U/S done in past. Pt with family h/o colon
CA. She agreed to follow up with colonoscopy and mammogram as
an outpatient.
.
#. Anemia - ACD secondary to renal disease, stable hematocrit
throughout admission. Treated with epogen and iron with
dialysis. She will follow up with colonoscopy as outpatient.
.
#. CODE: DNR/DNI discussed
Medications on Admission:
tylenol daily for OA
Discharge Medications:
1. mammogram
bilateral mammogram. Pt has never had one. H/O R.breast "lipoma"
2. colonoscopy
Screening and diagnostic colonoscopy. Pt has never had one.
3. gynecology
Pt needs gyn appointment/referral for complete pelvic exam and
pap smear.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Vancomycin 500 mg Recon Soln Sig: per dialysis protocol based
on trough Recon Soln Intravenous ONCE (Once) for 1 doses: you
should get one additional dose of vancomycin with dialysis on
[**8-13**] based on your trough. This will complete your course of
vancomycin.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*270 Capsule(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four to six hours as needed as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*1*
11. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 1 days: take this pill on [**2131-8-12**], then you
are finished with your antibiotics.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
CArdiac arrest
Pleural Effusion, hydropneumothorax s/p [**Hospital 74566**]
Hospital acquired pneumonia
Acute renal failure
CKD V on hemodialysis
HTN
minor: breast lipoma
Anemia from chronic kidney disease
Discharge Condition:
good
Discharge Instructions:
You were admitted because you were found to have a bloody
pleural effusion. In addition you had hypertension and chronic
kidney disease that were not treated. A bloody pleural effusion
can be a sign of malignancy, however the diagnostic studies have
not shown any evidence of malignancy. However, you will need to
have a mammogram and breast ultrasound, a pelvic exam and pap
smear to continue to evaluate for any evidence of cancer. You
will also need a colonoscopy as you have not yet had these
exams. These are very important. It is important that you take
your medications as prescribed and follow up with the
appointments below.
.
In addition, you had a cardiac arrest during the lung biopsy
procedure that you had. It is unclear why this happended to you
but as we discussed, we feel that you should have further work
up to make sure that you do not have coronary artery disease.
We wanted to do a stress test for your heart in the hospital
however you opted not to have that. Please ask your primary
care doctor to arrange for you to have that test as an
outpatient.
You are now on hemodialysis to treat your kidney failure.
Please follow up with dialysis as arranged. In addition you
have an appointment with the kidney doctor as listed below.
You should also follow up with the lung doctors as listed below.
You have a blood clot in the cephalic vein of your left arm.
Please ask your doctor [**First Name (Titles) **] [**Last Name (Titles) **] an ultrasound to re-evaluate
this to make sure that it has not gotten any larger.
You have some new medications including lipitor and lisinopril.
Please have your doctor check your liver enzymes and a chemistry
panel at your appointment.
[**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 15170**] will be contacting you to set up follow up to
discuss peritoneal dialysis.
Call your doctor or return to the hospital if you experience any
concerning symptoms including shortness of breath, chest pain,
fever, worsening cough, or any other concerning symptoms.
Followup Instructions:
You will be having dialysis treatments at Physicians Dialysis,
INC in [**Location (un) 1157**], MA. [**Street Address(2) 74567**], PH#[**Telephone/Fax (1) 74568**] on
monday wednesday and friday. You will be getting one more dose
of vancomycin at your dialysis appointment on monday based on
your trough level.
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2131-8-15**] 3:00
2. You have an appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27542**]
[**Telephone/Fax (1) 27541**] on [**2131-8-20**] at 1:30 for treatment of your high blood
pressure, kidney disease and to fascilitate mammography, breast
ultrasound, colonoscopy, and gyn exam. In addition, please ask
him to set up an appointment for a stress test for your heart.
You also need a repeat ultrasound of your arm to follow up on
the blood clot that was seen in your left cephalic vein.
4. Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**]
Date/Time:[**2131-8-23**] 9:30. This appointment is to follow up from
the chest tube.
5. Dr. [**Last Name (STitle) **] (pulmonary) [**2131-9-12**] at 4pm. The phone number
to call and reschedule this appointment is [**Telephone/Fax (1) **].
|
[
"428.0",
"285.21",
"997.1",
"403.91",
"410.71",
"427.5",
"585.6",
"428.31",
"783.21",
"511.8",
"997.3",
"511.9",
"510.9",
"486",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"33.24",
"34.21",
"39.95",
"34.24",
"34.09",
"96.6",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
14295, 14363
|
8611, 9500
|
351, 503
|
14612, 14619
|
3212, 8588
|
16705, 18092
|
2498, 2634
|
12569, 14272
|
14384, 14591
|
12524, 12546
|
14643, 16682
|
2649, 3193
|
276, 313
|
9528, 12498
|
531, 2056
|
2078, 2277
|
2293, 2482
|
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