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46,360
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6468
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Discharge summary
|
report
|
Admission Date: [**2153-4-6**] Discharge Date: [**2153-4-10**]
Date of Birth: [**2097-12-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain, positive exercise tolerance test
Major Surgical or Invasive Procedure:
Cardiac catherization with 2 stents (DES) placed to right
coronary artery.
History of Present Illness:
This is a 55-year-old woman with DM II, HTN, hyperlipidemia and
an extensive family history of early CAD who is admitted on [**4-6**]
after anginal symptoms during outpatient ETT and EKG changes
suggestive of myocardial ischemia.
.
Ms. [**Known lastname 24850**] complains of 4 months of exertional chest pain.
She is aware of a "pressure" in her chest after about 10 minutes
of exercise (such as walking up stairs). It is associated with
some mild SOB and palpitations; she [**Known lastname **] nausea, vomiting, or
diaphoresis. Prescribed nitro by outpatient provider.
.
On admission, Ms. [**First Name (Titles) 24851**] [**Last Name (Titles) **] chest pain, shortness of
breath, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. Other review of systems is
negative for abdominal pain, constipation, fever, chills, or
other concerning signs or symptoms. Ms. [**Known lastname 24850**] does
complain of a headache, which she states is her usual migraine.
Past Medical History:
--DM II
--Dyslipidemia
--Hypertension
--Anxiety
--Migraines
--Osteoporosis
--Iron deficiency anemia
Social History:
Originally from [**Male First Name (un) 1056**]. Lives with uncle. [**Name (NI) **] 5 children
ranging in age from 42 to 34. [**Name (NI) 4273**] tobacco, ETOH, or other
drug use.
Family History:
Brothers died at 60 and 65 of MI. Mother died at 57 of MI.
Sister died at 56 of MI. Father died at 80 of MI. Multiple
family members with DM II and hypertension. No family history
of cancer.
Physical Exam:
VS: T 98.0 BP 154/66, HR 75 RR 16 O2 sat 100% RA, blood sugar
135
GENERAL: Pleasant woman, appears stated age, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVP not elevated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Midline scar from
tubal ligation surgery.
EXTREMITIES: No clubbing, cyanosis, or edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+, Radial 2+, Popliteal 2+
Left: Carotid 2+, Radial 2+, Popliteal 2+
Pertinent Results:
[**2153-4-6**] 09:55PM GLUCOSE-256* UREA N-21* CREAT-1.1 SODIUM-138
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-31 ANION GAP-15
[**2153-4-6**] 09:55PM estGFR-Using this
[**2153-4-6**] 09:55PM CK(CPK)-58
[**2153-4-6**] 09:55PM CK-MB-NotDone cTropnT-<0.01
[**2153-4-6**] 09:55PM CALCIUM-10.2 PHOSPHATE-4.5 MAGNESIUM-1.6
[**2153-4-6**] 09:55PM WBC-6.6 RBC-4.45 HGB-12.8 HCT-39.2 MCV-88
MCH-28.7 MCHC-32.6 RDW-13.1
[**2153-4-6**] 09:55PM PLT COUNT-301
[**2153-4-6**] 09:55PM PT-12.2 PTT-24.1 INR(PT)-1.0
.
EKG: T wave inversions in V1-V5. ST depressions in I and II.
.
ETT [**2153-4-6**]:
Ms [**Known lastname 24850**] is a 55 year old woman with history of
hyperlipidemia, diabetes, hypertension who presents with typical
angina
for several months. She completed 4 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**]
protocol
representing a poor exercise tolerance for her age; ~ 2.8 METs.
The
test was stopped due to fatigue. She complained of substernal
chest
pain ([**7-5**]) 2 minutes into exercise that peaked at 7/10 which
resolved 5
minutes into recovery. There were 0.[**Street Address(2) 20505**] depression at
peak
exercise which resolved upon rest. During recovery she had T
wave
inversions starting from 2 minutes in recovery to 7 minutes in
recovery.
She had a run of atrial tachycardia 2 minutes into recovery
lasting for
6 beats. The rhythm was sinus. The patient was hypertensive at
baseline
however had appropriate hemodynamic response to exercise.
IMPRESSION: Anginal symptoms at low workload with ST changes
suggestive
of myocardial ischemia. Nuclear report sent separately.
.
Nuclear stress [**4-6**]:
Probably normal myocardial perfusion at level of exercise
achieved with mild fixed apicoanterior and apical defect which
is commonly seen with our current camera. However, given the
stress results an LAD distribution lesion can not be excluded.
.
Cath [**4-9**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated
single vessel CAD. The LMCA had no angiographically apparent
CAD. The
LAD had a 50% stenosis in the mid vessel. The LCx had no
angiographically apparent CAD. The RCA had a proximal 50%
stenosis and a
distal 70% stenosis.
2. Limited resting hemodynamics revealed moderate systemic
arterial
systolic hypertension with an SBP of 154 mmHg.
3. Successful PTCA and placement of a 2.5x12mm Promus drug
eluting stent
in the mid RCA and a 2.5x12mm Promus drug eluting stent in the
proximal
RCA. Final angiography showed normal flow, no apparent
dissection, and
no residual stenoses. (See PTCA comments.)
4. The right common femoral arteriotomy was successfully closed
using a
6 Fr Angioseal VIP device.
.
FINAL DIAGNOSIS:
1. Single vessel CAD.
2. Successful placement of DES to RCA.
Brief Hospital Course:
This is a 55-year-old woman with a past medical history of DM
II, HTN, hyperlipidemia, and a strong family history of CAD who
was admitted to [**Hospital1 18**] after an ETT suggestive of myocardial
ischemia. Patient underwent cardiac catherization on [**4-9**] and
had 2 DES placed to RCA.
CAD: Patient has multiple risk factors for CAD including HTN,
hyperlipidemia, DM II, and a strong family history of heart
disease. An ETT on [**4-6**] was suggestive of myocardial ischemia.
Patient underwent cardiac catherization (via right groin) on
[**4-9**] without complications. Two DES were placed to RCA. Ms.
[**Known lastname 24850**] was maintained on home lisinopril 10mg qd and started
on Plavix, Toprol 25mg qd, Simvastatin 40mg qd, and ASA 325mg
qd. She was maintained on telemetry and monitored with serial
EKGs. Last HgbA1C is 7.9--patient is on 3 oral hypoglycemics as
an outpatient, but may be switched to insulin by primary
provider. (Dr. [**Last Name (STitle) **], patient's PCP, [**Name10 (NameIs) **] been notified of
patient admission and elevated HgbA1C). Patient will follow-up
with Dr.[**Name (NI) 3733**] in cardiology clinic on [**4-17**].
.
ASPIRIN DESENSITIZATION: Patient with known allergy to aspirin
including shortness of breath, chest pain, and diaphoresis. Ms.
[**Known lastname 24850**] was successfully desensitized to aspirin in CCU on
[**4-8**] via ASA desensitization protocol. She should continue
taking aspirin daily; if she fails to do so, her allergy may
return.
.
DIABETES: Patient with DM II for the last ~20 years not ideally
controlled on 3 oral agents. (Last HgbA1C is 7.9). During this
admission she was started on glargine and an insulin sliding
scale. Ms. [**Known lastname 24850**] will be discharged on her home
hypoglycemics, but her PCP may decide to switch to insulin for
superior control. Dr. [**Last Name (STitle) **] is in agreement with this plan.
.
HYPERLIPIDEMIA: Patient was discharged on Simvastatin 40mg QD.
.
HYPERTENSION: Patient was maintained on home ACE-I and started
on Toprol 25mgQD.
.
ANXIETY: Patient with baseline anxiety, exacerbated by hospital
stay. Patient was seen by social work consult, and may benefit
from counseling as an outpatient.
.
CHRONIC BACK PAIN, NEUROPATHY: Nortryptaline was continued.
Medications on Admission:
Glimepiride 4 mg Tablet
Lisinopril 10 mg Tablet
Lovastatin 40 mg Tablet
Metformin 1,000 mg Tablet
Nitroglycerin 0.4 mg Tablet, Sublingual
Nortriptyline 10 mg Capsule
Pioglitazone [Actos] 45 mg Tablet
Propoxyphene N-Acetaminophen 100 mg-650 mg Tablet TID prn
Omeprazole
Discharge Medications:
1. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take one tablet as needed for chest pain for up to 3 tablets in
15 minutes. Call your doctor if you take more than one tablet,
and call 911 if you take 3 tablets.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Succinate 25 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*
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Do not take until evening of [**4-11**].
10. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO three times a day as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Coronary artery disease
2. Stable angina
3. Abnormal exercise tolerance test
.
Secondary
1. DM II
2. Hypertension
3. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Ms. [**Known lastname 24850**],
It was a pleasure taking care of you on this admission. You
were admitted to the hospital because of an exercise tolerance
test (stress test), which showed some damaged heart muscle. You
had a cardiac catherization on [**4-9**] and 2 DES (drug eluding
stents) were placed into your right coronary artery. IT IS VERY
IMPORTANT THAT YOU TAKE A MEDICATION CALLED PLAVIX (CLOPIDOGREL)
UNTIL INSTRUCTED OTHERWISE BY YOUR DOCTOR.
.
You also underwent a procedure during which we "desensitized"
you to aspirin. You can now take aspirin without having an
allergy to this medication. It is very important that you take
aspirin every day or else your allergy may return.
.
The following changes were made to your medications:
1. START Plavix (Clopidogrel) 75mg once a day
2. START Aspirin 325mg once a day
3. START Toprol XL 25mg once a day
4. STOP taking omeprazole
5. START Ranitidine 150mg once a day
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
.
Return to the hospital if you develop chest pain, shortness of
breath, severe headache, palpitations, nausea, vomiting,
diarrhea, bleeding in your urine or stools, fevers, chills, or
other concerning signs or symptoms.
Followup Instructions:
[**2153-4-17**] 11:00a [**Last Name (LF) **],[**First Name3 (LF) 2352**]
[**Location (un) **] ([**Location (un) 2352**], MA), [**Location (un) **]
[**Location (un) 2352**] - ADULT MEDICINE (SB)
[**2153-4-17**] 04:00p [**Doctor Last Name **]-CC7
[**Hospital6 29**], [**Location (un) **]
CC7 CARDIOLOGY (SB)
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21,975
| 131,699
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8823
|
Discharge summary
|
report
|
Admission Date: [**2108-10-6**] Discharge Date: [**2108-10-12**]
Date of Birth: [**2036-8-7**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Amlodipine / Percocet
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 13972**] is a 72M with CAD h/o CABG (LIMA-LAD, SVG-OM,
SVG-Ramus, [**2102**], last cath [**3-29**] with 3VD patent LIMA to LAD,
patent SVG to OM, patent SVG to R1, but R1 terminates after
touchdown point, no intervention), paroxysmal afib (last episode
of PAF in [**7-29**] with trop leak), PVD, DM2 and ESRD on HD & PD
s/p HD day of admission (removal of 4L) presents to ED with
fever to 102, hypotension, and AF with RVR. He had recently
been seen by his PMD for LE cellulitis and was given an rx for
Augmentin x 1 day. He denies any chest pain, LH, dizziness,
palpitations. He reports a HA which is not unusual for him
after HD. Per his wife he has had persistent diarrhea for the
past month, [**1-27**] loose stool/day. He also suffers from
post-prandial nausea which has been present for months. He has
a chronic cough and reports worsening DOE for past 3-4 months.
Known to have low SBP (SBP 85/40 in clinic).
.
In the ED the patient had temperature to 102, ventricular rate
in 100s, BP 79/47. He was given gentle IVF, flagyl, vancomycin,
and ceftriaxone. He was started on amiodarone load 150mg,
followed by amiodarone 1mg/min gtt. CXR showed ? aspiration
PNA, unable to send PD fluid for culture as pt was empty.
Past Medical History:
1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing
ulcer on [**2-26**] s/p atherectomy of L SFA popliteal tbioperoneal
trunk with angioplasty x 2. Pt had recent right first toe
amputation and left TMA on [**2107-3-24**].
3)Paroxysmal atrial fibrillation
4)Type II DM: followed by [**Last Name (un) **]
5)Hyperlipidemia
6)Chronic bronchiectasis
7)EF 35%
p-MIBI [**2108-2-27**]: Mild-moderate anterior-lateral and apical
reversible defect. 2. Mild global hypokinesis and septal
akinesis. 3. Ejection fraction is 35%.
8)BPH
9)Anemia of chronic illness
10)CRI on daily peritoneal dialysis
.
PAST SURGICAL HISTORY:
1) s/p angioplasties of the left common femoral, superficial
femoral, tibioperoneal trunk in ([**2106-11-24**])
2) left CEA ([**2102**] at [**Hospital1 2025**])
3) CABG (LIMA to the LAD and saphenous vein graft to the
obtuse marginal 1 and the ramus intermedius - [**2103-9-24**])
4) s/p cholecystectomy with exploratory lap with repair of
liver lacerations ([**2105-11-23**])
5) PD catheter placement in ([**2106-9-24**])
6) right eye cataract with intraocular lens, right
eye vitrectomy
7) right common femoral artery to posterior
tibial bypass graft with in situ saphenous vein in [**Month (only) 404**] of
[**2106**].
Social History:
Patient has been married for 42 years with a supportive wife who
"visits me every single day I'm in the hospital and drives me to
dialysis." He expresses some anxiety regarding feeling like "a
burden" on his family. He has two children, one 29 yo son who
is a financial analyst in [**Location (un) 21601**], and one older daughter who
is raising five children in [**Location (un) 30790**], [**State 2748**]. He is very
proud of his family. He works as a pharmacist. He used to own
his own pharmacies but sold them to [**Doctor First Name **] and has worked for
the past 18 years at the VA. He says the VA is "holding my job
for me." He has enjoyed golf and tennis in the past and his loss
of mobility has been difficult for him. He is a former smoker,
denies alcohol and drug use.
Family History:
Father with DM type 2
Two sisters and one brother--all well
Physical Exam:
VS 101.4 BP 85/37 HR 82 RR 22 O2sat 91%
Gen: AAOx3, moaning in pain, somnolent
HEENT: dry MM, EOMI, PERRL
neck: JVD to 15cm
CVR: normal s1s2, 2/6 systolic ejection murmur.
Chest: Tunneled HD catheter on right chest, some minimal
erythema around site. No drainage or tenderness.
Lungs: Rhonchorous throughout.
Abd: NT/ND, bs normoactive, soft, PD dressed, clean.
Ext: tense RLE, erythematous, tender to palpation, warm. LLE
s/p toe amputation.
Pertinent Results:
Admit labs:
[**2108-10-6**]
Trop-*T*: 0.18
Comments: Corrected Result
Previously Reported As 1.83
Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3510**] At 1640 On [**2108-10-7**]-Pap
Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
141 102 28 AGap=12
-------------< 116
4.0 31 2.0
CK: 71 MB: Notdone
Ca: 7.5 Mg: 1.5 P: 2.9 D
ALT: 21 AP: 107 Tbili: 0.5 Alb:
AST: 19 LDH: Dbili: TProt:
[**Doctor First Name **]: 5 Lip:
106
11.4 \ 12.6 / 252
/ 38.7 \
N:83 Band:5 L:3 M:6 E:2 Bas:0 Atyps: 1
PT: 21.4 PTT: 117.2 INR: 2.1
Past cardiology studies:
[**2108-2-27**] Persantine MIBI: IMPRESSION: 1. Mild-moderate
anterior-lateral and apical reversible defect. 2. Mild global
hypokinesis and septal akinesis. 3. Ejection fraction is 35%.
.
Cath [**2106-12-22**]:
R dominant system
LMCA: 60% occluded
LAD: widely patent LIMA to LAD. SVG to RI 80% ostial
LCX: patent SVG to OM. LCX 80% prox.
RCA: proximally occluded, filled by collaterals from LIMA/SVG
.
Cath [**2108-3-28**]
1. Selective coronary angiography in this right dominant
circulation
demonstrated severe native vessel coronary artery disease. The
LMCA was diffusely diseased with 60% distal stenosis. The LAD
was totally
occluded in the proximal segement. The distal LAD had mild
disease and was supplied by the LIMA graft. The LCx had severe
diffuse disease. The OM and Ramus were totally occluded at their
origins, but filled via an SVG.
2. Saphenous vein angiography demonstrated widely patent SVG to
OM and SVG to Ramus. The Ramus was totally occluded after the
touchdown point and filled via collaterals from the grafted OM.
3. Arterial conduit arteriography demonstrated a widely patent
LIMA to LAD.
4. Opening pressure in the central aorta was moderately
elevated.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA to LAD.
3. Patent SVG to OM.
4. Patent SVG to Ramus, but total occlusion after touchdown
point.
.
PFTs [**2105-4-8**]:
FEV1 58% predicted, FEV1/FVC 96%. c/w restrictive pattern.
former smoker 1.5 pack per day x25 years, not smoked for 20 yrs
.
CURRENT STUDIES:
[**2108-10-6**] CXR: IMPRESSION:
1. Increased left lower lobe opacity, which may represent
pneumonia, although atelectasis is possible.
2. Right middle lobe opacity, highly suspicious for pneumonia.
3. Worsening fluid overload with increased pulmonary
vascularity and small effusions.
Cardiology Report ECG Study Date of [**2108-10-6**] 4:08:18 PM
Atrial fibrillation with a mean ventricular response, rate 160.
Delayed
anterior precordial R wave progression. Marked inferolateral ST
segment
depression. Compared to the previous tracing of [**2108-8-19**] cardiac
rhythm now
rapid atrial fibrillation with repolarization abnormalities.
Norable labs during course:
TSH:4.3 Free-T4:1.1
Other Blood Chemistry:
T4: 4.6
T3: 62
Discharge labs:
[**2108-10-12**]
103
8.6 \ 11.7 / 336
/ 36.4 \
PT: 21.6 PTT: 35.0 INR: 2.1
Brief Hospital Course:
This is a 72 year old M with h/o ESRD s/p HD day of admission
(took off 4.2L), severe PVD s/p multiple interventions,
paroxysmal AFib, CAD s/p CABG, CHF EF 30%, DM2, bronchiectasis
admitted to CCU with a-fib/RVR, self-converted to NSR, fever,
hypotension, and LE cellulitis.
.
CARDIAC
# Rhythm: Mr. [**Known lastname 13972**] has a history of paroxysmal Afib. He
presented to the ED following hemodialysis in atrial
fibrillation, but hemodynamically stable. He was also noted to
have a troponin leak. He was given an esmolol drip in the ED
with no response, followed by an amiodarone load 150mg then
1mg/min drip. On the way up to the CCU he converted back to
sinus rhythm. This was attributed more to chance than to the
amiodarone as the patient takes amiodarone at home. The patient
remained in sinus rhythm for the first 24 hours of his
hospitalization, however on hospital day 2 he flipped into rapid
atrial fibrillation with RVR. This was terminated with PO and
IV metoprolol. He continues to flip from Afib to sinus. He
remained asymptomatic when he was in atrial fibrillation. On
hospital day 1 he was placed back on his home PO amiodarone dose
of 200mg daily. Beta blockers and ace inhibitors were held due
to his low blood pressures. On HD2, his blood pressure rose and
he was restarted on low dose beta blocker. On HD3 as the
patient continued to return to atrial fibrillation from sinus,
digoxin was started and his beta blocker was increased to QID.
The future need for PPM placement with AVJ ablation was
discussed with the patient, and can be considered by Dr.
[**Last Name (STitle) **] in follow up if A fib becomes a problem. [**Name (NI) **] will remain
on coumadin with INR goal [**1-27**].
.
# CAD: Mr. [**Known lastname 13972**] has known unrevascularized disease (ramus).
He remained chest pain free during the admission and was
continued on aspirin and a statin. His elevated troponin and CK
were felt to be secondary to demand ischemia in the setting of A
fib.
.
# LV function: Based on previous persantine MIBI, Mr. [**Known lastname 13972**]
has an EF of 35%. His fluid status was carefully monitored in
the setting of ESRD and low EF. He was placed on fluid
restriction.
.
Pneumonia/CHF
He presented with respiratory distress/CHF, likely secondary to
pulmonary edema
CXR consistent w/ pneumonia and perhaps some pulmonary edema. He
was treated with zosyn and vancomycin, and sputum culture showed
1 colony of MRSA which suggested a low burden of disease, adn
given his clinical improvement after hemodialysis with removal
of fluid, this pneumonia was not felt to be secondary to MRSA.
# Cellulitis
Had been treated with augmentin for LE cellulitis as outpatient,
now febrile with worsening cellulitis. Source may be cellulitis
vs. PNA vs HD line. His cellulitis was improving on vanc/zosyn,
and he was changed to augmentin. If he does resolve in the next
week, he can be considered for vancomycin with dialysis for 14
days to cover MRSA.
# ESRD - The renal team followed and assisted with
ultrafiltration for removal of fluid. His peritoneal dialysis
was discontinued and he was moved to three times weekly
dialysis. His other dialysis medications were continued and
antibiotics were renally dosed.
# DM2 - He was maintained on NPH with sliding scale insulin, and
his regimen was tailored slightly.
# Hypothyroidism: Continue levothyroxine. His TSH was slightly
elevated, but given his hospitalization and the possibility of
sick euthyroid his TFTs should be rechecked as an outpatient..
Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY.
2. Megestrol 20 mg Tablet Sig: One (1) Tablet PO QD
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QOD ().
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet, 1 Tablet PO QPM
9. Metoprolol Tartrate 50 mg Tablet, 1 tablet PO QAM
10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO QD
11. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
12. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
13. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
sprays to each nostril Nasal once a day as needed.
14. Niferex 60 mg Capsule Sig: Two (2) Capsule PO once a day: Do
not take with your levothyroxine.
15. Folic Acid Oral
16. Renagel Oral
17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
19. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Fourteen (14) units Subcutaneous qam.
20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Fourteen (14) units Subcutaneous at bedtime.
21. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: Per home insulin sliding scale.
22. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for pain.
23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily): may discontinue when cellulitis improved.
Disp:*30 Capsule(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed as dir Subcutaneous four times a day: 16 units in
morning, 8 in evening with sliding scale of humalog (see
attached scale or resume your previous scale).
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO QODHS (every
other day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
13. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): take after hemodialysis for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
to be followed by your PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] confirm dose before taking
on hemodialysis days.
Disp:*30 Tablet(s)* Refills:*2*
15. Hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours as needed for pain.
16. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
17. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
cellulitis
Congestive Heart Failure
Atrial fibrillation with rapid ventricular response and
myocardial strain
community aquired pneumonia
Secondary:
Coronary Artery Disease
Diabetes Mellitus
Peripheral vascular disease
End stage renal disease, on hemodialysis
Discharge Condition:
Good, off oxygen, felling well to go home
Discharge Instructions:
You were admitted to the hospital for congestive heart failure
and pneumonia. You had an abnormal heart rhythm called atrial
fibrillation that required some changes to your medications.
It is important you continue to take all of your medications as
prescribed. You were started on digoxin for your atrial
fibrillation, and doses of your other medications have been
changed.
Call Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **] or 911 if you experience
worsening shortness of breath, cough, fevers, chills, chest
pain, profuse sweating, severe leg pain or leg rash.
Check your weight daily and eat less than 2 grams salt daily.
Call your PCP if your weight increases by more than 5 pounds.
Followup Instructions:
Please follow up with your PCP [**Name9 (PRE) 3109**],[**Name9 (PRE) **] [**Telephone/Fax (1) 3110**] in
[**12-26**] weeks. They are aware that you are being discharged, and can
follow up your INR which will be drawn at dilaysis, with a goal
of [**1-27**]. He can also recheck your thyroid function tests in [**1-28**]
weeks.
Please follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4022**]. Call now for an
appointment in the next month.
Please follow up with Dr. [**First Name (STitle) 805**] at hemodialysis.
|
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icd9cm
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[
[
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icd9pcs
|
[
[
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315, 330
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4295, 6068
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,159
| 140,479
|
21118+57221
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-7-4**] Discharge Date: [**2177-7-16**]
Date of Birth: [**2120-11-27**] Sex: F
Service: VSU
CHIEF COMPLAINT: Extensive pelvic tumor and clot involving
the IVC and right atrium.
HISTORY OF PRESENT ILLNESS: This is a 56 year-old over the
last two to four weeks has noted progressive fatigue and "hay
fever" allergies. Twelve days ago she felt pressure at mid
chest that lasted three to four hours and she felt it was
more difficult to breath. This did resolve. On Monday her
breathing was more difficult. She saw her physician who felt
maybe it was secondary to anxiety. She had tests that
included liver function tests reported as abnormal. She went
to her primary care physician regarding the abnormal liver
function tests findings and he felt maybe it was secondary to
gallstones. Ultrasound was obtained on [**7-4**], which raised
the question of clot. The patient had a CT of the abdomen,
which revealed a pelvic mass with clot versus tumor, which
extended into the right atrium. She also noted additional
symptoms of "queasiness" in the bowel times one week. This
was felt from mild regurgitation, but no actual [**Month/Year (2) **] emesis
or diarrhea. The patient has been taking Tylenol for her
sinus and knee pain. One year ago she was noted to have
fibroids by ultrasound inconclusive though. She went to
[**Location (un) 47**] and had an MRI and was told that it was negative
at that time. The patient is now admitted for further care
and evaluation.
PAST MEDICAL HISTORY: Nasal polyps.
Asthma.
Pneumonia in childhood.
Bronchitis as a child.
Multiple seasonal allergies.
Sinusitis.
Hypertension.
Nasal septal surgery.
Status post dilatation and curettage.
Menopause at the age of 40.
HABITS: She is a pack per day plus smoker.
ALLERGIES: Aspirin causes anaphylaxis. Penicillin causes
anaphylaxis. Lorabid reaction unknown.
MEDICATIONS:
1. Tampramine.
2. Tylenol.
3. Vitamins.
4. Intravenous heparin.
SOCIAL HISTORY: She was born in [**Location (un) **]. She came to the
states in [**2158**]. She works as an accountant. She denies
alcohol use. No pets in the home.
FAMILY HISTORY: Positive for breast cancer mother at 51 and
grandfather cerebrovascular accident.
REVIEW OF SYMPTOMS: Significant for fatigue and otherwise is
unremarkable.
PHYSICAL EXAMINATION: Vital signs 157/68, 95, 14, 90 percent
02 sat on room air. General appearance the patient is a
white female in no acute distress. HEENT examination was
unremarkable. Chest examination lungs are clear to
auscultation bilaterally. Heart is a regular rate and rhythm
without murmurs, rubs or gallops. Abdominal examination
palpable mass in the lower abdomen, normoactive bowel sounds.
There is no tenderness. The spleen is not enlarged.
Extremities aer without edema. Neurologically she is intact.
LABORATORIES ON ADMISSION: White blood cell count 10.9,
hematocrit 42.1, platelets 247, BUN 17, creatinine 1.0, K
3.3. CTA of the pelvic vessels was negative for
embolization. CT of the abdomen was a pelvic mass with IVC
clot versus tumor, which extended to the right atrium. Liver
function test, ALT 330, AST 96, alkaline phosphatase 152,
total bilirubin was 0.9.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit. Intravenous heparinization was
continued. The patient was placed on bed rest. Cardiology
was consulted and echocardiogram was done. A CA 125 and CEA
were obtained. The patient's hypokalemia was treated. The
patient's initial echocardiogram demonstrated left
ventricular cavity size as normal. This was a suboptimal
quality. There was a focal wall motion abnormalities that
could not be fully excluded. The overall ventricular systolic
function is normal. The right ventricular chamber size and
free wall motion are normal. The aortic valve was not well
seen, but leaflets appeared normal in mobility. Mitral valve
leaflets are structurally normal. The mitral valve is not
seen well. No mitral regurgitation is seen. There is no
pericardial effusion. The right atrial mass could not
adequately be assessed by transesophageal echocardiogram.
There was a cystic mass in the IVC on the right atrial
junction consistent with probable neoplastic process.
Although thrombus could not be excluded, but because of the
complex nature of the mass it is suggestive of tumor. There
was normal biventricular systolic function. The patient
underwent transesophageal echocardiogram, which confirmed IVC
mass and extension into the right atrium. Cardiothoracic was
consulted regarding this patient. Cardiothoracic felt that
they could not make recommendations regarding the patient
secondary awaiting further imaging. Heme/Oncology was
consulted. The patient's CEA was 19.9. They recommended gyn
consult for endometrial biopsy and recommended MRI/MRA to
assess IVC. The MRV, which was done on [**7-8**] demonstrated
right gonadal vein was markedly extended secondary to
thrombus. The thrombus extends to the inferior vena cava and
fills the super renal IVC, intrahepatic IVC and extends into
the right atrium. The upper limit of the thrombus was not
visualized on this examination. This extends above the
abdomen. Correlation with recent CT confirms that the
thrombus does extend into the right atrium and gadolinium
enhanced images demonstrate marked contrast enhancement of
the thrombus in the atrial phase prior to arrival of venous
return to the inferior vena cava. The arterial phase images
demonstrated a normal appearance in the abdominal aorta,
iliac arteries and major aortic branches. Of note, there are
markedly hypertrophied arteries feeding the massive tumor in
the pelvis, which appeared to represent hypertrophied uterine
arteries right greater then left. The mass was not
specifically evaluated in this study. Initial CT of the
abdomen and pelvis demonstrate pelvic mass with tumor
thrombus extending into the right gonadal vein with extension
to the IVC at the level of the right atrial junction with
extension into the proximal left renal vein. There is mass
centered in the region of the uterus and likely represents a
malignant neoplasm. There are tiny punctate pulmonary
nodules, which are most prominent within the right middle
lobe. There is prominent retroperitoneal lymph nodes and a
simple hepatic cyst. The patient's CEA was less then 1,
normal range is 0 to 4. The CA 125 was 15, normal range 0 to
35.
Vascular Surgery was consulted regarding this patient and
extension of her tumor. After consultation with the involved
services, thoracic, vascular and gyn/oncology it was
determined that the patient undergo an abdominal exploration
and excision of mass. The patient was then stabilized and
was transferred to the regular medical nursing floor on
[**2177-7-8**]. The patient continued on her intravenous
heparinization. Heme/oncology continued to follow the
patient. Final recommendations will be made awaiting final
pathology. The patient underwent on [**2177-7-11**] total abdominal
hysterectomy with bilateral salpingo oophorectomy, resection
of the tumor from ovarian vein and IVC,k resection of
mesenteric lymph node. Intraoperative findings showed an
enlarged uterus about 20 week size (uterus) with bilateral
invasion of tumor into the ovaries and parenchyma. The right
gonadal vein and IVC were invaded with tumor. The patient
tolerated the procedure well and was transferred to the PACU
in stable condition. She was extubated. She remained
hemodynamically stable. She was then transferred to the
Vascular VICU for continued monitoring and care. On
postoperative day one there were no overnight events.
Analgesic medication was adjusted for improved analgesic
control. Her postoperative hematocrit was 32.9 with a total
white blood cell count of 18.1. Platelets 231, BUN 11,
creatinine 0.7. Dressings were with staining serous
drainage. The abdomen was soft, nondistended. There were no
bowel sounds. The patient required intravenous bolus for low
urinary output. She remained NPO. Perioperative Levaquin
was continued. Platelets were monitored. Venodynes for deep
venous thrombosis prophylaxis. On postoperative day two the
patient was agitated and self discontinued her A line. Her
pain control required conversion of a morphine sulfate PCA to
Dilaudid PCA. She had a temperature maximum of 100.7 to
100.2. Her lung examination was unremarkable. Her abdominal
examination wounds were clean, dry and she had 1 plus edema.
Her white blood cell count showed a downward trend of 16.7,
hematocrit 28.1 and platelets of 182. Lopressor was
increased to improve her rate control and her intravenous
fluids were decreased. She remained NPO and she was placed
on a regular insulin sliding scale for her hyperglycemia. By
postoperative number three the patient still was without
flatus, but her hematocrit drifted to 25.6. She was
transfused 2 units of packed red blood cells. Her white
blood cell count continued to show improvement at 14.1. BUN
and creatinine were stable. Lung examination was
unremarkable. Wounds were clean, dry and intact.
Intravenous fluid was converted to D5 and half at 50 an hour.
Ambulation to chair was begun and she was continued NPO.
Postoperative day four the patient passed flatus. Clear
liquids were instituted, ambulation was begun. Post
transfusion hematocrit was 28.4. The remaining hospital
course was unremarkable. The patient was discharged to home
in stable condition. The discharge summary will be continued
mom[**Name (NI) 11711**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17755**], [**MD Number(1) 17756**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2177-7-16**] 08:17:28
T: [**2177-7-16**] 09:15:35
Job#: [**Job Number 56027**]
Name: [**Known lastname 8774**], [**Known firstname 6360**] J Unit No: [**Numeric Identifier 10511**]
Admission Date: [**2177-7-4**] Discharge Date: [**2177-7-16**]
Date of Birth: [**2120-11-27**] Sex: F
Service: VSU
ADDENDUM:
DISCHARGE MEDICATIONS:
1. Acetaminophen, caffeine, butalbital 325/40/50 mg tablets 1-
2 q.[**4-22**] h. p.r.n. as needed.
2. Cetirizine HCl 10 mg q.d. p.r.n.
3. Metoprolol 50 mg b.i.d.
4. Colace 100 mg b.i.d.
5. Hydromorphone tablets [**1-17**] q.[**4-22**] h. p.r.n. for pain.
DISCHARGE DIAGNOSES: Leiomyoma uteri.
Inferior vena cava tumor thrombus with extension to the right
atrium.
Hypertension.
FOLLOW UP: The patient's followup is in 1 week with Dr.
[**Last Name (STitle) **]. The patient should call for an appointment at [**Telephone/Fax (1) 10512**]. The patient should also call Dr.[**Name (NI) 332**] office of
GYN Oncology for final pathology and further appointment as
needed at [**Telephone/Fax (1) 10513**].
[**First Name11 (Name Pattern1) 255**] [**Last Name (NamePattern4) **], [**MD Number(1) 5142**]
Dictated By:[**Last Name (NamePattern1) 5143**]
MEDQUIST36
D: [**2177-7-16**] 10:22:26
T: [**2177-7-16**] 11:02:31
Job#: [**Job Number 10514**]
|
[
"236.0",
"401.9",
"276.8",
"276.0",
"493.90",
"285.9",
"238.1",
"780.6",
"795.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.67",
"99.04",
"88.72",
"68.6",
"40.29",
"38.65",
"65.61",
"38.07"
] |
icd9pcs
|
[
[
[]
]
] |
2176, 2336
|
10412, 10514
|
10130, 10390
|
3249, 10107
|
10526, 11111
|
2359, 2874
|
154, 223
|
252, 1520
|
2889, 3231
|
1543, 1988
|
2005, 2159
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,197
| 129,746
|
26957
|
Discharge summary
|
report
|
Admission Date: [**2117-3-29**] Discharge Date: [**2117-4-25**]
Date of Birth: [**2042-10-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 38616**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
pericardiocenthesis
skin biopsy
bronchoscopy
History of Present Illness:
74 yo man with a recent diagnosis of MDS, now presenting with
SOB and found to have AML and cardiac tamponade.
Fatigue and shortness of breath have been progressive over the
last week of [**Month (only) 547**]. Initially thought to be due to anemia so he
was offered transfusion and refused this. His SOB continued to
worsen so he presented to clinic on [**3-29**]. His sx were so severe
that even mild activity, such as changing clothes, was
exhausting. He also admitted to chest pain which he described as
a racing heartbeat without pressure or sharp pain. There were no
associated sx of N/V, diaphoresis, or radiating pain but he did
have LE edema x past few weeks. In clinic, vitals were notable
for an oxygen saturation 97%-100%, HR 109, T 99 and he appeared
distressed. Labs significant for new WBC of 17, up from 1K one
week prior, with 80% other cells, concerning for leukemic
transformation of MDS. He was admitted to the BMT service. A TTE
was obtained which showed cardiac tamponade so he was taken for
drainage. 250cc bloody fluid was removed. There was a piece of
tissue-like material within the pericardial fluid as well which
was sent for pathology. Opening pressure was 10, after drainage
was negative. post-drain echo did not show fluid but showed
hyperdynamic septum. No right heart cath was done. Pt was
transferred to the CCU for monitoring s/p drainage and felt
well.
.
ROS: Positive per HPI and for 6 lb weight loss over 3 weeks,
urinary frequency. Also for R sided neck strain. Negative for
fevers, chills, NS, abdominal pain, N/V, diarrhea, black or
bloody stools, myalgias, arthralgias, dysurea, hematuria,
dizziness or syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- MDS diagnosed [**2117-2-26**]
- Hypertension
- Hyperlipidemia
Social History:
He works as a case worker in a Chinese senior Center next door
his lives. He currently lives with his wife who is a homeopathic
practitioner. He has two adult children. Has 50 pack year
smoking history. Denies use of alcohol or illicit drugs.
Family History:
No early CAD, cardiomyopathy, sudden death. Unremarkable for any
hematologic or malignant disorders.
Physical Exam:
ADMISSION PE:
VS: T=97.4, BP=113/55, HR=97, RR=23, sat= 97% RA
GENERAL: lying in bed, appears uncomfortable but not acutely so,
responding to questions. States he has "been fighting for my
life all day."
HEENT: NCAT. Sclera anicteric.
NECK: no kussmaul sign
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, + friction rub louder with inspiration and heard best
at 4-5th intercostal spaces in midclavicular line
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA in right lung and
at bases bilaterally, mild wheezing with expiration over left
anterior chest wall
ABDOMEN: Soft, distended, NT. No HSM or tenderness.
EXTREMITIES: No c/c/e. 2+ pulses in radial and DP bilat.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PE:
Expired
Pertinent Results:
Pertinent Labs:
[**2117-3-29**] 09:50AM BLOOD WBC-17.1*# RBC-2.30* Hgb-7.8* Hct-23.1*
MCV-100* MCH-34.1* MCHC-33.9 RDW-15.2 Plt Ct-105*
[**2117-3-29**] 09:50AM BLOOD Neuts-2* Bands-0 Lymphs-16* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* Blasts-0 Other-79*
[**2117-3-30**] 01:20AM BLOOD WBC-15.0* RBC-2.05* Hgb-6.7* Hct-20.7*
MCV-101* MCH-32.9* MCHC-32.5 RDW-15.1 Plt Ct-78*
[**2117-3-30**] 12:51PM BLOOD WBC-31.6*# RBC-2.94*# Hgb-9.9*#
Hct-29.4*# MCV-100* MCH-33.7* MCHC-33.6 RDW-16.6* Plt Ct-91*
[**2117-3-30**] 10:30PM BLOOD WBC-14.8*# RBC-2.65* Hgb-9.0* Hct-26.5*
MCV-100* MCH-34.2* MCHC-34.1 RDW-16.8* Plt Ct-81*
[**2117-3-31**] 05:56AM BLOOD WBC-18.7* RBC-2.59* Hgb-8.7* Hct-26.1*
MCV-101* MCH-33.4* MCHC-33.2 RDW-17.1* Plt Ct-67*
[**2117-3-29**] 05:05PM BLOOD PT-17.1* PTT-31.8 INR(PT)-1.6*
[**2117-3-30**] 01:20AM BLOOD PT-17.8* PTT-30.5 INR(PT)-1.7*
[**2117-3-30**] 12:51PM BLOOD PT-17.1* PTT-27.6 INR(PT)-1.6*
[**2117-3-30**] 10:30PM BLOOD PT-17.6* PTT-30.5 INR(PT)-1.7*
[**2117-3-31**] 05:56AM BLOOD PT-16.6* PTT-28.5 INR(PT)-1.6*
[**2117-3-31**] 05:56AM BLOOD Gran Ct-370*
[**2117-3-29**] 05:05PM BLOOD Glucose-184* UreaN-31* Creat-1.3* Na-135
K-3.5 Cl-104 HCO3-21* AnGap-14
[**2117-3-30**] 01:20AM BLOOD Glucose-133* UreaN-32* Creat-1.3* Na-139
K-3.5 Cl-106 HCO3-22 AnGap-15
[**2117-3-30**] 12:51PM BLOOD Glucose-130* UreaN-36* Creat-1.4* Na-134
K-4.2 Cl-103 HCO3-20* AnGap-15
[**2117-3-31**] 05:56AM BLOOD Glucose-118* UreaN-50* Creat-1.8* Na-136
K-4.0 Cl-105 HCO3-20* AnGap-15
[**2117-3-29**] 05:05PM BLOOD ALT-18 AST-18 LD(LDH)-978* CK(CPK)-208
AlkPhos-47 TotBili-0.4
[**2117-3-29**] 06:11PM BLOOD CK(CPK)-196
[**2117-3-30**] 12:51PM BLOOD ALT-17 AST-29 LD(LDH)-1695* AlkPhos-62
TotBili-0.7
[**2117-3-30**] 10:30PM BLOOD LD(LDH)-1540*
[**2117-3-31**] 05:56AM BLOOD ALT-14 AST-15 LD(LDH)-1221* AlkPhos-49
TotBili-0.5
[**2117-3-29**] 05:05PM BLOOD CK-MB-3 cTropnT-0.45*
[**2117-3-29**] 06:11PM BLOOD CK-MB-3 cTropnT-0.44*
[**2117-3-29**] 05:05PM BLOOD Albumin-3.4* Calcium-8.1* Phos-2.5*
Mg-2.0
[**2117-3-30**] 01:20AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.1
[**2117-3-30**] 12:51PM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.0 Mg-2.1
UricAcd-7.1* Iron-108
[**2117-3-30**] 10:30PM BLOOD Calcium-7.7* Phos-4.7*# UricAcd-7.8*
[**2117-3-31**] 05:56AM BLOOD Calcium-8.1* Phos-4.8* Mg-2.3
UricAcd-8.5*
URINE:
[**2117-3-30**] 12:52PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2117-3-30**] 12:52PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2117-3-30**] 12:52PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2117-3-30**] 12:52PM URINE CastGr-8* CastHy-3*
[**2117-3-30**] 12:52PM URINE Hours-RANDOM UreaN-1274 Creat-204 Na-11
K-59 Cl-18
[**2117-3-30**] 12:52PM URINE Osmolal-677
MARROW:
[**2117-3-30**] 08:33AM OTHER BODY FLUID WBC-1333* Hct,Fl-5* Polys-1*
Lymphs-8* Monos-0 Mesothe-3* Other-88*
STUDIES:
ECHO ([**2117-3-29**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
Right ventricular chamber size and free wall motion are normal.
There is abnormal septal motion/position. 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. No mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is a moderate sized pericardial effusion. The
effusion appears circumferential. There is brief right atrial
diastolic collapse. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
IMPRESSION: Moderate pericardial effusion with evidence of
elevated intrapericardial pressures. Normal biventricular
systolic function.
Cardiac Cath ([**2117-3-29**]):
COMMENTS:
1. Pericardiocentesis performed via subxyphoid approach using
blunt
tipped needle. Pericardial location confirmed using by echo
using
agitated saline. Initial pericardial pressure of 8 mmHg. We
removed
250cc of serosanguinous fluid and left drain in place. Post
pericardial
pressure of 0 mmHg. The patient tolerated the procedure well and
was
transferred to CCU in stable condition.
2. Successful pericardiocentesis.
FINAL DIAGNOSIS:
1. Moderate pericardial effusion with tamponade physiology by
echo.
2. Successful pericardiocentesis with removal of 250cc of fluid,
sent
for routine labs and cytology.
ECHO ([**2117-3-29**]):
Pre-tap:
Pericardicentesis catheter was confirmed to be in the
pericardial space with injection of agitated saline (clip [**Clip Number (Radiology) **]).
Post Tap:
Overall left ventricular systolic function is normal (LVEF>55%).
There is abnormal septal motion and residual variation in mitral
valve inflow suggestive of effusive-contrictive physiology.
There is no residual pericardial effusion.
IMPRESSION: Sucessful pericardiocentesis with no residual
pericardial effusion.
CXR ([**2117-3-29**]):
IMPRESSION: No evidence of acute infiltrates on single portable
chest view. Recommend completion to PA and lateral chest view
whenever situation permits.
ECHO ([**2117-3-30**]):
The left ventricular cavity is small. Left ventricular systolic
function is hyperdynamic (EF>75%). There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Trivial residual pericardial effusion. Small,
"underfilled" left ventricle with hyperdynamic systolic
function.
Compared with the prior study (images reviewed) of [**2117-3-29**], the
patient is more tachycardic, with smaller ventricular cavity.
Consider interim intravascular volume depletion.
CXR ([**2117-3-30**]):
IMPRESSION: Enlargement of the cardiac silhouette possibly
related to
pericardial effusion in the absence of significant pulmonary
congestion.
Confirmation echocardiogram is recommended.
[**2117-4-1**] Sinus rhythm. Diffuse non-specific ST-T wave
abnormalities most notable in the inferior leads. Compared to
tracing #2 T wave changes are slightly more marked, suggest
clinical correlation.
CT Chest [**2117-4-2**]
1. No pneumonia or other indication of intrathoracic infection.
2. Small posteriorly layering nonhemorrhagic left pleural
effusion and associated relaxation atelectasis.
3. Severe multi-chamber cardiomegaly. Small pericardial
effusion. No indication of tamponade.
4. Probable anemia.
5. Mild atherosclerotic coronary calcification.
6. Splenomegaly.
ECHO [**2117-4-2**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). The right ventricular
cavity is dilated with depressed free wall contractility. There
is abnormal septal motion/position. The tricuspid valve leaflets
are mildly thickened. Tricuspid regurgitation is present but
cannot be quantified. The pulmonary artery systolic pressure
could not be determined. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
LENI [**2117-4-1**] No evidence for deep vein thrombosis in bilateral
lower extremities.
RENAL US [**2117-4-1**]
1. No evidence of obstruction.
2. Left and right renal cysts.
3. Mildly echogenic kidneys indicating parenchymal disease.
3. Prostate is enlarged.
Immunophenotyping on Pericardial Fluid [**2117-3-30**]
Cell marker analysis demonstrates that the majority of the cells
isolated from this pericardial fluid express immature antigens
CD34, myeloid associated antigens CD13. They are negative for
CD10, (cALLa) and CD20.
Blast cells comprise 69% of total gated events.
Immunophenotypic findings consistent with involvement by:
Acute myelogenous leukemia (similar to that seen in bone
marrow/peripheral blood).
Immunophenotyping on Bone Marrow
B cells comprise 33% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens.
T cells express mature lineage antigens, and have a normal
helper-cytotoxic ratio of 1.1.
Cell marker analysis demonstrates that the majority of the cells
isolated from this peripheral blood/bone marrow express immature
antigens CD34, HLA-DR, CD117, myeloid associated antigens CD33,
CD13, CD15, CD11C (dim), CD71. There are negative for lymphoid
associated antigens CD19 (dim) TdT, CD10 (cALLa) negative, CD14,
CD41, CD56 and CD64.
Blast cells comprise 84% of total gated events.
Immunophenotypic findings consistent with involvement by:
Acute myelogenous leukemia; correlate with concurrent bone
marrow biopsy (S12-20349L).
Bone Marrow Karotyping [**2117-3-29**]
44,[**Last Name (LF) **],[**First Name3 (LF) **](2)(p21p23),[**Doctor First Name **](5)(q13q33),?add(16)(p13.1),-17,-18
[16]/46,XY[2]
Bone Marrow Aspirate and Core Biopsy [**2117-3-29**]
CELLULAR ERYTHROID DOMINANT BONE MARROW (BASED ON ASPIRATE
SMEAR) WITH TRILINEAGE DYSPOIESIS, CONSISTENT WITH
MYELODYSPLASTIC SYNDROME, BEST CLASSIFIED AS REFRACTORY
CYTOPENIA WITH MULTILINEAGE DYSPLASIA. PLEASE CORRELATE WITH
CLINICAL, CYTOGENETIC AND MOLECULAR FINDINGS.
US of Left UE [**2117-4-4**] Occlusive thrombus in the mid to distal
brachial vein near the PICC line insertion site.
[**2117-4-8**] Chest CT without contrast:
1. Multifocal pneumonia, most severe in the right perihilar
region.
Bilateral pleural effusions. In this immunocompromised patient,
the etiology may be bacterial or fungal.
2. Scattered pulmonary cysts and right apical scarring.
3. Cardiomegaly and anemia.
4. Splenomegaly; leukemic infiltration cannot be excluded.
[**2117-4-8**] CT sinus/mandible
Mild mucosal thickening involving the ethmoidal sinuses as well
as the left maxillary sinus with no evidence of an infectious
process.
[**2117-4-9**] TTE
The estimated right atrial pressure is 0-5 mmHg. Left
ventricular wall thicknesses and cavity size are normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular cavity is mildly dilated with moderate global
free wall hypokinesis. Tricuspid regurgitation is present but
cannot be quantified. There is a trivial to very small
pericardial effusion. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There are
no echocardiographic signs of tamponade.
IMPRESSION: Trivial to very small echodense pericardial effusion
without echocardiographic signs of tamponade. Mildly dilated
right ventricle with depressed systolic function. Hyperdynamic
left ventricular function.
Compared with the prior study (images reviewed) of [**2117-4-1**] and
[**2117-4-2**], the effusion appears echodense and decreased in size.
The right ventricle appears mildly decreased in size and
function appears mildly improved.
Left Upper Extremity Derm biopsy
Leukemia cutis, see note.
Note: The section shows papillary dermal edema, marked
extravasated red blood cells, and exuberant perivascular and
dermal mononuclear infiltrate. The perivascular cells are
atypical and contain large nuclei, conspicuous nucleoli,
irregular nuclear membranes, dark chromatin and have
eosinophilic cytoplasm. Occasional eosinophils are also noted.
The atypical perivascular cells are highlighted by CD34 and
CD117 (C-kit) immunostains. CD68 highlights occasional admixed
histiocytes. Given the above histomorphology and
immunophenotype, the findings are compatible with leukemia
cutis. PAS, tissue gram, and AFB stains are negative for
microorganisms. Multiple levels have been examined.
CXR [**2117-4-16**] There is again seen consolidation in the right upper
lobe consistent with pneumonia. This has improved slightly
since the prior study. However, there is a new left
retrocardiac opacity that has developed and a small left-sided
pleural effusion. Resolution of these opacities is recommended.
There is a right-sided PICC line whose distal tip is not
optimally seen; however, it is at least to the level of the
upper SVC.
[**2117-4-18**] 8:44 pm STOOL CONSISTENCY: SOFT Source: Stool.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Pending):
C. difficile DNA amplification assay (Final [**2117-4-19**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
Cryptosporidium/Giardia (DFA) (Pending):
__________________________________________________________
[**2117-4-17**] 2:21 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2117-4-17**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2117-4-17**]):
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
[**2117-4-16**] 12:45 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
[**2117-4-17**] 12:34 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
__________________________________________________________
[**2117-4-13**] 8:00 pm BLOOD CULTURE
**FINAL REPORT [**2117-4-19**]**
Blood Culture, Routine (Final [**2117-4-19**]): NO GROWTH.
__________________________________________________________
[**2117-4-13**] 4:59 pm BLOOD CULTURE Source: Line-PICC 1 OF 2.
**FINAL REPORT [**2117-4-19**]**
Blood Culture, Routine (Final [**2117-4-19**]): NO GROWTH.
__________________________________________________________
[**2117-4-13**] 7:00 pm TISSUE Site: SKIN Source: Skin biopsy.
GRAM STAIN (Final [**2117-4-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2117-4-16**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2117-4-19**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2117-4-14**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2117-4-14**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
[**2117-4-13**] 5:00 pm URINE Source: Catheter.
**FINAL REPORT [**2117-4-14**]**
URINE CULTURE (Final [**2117-4-14**]): NO GROWTH.
__________________________________________________________
[**2117-4-13**] 9:30 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2117-4-15**]**
Respiratory Viral Culture (Final [**2117-4-15**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2117-4-13**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
__________________________________________________________
[**2117-4-12**] 10:35 am Rapid Respiratory Viral Screen & Culture
**FINAL REPORT [**2117-4-14**]**
Respiratory Viral Culture (Final [**2117-4-14**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2117-4-12**]):
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 DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2117-4-12**] AT
15:11.
__________________________________________________________
[**2117-4-12**] 10:35 am BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2117-4-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2117-4-14**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2117-4-19**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2117-4-14**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2117-4-12**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2117-4-13**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2117-4-14**]):
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
__________________________________________________________
[**2117-4-12**] 10:36 am BRONCHIAL WASHINGS
GRAM STAIN (Final [**2117-4-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2117-4-14**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2117-4-19**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2117-4-14**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2117-4-12**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2117-4-13**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
[**2117-4-11**] 8:30 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2117-4-17**]**
Blood Culture, Routine (Final [**2117-4-17**]): NO GROWTH.
__________________________________________________________
[**2117-4-11**] 9:18 pm BLOOD CULTURE
**FINAL REPORT [**2117-4-17**]**
Blood Culture, Routine (Final [**2117-4-17**]): NO GROWTH.
__________________________________________________________
[**2117-4-11**] 12:43 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
ACID FAST SMEAR (Final [**2117-4-12**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
[**2117-4-10**] 2:42 pm SPUTUM Site: INDUCED Source: Induced.
GRAM STAIN (Final [**2117-4-10**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2117-4-10**]):
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final [**2117-4-12**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
[**2117-4-10**] 8:59 am SPUTUM Site: INDUCED Source: Induced.
GRAM STAIN (Final [**2117-4-10**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2117-4-10**]):
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final [**2117-4-12**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
__________________________________________________________
[**2117-4-9**] 4:15 pm BLOOD CULTURE
**FINAL REPORT [**2117-4-15**]**
Blood Culture, Routine (Final [**2117-4-15**]): NO GROWTH.
__________________________________________________________
[**2117-4-9**] 1:18 pm BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2117-4-15**]**
Blood Culture, Routine (Final [**2117-4-15**]): NO GROWTH.
__________________________________________________________
[**2117-4-8**] 5:40 pm BLOOD CULTURE
**FINAL REPORT [**2117-4-14**]**
Blood Culture, Routine (Final [**2117-4-14**]): NO GROWTH.
__________________________________________________________
[**2117-4-8**] 3:41 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2117-4-14**]**
Blood Culture, Routine (Final [**2117-4-14**]): NO GROWTH.
Brief Hospital Course:
74M with MDS transformed to AML, complicated clinical course
including multifocal pneumonia in the setting of neutropenia.
# Acute Myelogenous Leukemia: MDS transformed to AML. Patient
started on hydroxyurea. He was then initiated on daunorubicin
and ara-C, he had an anaphylactic reaction about 15 minutes into
the ara-C therapy, and a code blue was called, although no
compressions or intubation were performed. He was transferred to
the [**Hospital Unit Name 153**] and stabilized with supportive care, including
steroids, nebulizers, benadryl. The patient was then transferred
back to the floor and had decitabine therapy for 5 days, without
significant decrease in blast count. Allergy was consulted and
recommended a protocol for desensitization to ara-C, but it was
felt that the risks of this protocol outweighed the limited
benefit. He developed leukemia cutis. He was then started on
Mitoxantrone and Etoposide for one night. During this night, the
patient was significantly more tachypneic and appeared more
sick. A discussion with the family regarding the very limited
expected benefit and likely harm of ongoing chemotherapy
resulted in the decision to transfer to a more comfort-based
approach, in which no more chemotherapy, the patient was made
DNR/DNI but antibiotics were continued. Several days later, the
patient expressed a desire to be made CMO. Family was present
and agreed. He was placed on a morphine gtt and expired shortly
thereafter.
.
# Multifocal Pneumonia: The patient has multifocal pneumonia
seen on CT chest and subsequent CXRs are consistent with
progression of disease. He was broadened with worsening clinical
symptoms and chest x-rays to Vancomycin, Meropenem, Levofloxacin
and Ambisome, but his clinical status continued to worsen
despite these broad-spectrum antibiotics. He was evaluated for
TB with induced sputums, which were negative. BAL and bronchial
washings negative. He was made CMO and antibiotics were d/c'ed.
.
# Neutropenic Fever: Mr [**Known lastname **] continued to spike fevers despite
broad-spectrum antibiotics, as discussed above in multifocal
pna.
.
# Acute Kidney Failure: FeNa was consistent with intrinsic renal
failure. A possible etiology of his renal failure was his
leukemia.
.
# Early tamponade / pericardial effusion: The patient presented
to the CCU with fatigue, DOE. A TTE was obtained which showed
cardiac tamponade so he was taken for drainage. 250cc bloody
fluid was removed. Opening pressure was 10, after drainage was
negative. post-drain echo did not show fluid but showed
hyperdynamic septum. The pericardial drain was left in for less
than a day then removed. Interval (post-drain) echocardiograms
showed no reaccumulation of fluid in the pericardial space. The
patient remained hemodynamically stable, and was transferred to
the BMT service for further therapy of his AML. On HD5, his
pericardial fluid culture was positive for p.acnes. He was
already being covered with vancomycin at this time for
neutropenic fever, as discussed elsewhere.
.
# Lower Extremity Edema: Pt also appears to have mild diastolic
dysfunction.
.
# Pancytopenia: Secondary to AML and cytoreductive therapy. The
patient received multiple platelet and PRBC transfusions.
.
# Anaphylaxis to Cytarabine: resolved. He had acute worsening of
his baseline shortness of breath likely secondary to
bronchospasm after he received danorubicin and cytarabine
(likely cytarabine as the causative [**Doctor Last Name 360**]). Allergy recommended
a desensititization protocol, which was not used.
.
# Leukemia Cutis: confirmed on biopsy.
.
# RUE DVT: PICC associated and thrombocytopenia precludes
treatment, but high risk for infection so was monitored closely.
.
CHRONIC CARE
# HLD: restarted home atorvastatin 80 mg daily
.
TRANSITIONS OF CARE:
Expired
Medications on Admission:
atorvastatin 80 mg daily
vitamin D2
lisinopril 10 mg daily
aspirin 81 mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]
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61,051
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Discharge summary
|
report
|
Admission Date: [**2172-8-25**] Discharge Date: [**2172-9-6**]
Date of Birth: [**2114-3-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
dyspnea, hoarseness, and cough
Major Surgical or Invasive Procedure:
Bronchoscopy x2
Tracheal Y-stent placement [**2172-8-25**]
Pigtail catheter placement (right) [**2172-8-25**] for pleural effusion
Intubation [**2172-8-25**], re-intubated [**2172-8-26**] after attempted
extubation
Chest tube placement (right) [**2172-8-26**] for pneumothorax
Radiation therapy x2
Chemotherapy x3days
Lumbar puncture [**2172-9-3**]
History of Present Illness:
58 year-old female, 60 pack-year smoker, with dyspnea,
hoarseness, and cough x1 month admitted to [**Hospital1 18**] SICU [**2172-8-25**]
after found to have large mediastinal mass, today found to be
poorly-differentiated carcinoma, suspected small cell. On
initial evaluation, patient was found to have 3mm opening of
distal trachea secondary to external compression from
mediastinal mass, RUL mass, RUL collapse, and clinical findings
consistent with SVC sydrome. Y-stent was placed that evening, in
addition to Pigtail catheter for right-sided effusion. Patient
remained intubated following surgery, on paralytics due to
low-lying ET tube and small volume bleeding after endobronchial
biopsy. On [**2172-8-26**], extubated was attempted. Patient was
reintubated within 10 minutes due to neurological
unresponsiveness, hypoxia (O2 saturation 80s), and hemodynamic
instability. She was found to have a right pneumothorax, which
improved with subsequent placement of chest tube. Patient was
also noted to have pericardial effusion; given absence of
physiologic tamponade, cardiology decided against
pericardiocentesis.
.
Hospital course also complicated by hyponatremia on admission
(Na 118) attributed to SIADH and improved with fluid restriction
(Na 126). Also with hypotension (sBP 90s) following reintubation
on [**2172-8-26**]. Given hyperkalemia, hyponatremia adrenal
insufficiency was suspected; evaluated by endocrine team who
recommended stress dose steroids pending further evaluation of
etiology of hypotension. Also with non-anion gap metabolic
acidosis, transient hypothermia (T 95 [**2172-8-26**]) of unknown
etiology.
.
Per report, patient has done well today. She remains intubated,
on pressure support. Given the above pathology results, patient
is transferred to the medical ICU ([**Hospital Ward Name 332**]) for radiation
therapy.
.
On arrival to the [**Hospital 332**] medical ICU, patient is intubated,
sedated, and unable to provide history.
Past Medical History:
Hypertension
s/p cerebral sneurysm repair x3
GERD
Social History:
Per review of records, 60 pack-year history
Family History:
Unable to obtain.
Physical Exam:
On [**Hospital Unit Name 153**] admission [**2172-8-27**]:
96.0, 103, 120/68, 13, 97% [PS 14/5 50%]
General: Intubated, sedated, not responsive to verbal stimuli;
swelling of head, neck, and upper extremities; wasting of lower
extremities
Skin: Mottled at arms and superior to nipple line;
telangiectasias on chest wall
HEENT: Temporal wasting; pupils symmetric, minimal reactivity to
light; sclerae anicetric; scleral edema; dry mucous membranes
Neck: Large; unable to appreciate neck veins secondary to
swelling; right anterior chain palpable lymph node
Chest: Right chest tube, pigtail catheter in place
Lungs: Upper airway noise; by anterior ausculation, few
expiratory wheezes diffusely; breath sounds appreciable in all
lung fields
CV: Tachycardic; regular rhythm; pronounced S2 at apex; I/VI
early systolic murmur at left LLSB; unable to assess pulsus
paradoxus given quiet Korsakoff sounds
Abdomen: Hypoactive bowel sounds; soft, non-distended
GU: Foley
Ext: Right DP 1+, left DP appreciated with Doppler; no lower
extremity edema; upper extremity nonpitting edema
Pertinent Results:
On admission [**2172-8-26**]:
WBC-11.1* RBC-3.47* Hgb-10.9* Hct-31.9* MCV-92 MCH-31.5
MCHC-34.2 RDW-12.5 Plt Ct-393
Glucose-112* UreaN-9 Creat-0.8 Na-118* K-4.8 Cl-82* HCO3-24
AnGap-17
ALT-7 AST-21 LD(LDH)-584* AlkPhos-75 TotBili-0.2
Cortsol-25.7*
Hgb-13.5 calcHCT-41 O2 Sat-82
.
Imaging:
[**8-25**] CT Chest without contrast:
1. Large mediastinal mass causes narrowing of the right
pulmonary artery, superior vena cava, and trachea and occlusion
of the pulmonary artery supplying the right upper lobe in
addition to the right upper lobe bronchus. These findings are
most concerning for a primary lung carcinoma.
2. Right upper lobe collapse with nonenhancing lung parenchyma.
Tumor involvement cannot be excluded. Atelectasis of the right
lower and middle lobe.
3. Large right pleural effusion.
.
[**8-25**] Tracheal mass tissue pathology:
Immunohistochemical studies show that tumor cells are positively
stained by TTF-1 and CK7; they are negative for CK20,
chromogranin, and synaptophysin. The tumor shows areas of
necrosis, extensive apoptosis and focal lymphatic vascular
invasion; some areas the tumor cell size approaching that of a
small cell carcinoma, but much of the tumor has larger nuclei.
Overall, the tumor probably fits into the spectrum of a small
cell carcinoma of lung.
.
[**8-26**] Pleural fluid cytology:
Rare groups of epithelioid cells, too few to characterize
further. By immunohistochemistry: mesothelial cells stain for
calretinin and WT-1. Epithelial markers [**Last Name (un) **]-31, CEA, and B72.3
are negative. Rare cells are highlighted by TTF-1; however,
these cells are not cytologically atypical and may represent
non-specific reactivity.
.
[**8-26**] EKG: Sinus tachycardia. Low QRS voltage in limb leads. No
previous tracing available for comparison.
.
[**8-26**] Echo:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a small to moderate sized, primarily
anterior pericardial effusion without right ventricular
diastolic collapse. IMPRESSION: Suboptimal image quality.
Mild-moderate, primarily anterior pericardial effusion. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function.
If clinically indicated, a follow-up study is suggested.
.
[**8-27**] CT chest/abdomen/pelvis with and without contrast:
1. Vascular findings unchanged from [**2172-8-25**]. Narrowing of SVC
and left
brachiocephalic vein by large mediastinal mass. The SVC is
narrowed to
approximately 5 mm over a region extending 3 cm in craniocaudal
dimension.
Indirect evidence of right brachiocephalic vein occlusion,
likely complete. Unchanged narrowing of right pulmonary artery.
Splayed but patent aortic arch branches.
2. Interval decrease in large right pleural effusion, with small
anterior
pneumothorax. Right chest tube terminating at apex.
3. No interval change in large infiltrative hypoattenuating
right
hilar/mediastinal mass.
4. No evidence of metastases in the abdomen or pelvis. Slightly
bulky left
adrenal gland without discrete nodule or mass.
5. Anasarca and small amount of peritoneal fluid collecting in
the pelvis,
likely related to edema.
6. Interval tracheal stenting with improved caliber of airway.
.
[**2172-8-27**] ECHO: Compared with the prior study (images reviewed) of
[**2172-8-26**], the size of the pericardial effusion is unchanged
with no signs of tamponade. The left ventricle seems to be
underfilled.
.
[**8-28**] CT Head:
1. Within limits of this modality, no evidence of enhancing mass
or edema to suggest metastatic disease.
2. Status post bilateral frontal craniotomy and probable
aneurysm clipping
with encephalomalacic changes in the right frontotemporal and
left temporal lobes. No evidence of acute hemorrhage or infarct.
3. Probable chronic bifrontal subdural hygromas with minimal
mass effect on the subjacent frontal gyri; these may relate to
the extensive remote surgery
.
[**2172-9-2**] CT Head (performed due to worsened mental status):
1. Unchanged examination from recent exam of [**2172-8-28**].
2. Status post bilateral frontal craniotomies with aneurysm
clipping and
encephalomalcia, as described above. No evidence of acute
hemorrhage or
infarct.
.
[**2172-9-3**] Renal US:
1. Mildly echogenic kidneys consistent with medical renal
disease. There is no evidence of hydronephrosis, stone, or mass.
2. The left kidney remains atrophic and lobulated, similar to
[**2172-8-27**].
.
[**2172-9-4**] CT Chest w/o contrast (to evaluate tumor s/p XRT and
chemo for future XRT sessions):
1. Right anterior pneumothorax has resolved.
2. Mixed response of the tumor to radiotherapy with a decrease
of the central component of the tumor and a mixed response of
the peripheral tumor components:
3. The peripheral consolidations in the right upper lobe have
overall
decreased in size, however, a new cavitary lesion has formed
measuring 11 x 19 mm.
4. The peripheral consolidations in the right lower lobe and
left lower lobe have increased in size, number and density and
may be part of post-
obstructive, post-radiotherapy, post-infectious, or acute
inflammatory
changes.
5. Lymphangio-carcinomatosis in the right upper lobe.
6. There is new small right pleural effusion and increased
moderate left
pleural effusion.
7. Left adrenal gland mass is only partially visualized in this
study.
.
[**2172-9-3**] EEG: Markedly abnormal portable EEG due to the very
disorganized and slow background rhythms. This suggests a
widespread and moderately severe encephalopathy in both cortical
and subcortical structures. Medications, metabolic disturbances,
and infection are among the most common causes. Although there
were fleeting asymmetries, there was no reliable area of focal
slowing. Encephalopathies may obscure focal findings. There are
some sharp features, but no clearly epileptiform abnormalities
and no electrographic seizures.
.
[**2172-9-5**] LENI: no DVT
.
[**2172-9-5**] ECHO: final read pending
.
Micro:
[**2172-8-26**] Pleural fluid:
GRAM STAIN (Final [**2172-8-26**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2172-8-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2172-9-1**]): NO GROWTH.
ACID FAST SMEAR (Final [**2172-8-27**]): no AFB seen on direct smear
ACID FAST CULTURE (Preliminary): PENDING
Cytology: Atypical cells, non-specific findings
.
[**2172-9-4**] BAL:
GRAM STAIN (Final [**2172-9-4**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
.
[**2172-9-3**] CSF:
GRAM STAIN (Final [**2172-9-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
Cytology: no malignant cells
.
C. diff negative
.
[**8-30**] Blood Cx ?????? NGTD
[**9-5**] Blooc cx - pending
.
Bronchoscopy [**2172-9-4**]: lots of necrotic tissue noted, ETT tube
dislodged between stent and tracheal wall, repositioned during
bronch.
Brief Hospital Course:
[**Hospital Unit Name 153**] Course [**Date range (3) 84902**]
58F with likely small cell carcinoma complicated by SVC
syndrome, airway compromise requiring Y-stent, pericardial
effusion, resolved pleural effusion and pneumothorax, and
electrolytes disturbances admitted to [**Hospital Unit Name 153**] for radiation
decompression therapy and chemotherapy. Pt developed respiratory
failure and renal failure.
.
#. Hypoxic respiratory failure: Pt was initially transferred
from SICU to [**Hospital Unit Name 153**] on CPAP/PS. She developed increasing
respiratory failure and was changed to AC mode. In the [**Hospital Unit Name 153**],
she underwent XRT x2 and then chemotherapy for 3 days. Increased
hypoxia may have been due to pneumothorax, which resolved,
pleural effusions, atelectasis, possible VAP, tumor compression.
During hypoxic episodes, pt underwent bronchoscopy twice, both
times of which demonstrated the ETT lodged between tracheal wall
and stent. Pt's saturation improved with repositioning.
Respiratory status also complicated by possible underlying COPD
given smoking history with possible air stacking/trapping. Pt
was started on vancomycin, cefepime and ciprofloxacin (started
[**2172-8-31**] for 8 day course) for VAP. Vanco was later held as the
level was elevated in the setting of renal failure. Patient's
family decided to persue comfort only care on [**2172-9-6**], and she
was terminally extubated. Patient expired 15 minutes later from
respiratory failure and asystole secondary to lung cancer.
.
# Altered Mental Status: Pt had decline in mental status over
time. She initially withdrew from noxious stimuli but later was
less responsive. AMS continued despite sedation being off. AMS
most likely due to toxic metabolic syndrome in setting of uremia
and multi-system organ failure. Differential also included
seizure (given hx of cerebral aneurysm repair, on
anti-epileptics presumably prophylactically) although EEG did
not demonstrate focal abnormalities. LP did not demonstrate
infection or spread of malignancy. CT head [**2172-9-2**] negative for
acute process.
.
#. Small cell lung carcinoma: per pathology, the tumor probably
fits into the spectrum of a small cell carcinoma of lung. Given
associated SVC syndrome, prognosis poor. CT head/[**Last Name (un) 103**]/pelvis
negative for metastases. Pt underwent 3 days of chemotherapy
and 2 sessions of XRT. Initially, XRT was clinical emergency -
normal and pathologic tissue was likely treated; necrotic tissue
noted on bronchoscopy [**2172-9-4**]. Pt was to undergo formal tissue
planning session on [**2172-9-8**] to better delineate area of radiation
however family decided to persue comfort only care on [**2172-9-6**].
.
# Acute Renal failure: In setting of chemo with carboplatin.
Urine casts consistent with ATN. Uric acid and electrolytes
elevated 4-5d post chemotherapy concerning for tumor lysis
syndrome. The next therapeutic step was dialysis as patient
became oliguric despite volume overload but the family wished
for comfort only care given dismal prognosis of her lung cancer.
.
#. Metabolic acidosis: Originally thought to be non-gap
metabolic acidosis due to hypoaldosteronism and type IV RTA.
With low albumin, however, this is a gap metabolic acidosis,
most likely due to uremia. Unable to increase RR to compensate
due to concern for auto-peeping in setting of possible COPD.
Goal pH is 7.3-7.35. On [**2172-9-5**], pt's acidosis worsened with pH
7.16-7.18. Despite adjusting ETT placement and decreasing RR to
reduce auto-peep, pt's acidosis worsened. Bicarbonate was given.
.
# Tachycardia/Hypotension ?????? Pt with tachycardia to 140s and
episodes of hypotension to SBP low 80s. Pt with new A-fib on
telemetry and EKG. DDx includes possible enlarging pericardial
effusion/tamponade but pulsus paradoxus was normal and ECHO
[**2172-9-5**] was unchanged from prior. No pneumothorax seen on CXR.
Unable to assess for PE by CTA as pt in renal failure and VQ
would not be helpful in setting of other lung pathology. LENI's
negative for DVT. PE likely given malignancy and prolonged bed
rest but unable to do CTA given renal failure and VQ scan not
helpful in setting of lung changes. Even if it had been
positive, heme/onc recommended against anti-coagulation in
setting of possible tumor necrosis/hemorrhage. Pt remained
tachycardic to 130s despite numerous fluid boluses.
.
#. Electrolyte disturbances: Pt developed hypernatremia on
[**2172-9-4**] most likley due to dehydration with free water deficit
of 1.4L, started on D5W. Pt had hyponatremia and hyperkalemia on
admission, both resolved. Unclear etiology of electrolyte
disturbances on admission- hyponatremia thought to be secondary
to possible adrenal insufficency (now discarded) or possibly
SIADH. Low UNa does not exclude SIADH; renal recommended
rechecking urine lytes with saline load, whcih was not done in
setting of pt??????s other medical issues. Hyperkalemia originally
attributed to hypoaldosteronism and Type IV RTA, but unlikely
per endocrine because of low urine sodium.
.
#. SVC syndrome: Incomplete occlusion of SVC; near complete
occlusion of brachiocephalic veins. Clinically identified by
upper extremity and facial swelling/plethora and mottled skin.
Also with scleral edema. Unable to assess jugular venous
distension given considerable swelling. Seen in appoximately 10%
cases of SSLC. Improved edema on exam compared to admission. SVC
syndrome occurred after Y-stent placed. Possible that tumor
pushing into trachea shifted to compress SVC after stent
placement. She underwent radiation therapy and chemotherapy for
decompression.
.
#. Pleural effusion: s/p right pigtail catheter placement
[**2172-8-25**], removed [**2172-8-31**]. LDH effusion/serum 0.68 (exudate by
Light??????s criteria). Greatest concern for malignant effusion
however cytology was nonspecific. Cultures of fluid all
preliminary negative.
.
#. Pneumothorax: Developed pneumothorax in setting of
re-intubation that resolved after chest tube placement.
.
#. Pericardial effusion: Suspected by cardiology to be
malignant effusion. Felt not to be large enough for percutaneous
drainage. EKG without signs of electrical alternans but does
have low voltages. Repeat ECHO done [**2172-9-5**] in setting of
hypotension demonstrated no change in pericardial effusion.
.
# Sinus Pause on telemetry: Pt had episodes of sinus pauses on
tele night of [**8-30**] with turning to right side. Occurred again
[**2172-9-4**] again with re-positioning. Metoprolol was held and
glucagon given in case this was due to beta blocker toxicity,
but pauses decreased in frequency and duration on their own
without intervention. Cardiology consulted who felt it was
vagally mediated. [**Month (only) 116**] have been due to ETT tube displacement
pressing on carotid when pt was turned.
.
# Leukopenia/thrombocytopenia ?????? Most likely due to chemotherapy
and no improvement in counts on neupogen. She was repeatedly
pan-cultured with negative results.
.
#. Anemia: Normocytic and likely due to anemia of chronic
disease given malignancy. Hemolysis labs were negative.
.
# s/p cerebral aneurysm repair: History of cerebral aneurysm
repair with a number of chronic changes on head CT. Her
antiepileptic medications were continued.
Medications on Admission:
Home medications:
Metoprolol
Omeprazole
Levetiracetam
Carbatrol
Medications on transfer to [**Hospital Unit Name 153**] [**2172-8-27**]:
Furosemide 10 mg IV ONCE Duration: 1 Doses
Carbamazepine 900 mg PO QPM
Carbamazepine 400 mg PO QAM
Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes
Potassium Phosphate IV Sliding Scale
Insulin SC Sliding Scale
Insulin Regular 10 UNIT IV ONCE, Dextrose 50% 25 gm IV ONCE
Duration: 1 Doses 08/20 @ 0608
Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO moderate/heavy
sedation
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Hydrocortisone Na Succ. 100 mg IV Q8H
Nicotine Patch 14 mg TD DAILY
LeVETiracetam 500 mg IV BID
Magnesium Sulfate IV Sliding Scale
Calcium Gluconate IV Sliding Scale
Potassium Chloride IV Sliding Scale
Albuterol-Ipratropium [**1-10**] PUFF IH Q6H
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC TID
Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"530.81",
"305.1",
"287.4",
"458.29",
"997.31",
"253.6",
"519.19",
"583.89",
"288.03",
"459.2",
"276.2",
"E933.1",
"255.41",
"427.31",
"401.9",
"518.81",
"345.90",
"276.7",
"511.81",
"512.1",
"584.5",
"E878.1",
"427.81",
"285.22",
"162.3",
"780.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"88.72",
"33.24",
"92.29",
"96.05",
"96.6",
"96.72",
"33.23",
"99.25",
"96.04",
"99.04",
"31.44"
] |
icd9pcs
|
[
[
[]
]
] |
19800, 19809
|
11498, 13037
|
344, 694
|
19861, 19871
|
3966, 7785
|
19927, 20064
|
2839, 2858
|
19768, 19777
|
19830, 19840
|
18806, 18806
|
19895, 19904
|
2873, 3947
|
18824, 19745
|
10679, 10985
|
11050, 11181
|
11020, 11020
|
274, 306
|
722, 2688
|
7794, 10646
|
13052, 18780
|
2710, 2762
|
2778, 2823
|
11210, 11475
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,254
| 189,762
|
20555
|
Discharge summary
|
report
|
Admission Date: [**2191-10-17**] Discharge Date: [**2191-10-26**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Mr. [**Known lastname 51023**] is an 86 year-old gentleman who has dyspnea
symptoms fibrothorax. I performed pleural biopsy on [**2191-10-6**] and confirmed that this was a
benign condition.
Major Surgical or Invasive Procedure:
right thoracotomy decortication
History of Present Illness:
A pleural biopsy was performed on [**2191-10-6**] and confirmed
that this was a
benign condition. Pt was admitted for a right thoracotomy
decortication.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Peripheral vascular disease.
3. History of atrial fibrillation/flutter, on anticoagulation.
4. Sensorineural hearing loss.
5. Mild cognitive impairment.
6. Osteoporosis.
7. Peptic ulcer disease.
PAST SURGICAL HISTORY: Status post CABG x3 in [**2189**]. Status post
right carotid endarterectomy in [**2189**].
Social History:
The patient is a retired accountant. He is a widower; his wife
died a few weeks prior to this admission in a skilled nursing
facility.
Physical Exam:
General; well but thin appearing male in NAD looking younger
than stated years.
lungs: decreased on right base, clear on left.
COR: RRR S1, S2 (has hx of afib -was cardioveted on last
admission)
Abd: soft, NT, ND, +BS
extrem: no C/c/E
Neuro: A+OX3 vibrant.
Pertinent Results:
[**2191-10-17**] 03:31PM TYPE-ART PO2-135* PCO2-46* PH-7.36 TOTAL
CO2-27 BASE XS-0
[**2191-10-17**] 03:16PM GLUCOSE-132* UREA N-14 CREAT-0.8 SODIUM-141
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15
[**2191-10-17**] 03:16PM WBC-17.4*# RBC-3.39*# HGB-10.1* HCT-29.4*
MCV-87 MCH-29.9 MCHC-34.4 RDW-14.1
[**2191-10-17**] Pathology Tissue: PLEURA. [**2191-10-17**] [**Last Name (LF) 1533**],[**First Name3 (LF) 1532**]
P. Not Finalized
Brief Hospital Course:
Pt was admitted on [**2191-10-17**] and taken to the OR for a right
thoracotomy, decortication d/t fibrothorax from presumed CABG in
recent past.
Or course was uneventful and a 750cc blood loss was reported. he
was extubted on the post op night w/o difficulty.
Pt had an epidural for pain control and required a small amount
of neo to keep his MAP >60. On POD#1, pt went into afib (his
beta blocker had been held post op d/t hypotension). Cardiology
was consulted and he was successfully chemically converted with
ibutilide. He was then started on po amiodarone load. His BP
improved when his epidural was changed from bupivicane to
demerol and his lopressor was started.
His chest tubes were to sxn w/ almost continuous air leaks from
all 3 tubes.
Pt was progresing well; anticoag and diuresis were initiated
started and was transferred from the ICU on POD#3.
POD#4 epidural was d/c'd and pt was placed on PCA w/ good
control.
Chest tube was d/c'd on POD#5; 2 blakes remained in place to
water seal w/ air leak.
Remained in rate controlled afib/flutter. Placed back on home
med toprol XL and cont'd on amiodarone po load and coumadin.
POD#6 anterior [**Doctor Last Name **] clamped then removed after CXR w/o add'l
vol loss.
PCA d/c'd and pt's pain was well controlled on po pain med.
On POD#8 pt's remaining [**Doctor Last Name **] was placed to a Heimlick valve.
Pt wa d/c'd home on POD#9 after being cleared by physical
therapy for home PT.
Medications on Admission:
FLomax, Lisinopril 10', Lipitor 40', Protonix, Lopressor XL
100', home 02
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*120 Tablet(s)* Refills:*0*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Cilostazol 100 mg Tablet Sig: 0.5 Tablet PO bid ().
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: begin [**2191-10-26**] until [**2191-11-2**] .
Disp:*28 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Begin taking this medication dose on [**11-3**].
Disp:*30 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
right thoracotomy decortication
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office if you experience chest pain,
shortness of breath, fever, chills, redness or drainage from
your surgical incision.
Cover your chest tube site with a clean dressing every other
day.
No heavy lifting for 6 weeks. No showering, tub bathing or
swimming until chest tube is removed.
DO NOT cover or plug the (white)open side of the drainage
collection chamber.
Never remove the Heimlick valve from the chest tube.
You may unscrew the white cap to empty the draiange then
replace.
To check for a leak:
1. disconnect the drainage collection chamber from the Hemlick
valve.
2. place the Hemlick valve in a cup of water and cough. You want
to do this daily until you do not see bubbles int he water.
Have your INR checked on friday by the VNA and then your
regularly scheduled mondays in [**Location (un) 620**].
Take all new medications as directed.
Followup Instructions:
Call Dr.[**Name (NI) 54982**] office [**Telephone/Fax (1) 54983**] for a follow up
appointment in 10 days. Please call ahead of time to make the
appointment.
You will also need a CXR on that day before your
appointment-radiology [**Location (un) **] [**Hospital Ward Name 23**] Clinical Center.
Continue to have your INR checked regularly.
Make a follow up appointment with your primary care doctor.
Completed by:[**2191-11-9**]
|
[
"443.9",
"511.0",
"V45.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.51"
] |
icd9pcs
|
[
[
[]
]
] |
4868, 4917
|
1979, 3427
|
462, 496
|
4993, 5000
|
1510, 1956
|
5926, 6357
|
3551, 4845
|
4938, 4972
|
3453, 3528
|
5024, 5903
|
973, 1065
|
1233, 1491
|
232, 424
|
524, 678
|
722, 950
|
1081, 1218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,336
| 156,095
|
18841
|
Discharge summary
|
report
|
Admission Date: [**2191-9-14**] Discharge Date: [**2191-9-27**]
Date of Birth: Sex: F
Service: PLSUR
HISTORY OF PRESENT ILLNESS: The patient is a 19-year-old
female who was an unrestrained driver of a truck, which
rolled over and resulted in substantial multiple injuries in
[**8-13**]. She had, among other injuries, a degloving
significant tissue loss of the right thigh area. The patient
had necrotizing fasciitis and required debridement of this
area, which ultimately was closed with a skin graft. She is
coming into the hospital now to have a flap to recontour this
area.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2191-9-14**] where a TRAM flap was performed from the abdomen to
the right thigh. The procedure went very well and the
patient recovered uneventfully except for dehiscence of a
small area on the right posterior thigh. This resulted in an
open area that required skin grafting for closure. She was
ultimately taken back to the operating room on [**2191-9-22**] for
the skin graft, which was performed uneventfully. The skin
graft was noted to be doing well by [**2191-9-27**] and the patient
was discharged home.
DISCHARGE DIAGNOSIS: Status post flap to right thigh.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **] in
clinic in the next couple of weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10418**], [**MD Number(1) 18192**]
Dictated By:[**Last Name (NamePattern4) 27436**]
MEDQUIST36
D: [**2191-11-22**] 11:31:19
T: [**2191-11-22**] 20:27:45
Job#: [**Job Number **]
|
[
"V54.01",
"736.89",
"998.59",
"997.3",
"738.8",
"905.4",
"518.0",
"682.6",
"E929.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"77.65",
"93.56",
"86.69",
"54.72",
"38.93",
"78.69",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
1219, 1253
|
633, 1197
|
1265, 1638
|
162, 615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,675
| 170,865
|
27717
|
Discharge summary
|
report
|
Admission Date: [**2120-6-11**] Discharge Date: [**2120-6-20**]
Date of Birth: [**2062-8-28**] Sex: M
Service: MEDICINE
Allergies:
Cinnamon
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation/mechanical ventilation
Central venous line placement
History of Present Illness:
Mr. [**Known lastname 37081**] is a 57 yo man with metastatic colon cancer to the
lung and liver who was discharged from [**Hospital1 18**] on [**6-6**] for
respiratory distress/presumed pneumonia for which she was
treated with 14 days of vancomycin/levofloxacin. He was at a [**Hospital1 1501**]
for 1 week and was noted to have poor po intake with difficulty
swallowing. Yesterday his daughter was with him and noticed that
he choked on water and was in significant respiratory distress.
His daughter left and came back the next mornign when he seemed
to be near his baseline. He then took a sip of water and oral
morhphine which he visibly aspirated and was in severe distress
afterwards. This morning he was noted to be in increased
distress with a witnessed aspiration event. He was intubated on
arrival with a 74% sat on 100% NRB; VS HR 121 BP 101/59, RR 31,
T 98.9. He was given vancomycin, zosyn, and azithromycin for
abx. A CVL was placed, he was given 4L NS and and he was started
on levophed.
Past Medical History:
Hypertension
Metastatic colon CA: diagnosed in [**2118**] with wt loss and
abdominal pain; metastatic to lung and liver on presentation. He
underwent an exploratory laparotomy and diverting colostomy on
[**2118-7-14**]. After this, he began treatment on [**2118-9-16**] with
Avastin and Xeloda. He underwent six cycles of this. On
[**2119-6-28**], he was found to have innumerable pulmonary nodules
and increase in his right hilar mass and increase in the liver
metastases, as well as a new splenic lesion. A port was placed
on [**2119-7-28**], so that he would be able to undergo further
chemotherapy. He began cycle 1 of CAPOX on [**2119-8-11**]. He
progressed on CapeOx therapy was started on FLOX on [**2119-11-3**]. He
had evidence of progression on a CT dated [**2120-3-12**]. He was
started on FOLFIRI on [**2120-3-29**]. Last treatment on [**2120-5-3**]
Social History:
No ETOH
Quit smoking in [**2094**]
Family History:
Father - DM
Mother - Asthma, Ovarian Cancer
Physical Exam:
T AF BP 100/50 HR 108 RR 20 SaO2 95%
vent settings AC 60% 500x16 PEEP 5
levophed @ 0.12mcg/kg/min
General: cachectic AA man, intubed, sedated
HEENT: sclera icteric, edentulous
CV: tachy, RR no m/r/g. precordium hyperdynamic
Pulm: bronchial breath sounds
Abd: soft, non-distended very large liver, non-tender
Ext: trace BLE edema
Neuro: pupils reactive. moving all extremities on arrival
Pertinent Results:
Admission labs:
[**2120-6-11**] 01:14PM WBC-32.5*# RBC-3.70*# HGB-9.5* HCT-34.2*#
MCV-93 MCH-25.8* MCHC-27.9* RDW-22.2*
[**2120-6-11**] 01:14PM NEUTS-82* BANDS-4 LYMPHS-9* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-2*
[**2120-6-11**] 01:14PM PLT SMR-NORMAL PLT COUNT-371
[**2120-6-11**] 01:14PM GLUCOSE-75 UREA N-77* CREAT-2.7*# SODIUM-147*
POTASSIUM-6.2* CHLORIDE-108 TOTAL CO2-15* ANION GAP-30*
[**2120-6-11**] 01:14PM CALCIUM-8.4 PHOSPHATE-6.6*# MAGNESIUM-3.0*
[**2120-6-11**] 01:06PM PO2-104 PCO2-50* PH-7.18* TOTAL CO2-20* BASE
XS--9 COMMENTS-GREEN TOP
[**2120-6-11**] 01:06PM GLUCOSE-70 LACTATE-6.7* NA+-147 K+-5.8*
CL--110
[**2120-6-11**] 01:14PM PT-34.9* PTT-46.0* INR(PT)-3.7*
Brief Hospital Course:
57 yo man with metastatic colon cancer to lung and liver
presenting with respiratory failure and hypotension.
.
# Respiratory failure: This is more likely due to progressive
pulmonary metastases with possible aspiration component. He was
intubated and ventilated per ARDS net protocol. Bronchoscopy
had shown a mucus plug v. food particle but not much in way of
secretions. BAL cx grew oropharyngeal flora and yeast. He was
treated with 10 day course of vanc, zosyn, and levofloxacin.
.
# Shock: This is likely from septic shock and profound
dehydration. Pulmonary embolus is possible given his malignancy
but less likely given overall clinical picture. His INR is also
supratherapeutic. He was admitted with levophed and required
addition of vasopressin. He completed a 10 day course of abx as
above to cover aspiration pneumonia.
.
# Metabolic acidemia: This was from lactic acidosis and
hyperchloremic acidosis from NS fluid rescusitation. Pt was
treated with IVFs with bicarbonate.
.
# Acute renal failure: This worsened during his hospital stay.
Urine lytes, urine sediment were consistent with ATN. He was
initially aggressively fluid resuscitated and further IVFs were
held given his profound edema.
.
# Liver Failure: This is likely from replacement of liver by
tumor. Pt has decreased synthetic function with elevated INR but
received vitamin K anyhow. Ultrasound showed no portal vein
thrombosis.
.
# Coagulopathy: Again, this is likely from replacement of liver
by metastasis. DIC panel neg. Pt received vitamin K without
improvement.
.
# Metastatic colon cancer: Pt has end-stage disease and has
progressed through multiple regimens of chemotherapy. Dr.
[**Last Name (STitle) **]/[**Doctor Last Name **] of hematology/oncology followed his course.
.
# Coffee ground emesis: This occurred on admission, possibly [**3-2**]
esophagitis, gastritis, PUD, or mets. NG lavage showed clearing.
He was started on PPU. HCT was stable.
.
After a series of family meetings, the family understood the
gravity of the situation and agreed that resuscitation was not
indicated. Eventually, the family decided not to escalate care.
Pt became increasingly bradycardic then asystolic on [**2120-6-20**]
and expired. His daughter [**Name (NI) **] was at his side.
Medications on Admission:
1. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous DAILY (Daily) for 2 days.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
unit Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed.
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
11. Simethicone 80 mg Tablet, Chewable Sig: [**1-31**] Tablet,
Chewables PO QID (4 times a day) as needed.
12. Megestrol 400 mg/10 mL Suspension Sig: Eight Hundred (800)
mg PO DAILY (Daily).
13. Morphine Concentrate 20 mg/mL Solution Sig: 15-30 mg PO Q2H
(every 2 hours) as needed for pain.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic colon cancer
Respiratory failure
Septic shock
Metabolic acidosis
Acute renal failure
Liver failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"197.7",
"401.9",
"E928.9",
"038.9",
"578.0",
"507.0",
"V44.3",
"V15.82",
"153.9",
"276.51",
"518.81",
"286.7",
"584.5",
"995.92",
"197.0",
"E849.0",
"570",
"V70.7",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.24",
"33.22",
"96.04",
"38.93",
"00.17",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7134, 7143
|
3540, 5814
|
277, 342
|
7296, 7305
|
2799, 2799
|
7357, 7363
|
2330, 2376
|
7106, 7111
|
7164, 7275
|
5840, 7083
|
7329, 7334
|
2391, 2780
|
230, 239
|
370, 1375
|
2815, 3517
|
1397, 2261
|
2277, 2314
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,500
| 192,495
|
46741
|
Discharge summary
|
report
|
Admission Date: [**2108-7-9**] Discharge Date: [**2108-7-17**]
Date of Birth: [**2042-5-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
ETOH withdrawal
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Pt is a 66 year old man with PMHx sig. for ETOH abuse and
withdrawal seizures who presents with withdrawal symptoms. He
had a witnessed seizure by roommate early this AM. He was found
to be incontinent of urine and stool. He also had abrasions on
his knees bilaterally. His friend stated that he was drinking
last night. He arrived to the ED with tremors.
.
Per NH, the patient recently got some money and has been binge
drinking for several days. Pt had refused to go to the hospital.
Pt apparently fell overnight, felt to be due to a seizure.
.
In the ED, initial VS were: 100.9 164 (?ST) 171/97 20 97RA. Tmax
102.8. FSG was 259. Exam was sig. for talking "gibberish" and
shaking R arm. HR improved to 100s after 4L NS and lactate
improved from 6.4 to 3.2; banana bag is hanging. UOP was 2200.
Pt received valium 5 mg IV x2, 10 mg IV x1. Pt was subsequently
intubated for airway protection and pt was started on propofol
and versed. Labs were sig. for WBC 13.3, Cr of 2 (improved to
1.5 after IVFs). 1st set of CEs were neg. EKG showed ST. U/A
sig. for proteinuria and ketonuria. CXR showed no infiltrate. CT
head preliminarly negative. CT neck was also obtained. LP
results show 4 WBC, 23 RBC, protein 49, glucose 133. Pt was
given CTX and vanc.
Past Medical History:
1. Alcohol abuse with history of withdrawal seizures, last
seizure many years ago.
2. Hypertension
3. Depression
Social History:
Patient lives at [**Hospital1 **] Senior Living Communities. Per prior
SW note, pt's closest relative is his local sister. [**Name (NI) **] has been
drinking [**1-27**] pints of vodka per day for the last 40 years. He
smokes 1PPD x 50 years.
Family History:
noncontributory
Physical Exam:
VS: 101, 148/67, 86, 22, 99% on 4L NC
General: Thin elderly male in NAD, intubated
HEENT: Dry mucous membranes
Neck: in C-collar
Respiratory: CTAB, no crackles or wheezes
Cardiovascular: tachycardic, regular rhythm, no m/r/g
Abd: Normoactive bowel sounds, soft, nontender, liver tip ~[**2-28**]
finger breadths below costal margin
Ext: Thin, warm, no edema, 2+ pulses
Neuro: Unresponsive to verbal, tactile, and noxious stimuli off
propofol (but on versed)
Skin: no jaundice, spider angiomas, palmar erythema.
Pertinent Results:
LABS ON ADMISSION:
[**2108-7-9**] 07:00AM BLOOD WBC-13.3*# RBC-5.24# Hgb-15.5# Hct-50.5#
MCV-96 MCH-29.5 MCHC-30.6* RDW-15.2 Plt Ct-282
[**2108-7-9**] 07:00AM BLOOD Neuts-68.5 Lymphs-27.5 Monos-3.0 Eos-0.4
Baso-0.6
[**2108-7-9**] 07:00AM BLOOD PT-12.9 PTT-20.1* INR(PT)-1.1
[**2108-7-9**] 07:00AM BLOOD Glucose-231* UreaN-20 Creat-2.0* Na-139
K-8.1* Cl-91* HCO3-12* AnGap-44*
[**2108-7-9**] 09:00AM BLOOD ALT-43* AST-94* LD(LDH)-544* AlkPhos-75
TotBili-0.6
[**2108-7-9**] 07:00AM BLOOD cTropnT-<0.01
[**2108-7-9**] 09:00AM BLOOD Albumin-4.2 Calcium-7.9* Phos-2.4* Mg-2.4
[**2108-7-9**] 09:00AM BLOOD Osmolal-290
[**2108-7-9**] 07:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
URINE:
[**2108-7-9**] 07:25AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2108-7-9**] 07:25AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2108-7-9**] 07:25AM URINE RBC-0-2 WBC-0-2 Bacteri-0 Yeast-NONE
Epi-[**3-29**]
[**2108-7-9**] 07:25AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
CSF:
[**2108-7-9**] 09:15AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-23*
Polys-71 Lymphs-17 Monos-12
[**2108-7-9**] 09:15AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-33*
Polys-49 Lymphs-37 Monos-14
[**2108-7-9**] 09:15AM CEREBROSPINAL FLUID (CSF) TotProt-49*
Glucose-133
.
RADIOLOGY:
CT Neck:
IMPRESSION:
1. No acute fracture or malalignment. Multilevel degenerative
changes as
described above.
2. Centrilobular emphysema.
.
CT Head:
IMPRESSION: No acute intracranial process seen.
Brief Hospital Course:
66 yo M with PMHx sig. for ETOH abuse and withdrawal seizures
who presents with withdrawal symptoms.
.
# ETOH abuse, ongoing, with withdrawal: According to the
facility, the patient had been binge drinking recently (prior to
admission). Patient was suspected to have a seizure at the
facility. Pt was tremulous on arrive to ED with vitals signs
suggestive of withdrawal (tachycardia, hypertensive, febrile).
His serum ETOH level was 0. Serum/urine tox screen was
negative. Osmolar gap was 0. Pt was treated with valium per
CIWA scale. He received vitamin supplementation with thiamine,
folate, multivitamin.
.
Pt. was noted despite resolution of his withdrawal to have
evidence of wernicke's encephalopathy by inattentiveness,
amnesia, gait d/o and persistent nystagmus.
.
Given his gait d/o and unsafe ambulation, pt. was sent to the
[**Hospital **] hospital as no other safe discharge could be arranged.
.
# Acute mental status changes: This was most likely secondary to
etoh withdrawal. CT head neg. for acute pathology. LP results
were negative for meningitis. His mental status cleared after
he was off sedation and extubated to his likely baselin of a
mild chronic encephalopathy as above.
.
# Respiratory status: Pt was intubated for airway protection and
extubated within 24 hours. He was also treated for an
aspiration pneumonia with levo/flagyl.
.
# Acute renal failure: Initially, his Cr responded to IVFs,
going from 2.0 to 1.5. Later on, he had elevated CKs with a
mild rhabdo-like picture. He was treated with IVFs with
resolution.
.
# Depression: Pt was continued on fluoxetine.
.
# UTI - alpha strep. Foley d/c'd. Levofloxacin continued for
10 day course.
.
Communication: [**Name (NI) **] [**Name (NI) 25699**] (brother, [**Name (NI) 382**] [**Telephone/Fax (1) 99211**]
Medications on Admission:
Certagen tablets
Fluoxetine 20 mg daily
folic acid 1 mg daily
Mag oxide 800 mg [**Hospital1 **]
Vitamin B12 50 daily
Vitamin B1 100 mg daily
Vitamim D 800 units daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Chronic alcoholism with acute withdrawal complicated by:
seizure, rhabdomyolysis, acute renal failure
Likely wernicke's encephalopathy as manifest by all three
classic symptoms: gait disorder (ataxic), oculomotor dysfunction
(sustained rt sided nystagmus), encephalopathy as manifest by
inattention, flat affect, amnesia.
Urinary tract infection, alpha streptococcus
Discharge Condition:
AF and VSS, ambulatory with assistance with walker, tolerating
po intake and voiding without difficulty
Discharge Instructions:
Abstain from alcohol.
Followup Instructions:
With [**Hospital **] Hospital as arranged
Provider: [**Name10 (NameIs) 1947**] CLINIC (SB) Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2108-9-7**] 10:15
|
[
"303.01",
"599.0",
"728.88",
"584.9",
"311",
"349.82",
"291.81",
"041.01",
"780.39",
"265.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.04",
"96.71",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
6841, 6914
|
4216, 6020
|
329, 354
|
7327, 7433
|
2607, 2612
|
7503, 7664
|
2044, 2061
|
6238, 6818
|
6935, 7306
|
6046, 6215
|
7457, 7480
|
2076, 2588
|
274, 291
|
382, 1632
|
4144, 4193
|
2626, 4135
|
1654, 1769
|
1785, 2028
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,514
| 187,690
|
54810
|
Discharge summary
|
report
|
Admission Date: [**2125-5-14**] Discharge Date: [**2125-5-21**]
Date of Birth: [**2068-7-20**] Sex: F
Service: SURGERY
Allergies:
morphine / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
free air [**1-18**] jejunal perforation
Major Surgical or Invasive Procedure:
[**2125-5-14**]: Repair of perforated gastro-jejunal marginal ulcer
of RYGBP. Harvest of omental pedicle
History of Present Illness:
56F w/ hx of lap RYNGB done in [**2121**] at [**Hospital3 **]. Now
presents with history of abd pain that started last Saturday,
she was seen at an OSH were she had a negative x-ray she was
diagnosed with bowel gas and sent home. She continued to have
abdominal pain and low grade fevers. Hence she re-presented to
[**Hospital **] hospital were an upright KUB showed evidence of free
air.
Hence she was transferred here for further care.
Here she denied nausea, emesis, hematemesis,diarrhea or melana.
She c/o increasing abdominal pain of the last 4hours, but denied
any history of gastric ulcers or NSAIDS or ASA abuse. She denied
any SOB,CP, dizziness, seizure activities or hx of CAD.
Past Medical History:
Past Medical History:
ITP ( recent dx)
Obesity
Hypothyroidism
Past Surgical History:
Lap RYNGB
Lap cholecystectomy
Left Hip replacement
Medications:
Levothyroxine 50mcg
Steroid 30mg Qday on a taper ( recent steroid tx for ITP)
MV
Allergies:
Morphine and Sulfa
Social History:
Social History:
Lives with partner denies tobacco, EtOH or illicit drugs
Family History:
non-contributory
Physical Exam:
On admission
Physical Exam:
Vitals: temp hr 105 109/77 sat 100% RA
GEN: A&O, mild distress
HEENT: NCAT, scleral icterus, mucus membranes dry, op clear
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft,obese, nondistended, tender to palpation with rebound
tenderness, voluntary guarding.
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
Laboratory on admission:
Lactate 5.4
rest of lab Pending
Per OSH: 10>42.5<212, INR 1.04
140 101 14
-------------< 125 LFT: T.bili: 0.8 AST:36, ALT: 98 AP: 68
4.5 28 0.9
Imaging:
Upright KUB: Free air
[**2125-5-18**] UGI SGL W/O KUB:
No evidence of leak
Labs on discharge:
[**2125-5-21**] 05:44AM BLOOD WBC-18.8* RBC-3.54* Hgb-9.9* Hct-31.8*
MCV-90 MCH-28.1 MCHC-31.3 RDW-14.2 Plt Ct-142*
[**2125-5-21**] 05:44AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-140
K-3.5 Cl-107 HCO3-26 AnGap-11
[**2125-5-21**] 05:44AM BLOOD Calcium-7.3* Phos-2.1* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname 10684**] was taken emergently to the operating room from the
ED on [**2125-5-14**] for exploration for free air. She was
resuscitated prior to the OR with about 4L of crystalloid. In
the OR, a perforation was diagnosed near/just distal to the
gastrojejunostomy site (efferent limb of her gastric bypass). A
[**Location (un) **] patch was performed. She was extubated and taken to the
ICU for further monitoring and resuscitation.
Her post-operative course was uncomplicated. She was
transferred out of the ICU on POD 1 and remained hemodynamically
stable.
Neuro: Pain was well controlled on PRN IV dilaudid. This was
transitioned to PO dilaudid when tolerating PO's. She remained
without neurological issues.
CV: She had no acute cardiac issues. She was initially slighly
hypotensive postoperatively but stabilized with IV fluid
resuscitation within the first 24 hours.
Resp: Extubated post-operatively and weaned from nasal cannula.
No acute issues. Incentive spirometry and pulmonary toilet were
encouraged.
GI: She remained NPO with an NGT which was placed
intraoperatively at the GJ junction. On POD 1, she was started
on tube feeds through the NGT at 10 cc/hr.
The NGT was carefully advanced 5 cm to ensure it was distal to
the repaired [**Location (un) **] patch. Tube feeds were slowly advanced to
goal over then next 24 hours. On POD4 she had an upper GI with
SBFT study to assess for leak at the site of repair which was
negative for leak. Her diet was then advanced to a soft diet
which she tolerated well. On POD6 she began having episodes of
frequent loose stool and her WBC went up to 25.8 from 10
(However, this coincided with her restarting her PO prednisone
for ITP. A c. diff sample was sent and was negative. Her WBC
trended downward to 18.8 on POD7.
GU: She received a total of 11,000 ml of crystalloid in the
perioperative period. Her urine output was initially low (5 cc
of urine in the OR) but picked up to normal 20-30 cc/hr
thereafter. A foley was placed perioperatively and removed on
POD5 at which time she continued to void adequate amounts of
urine without difficulty.
Heme: Patient with a history of ITP. Her platelets were low at
133 on admission. They were monitored and trended downward as
low as 64 on [**5-17**]. Hematology was consulted at that time and IV
hydrocortisone taper was initiated until starting PO's. She was
then transitioned to the recommended dose of 30 mg of prednisone
daily when tolerating PO's. However, the patient declined the 30
mg but agreed to take 20 mg daily given the risks/side effects
of the medication. Her platelets were stable at 142 upon
discharge and she was instructed to follow up with her
outpatient hematologist and PCP upon discharge to discuss her
prednisone dosing and for continued monitoring of her platelets.
She showed no signs of bleeding.
ID: Started on zosyn/fluc empirically on admission. This was
continued until POD5. She then remained afebrile without any
active signs of infection. As noted above, her WBC count did
increase with starting prednisone, but she remained without any
other active signs of infection.
Musculosk: Physical therapy was consulted to evaluate her
mobility postoperatively. She was encouraged to mobilize out of
bed and ambulate as tolerated which she was able to do
independently by the day of discharge.
On [**5-21**] she is afebrile, hemodynamically stable and tolerating a
regular soft diet. Her pain is well controlled on an oral
regimen. She is being discharged home with instructions to
follow up with her PCP, [**Name10 (NameIs) 2536**] and her hematologist.
Medications on Admission:
Levothyroxine 50mcg
Steroid 30mg Qday on a taper
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Perforated hollow viscus. Perforation of marginal ulcer at
gastrojejunal anastomosis of the prior Roux-Y gastric bypass.
Secondary:
Idiopathic thrombocytopenic purpura
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a peforation in your
bowel. You were taken to the operating room and had the area of
perforation repaired. You are recovering well from the procedure
and are now being discharged home with the following
instructions:
It is recommended that you eat a soft diet until your follow up
appointment in clinic.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Name10 (NameIs) 5059**] at your next visit.
Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Please follow up with your outpatient hematologist in [**12-18**] weeks
to have your platelets checked and to discuss your prednisone
dosing.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2125-5-29**] at 4:00 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please call the office of your Primary Care Provider [**Last Name (NamePattern4) **].[**First Name4 (NamePattern1) 402**]
[**Last Name (NamePattern1) 25442**] when you get home and make a follow-up appointment
for 4-8 days after discharge. Their office number is
[**Telephone/Fax (1) 80429**].
Completed by:[**2125-5-21**]
|
[
"V58.65",
"V14.5",
"458.29",
"567.21",
"V85.23",
"287.31",
"V58.83",
"539.89",
"V65.3",
"V43.64",
"534.10",
"244.9",
"278.01",
"V14.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.42",
"38.93",
"54.74",
"46.79",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6811, 6817
|
2544, 6164
|
341, 449
|
7039, 7039
|
1965, 1976
|
12201, 13060
|
1559, 1577
|
6263, 6788
|
6838, 7018
|
6190, 6240
|
7190, 12178
|
1275, 1452
|
1620, 1946
|
262, 303
|
2247, 2521
|
477, 1168
|
1990, 2228
|
7054, 7166
|
1212, 1252
|
1484, 1543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,447
| 127,105
|
38346
|
Discharge summary
|
report
|
Admission Date: [**2164-6-17**] Discharge Date: [**2164-6-24**]
Date of Birth: [**2110-9-28**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy with [**First Name4 (NamePattern1) 27175**] [**Last Name (NamePattern1) **] of perforated D.U.
History of Present Illness:
53 F who presents as a transfer from [**Hospital3 1280**] Hospital with 24
hours of abdominal pain. Pain crampy and diffuse. Has worsened
throughout the day. No radiation. She was hypotensive at her
jail and at [**Hospital3 1280**] Hospital. CXR at [**Hospital3 1280**] shows gross
free intraperitoneal air. She denies fevers, chills, nausea,
vomiting, diarrhea, constipation, or any other symptoms. Last
bowel movement last evening. Of note, she has been taking 800 mg
of motrin TID for the past 2 weeks.
Past Medical History:
PMH: HIV, HCV, RLL lung cancer, asthma, anxiety PSH: RLL lung
cancer resection via VATS, L. adrenalectomy for ? metastatic
lung ca, laparoscopic cholecystectomy, appendectomy, R. shoulder
surgery
Social History:
SH: currently in jail; h/o IVDA (heroine and cocaine - last use
4
weeks ago); smokes [**1-15**] ppd x 40 years; h/o EtOH abuse but not in
many years
Family History:
n/c
Physical Exam:
On admission:
A&O x 3, uncomfortable, pale
RRR
Lungs CTAB, R. VATS scars all well healed
Abdomen soft, distended, hypoactive bowel sounds, tender
diffusely with voluntary guarding
L. flank scar well healed
LE warm, no edema
On discharge:
99.8 99.6 110 132/85 18 97%2L
Gen: AAOx3. NAD
Card: RRR
Pulm: Breath sounds present b/l.
Abd: Soft. NT.ND. Incision with lower pole with WTD dressing.
Upper poles c/d/i s/ drainage. LLQ site of former JP drain
without drainge.
Pertinent Results:
137 104 5
--------------<98
3.4 24 0.4
Ca: 7.4 Mg: 1.7 P: 2.0
[**2164-6-17**] 02:00AM URINE MUCOUS-MANY
[**2164-6-17**] 02:00AM URINE HYALINE-166* BROAD-4*
[**2164-6-17**] 02:00AM URINE RBC-1 WBC-43* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-1
[**2164-6-17**] 02:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
[**2164-6-17**] 02:00AM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2164-6-17**] 02:00AM PT-19.2* PTT-33.2 INR(PT)-1.7*
[**2164-6-17**] 02:00AM PLT SMR-NORMAL PLT COUNT-193
[**2164-6-17**] 02:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-3+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-2+
TEARDROP-1+
[**2164-6-17**] 02:00AM NEUTS-48* BANDS-38* LYMPHS-7* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2164-6-17**] 02:00AM WBC-8.2 RBC-5.01 HGB-14.5 HCT-42.6 MCV-85
MCH-28.9 MCHC-34.0 RDW-14.4
[**2164-6-17**] 02:00AM estGFR-Using this
[**2164-6-17**] 02:00AM GLUCOSE-108* UREA N-31* CREAT-2.2* SODIUM-137
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-18* ANION GAP-16
[**2164-6-17**] 02:30AM GLUCOSE-101 LACTATE-3.2* NA+-136 K+-3.3*
CL--107
[**2164-6-17**] 05:39AM freeCa-0.99*
[**2164-6-17**] 05:39AM HGB-10.5* calcHCT-32
[**2164-6-17**] 05:39AM GLUCOSE-126* LACTATE-3.3* NA+-133* K+-2.7*
CL--109
[**2164-6-17**] 05:39AM PO2-109* PCO2-44 PH-7.24* TOTAL CO2-20* BASE
XS--8
[**2164-6-17**] 05:39AM PO2-109* PCO2-44 PH-7.24* TOTAL CO2-20* BASE
XS--8
[**2164-6-17**] 05:39AM PO2-109* PCO2-44 PH-7.24* TOTAL CO2-20* BASE
XS--8
[**2164-6-17**] 06:58AM PT-22.0* PTT-40.4* INR(PT)-2.0*
[**2164-6-17**] 06:58AM PLT COUNT-128*
[**2164-6-17**] 06:58AM WBC-1.7*# RBC-4.33 HGB-12.7 HCT-37.1 MCV-86
MCH-29.3 MCHC-34.2 RDW-14.4
[**2164-6-17**] 06:58AM CALCIUM-7.9* PHOSPHATE-4.4 MAGNESIUM-5.8*
[**2164-6-17**] 06:58AM GLUCOSE-123* UREA N-25* CREAT-1.4* SODIUM-139
POTASSIUM-2.7* CHLORIDE-111* TOTAL CO2-20* ANION GAP-11
[**2164-6-17**] 07:10AM freeCa-1.26
[**2164-6-17**] 07:10AM LACTATE-2.9*
[**2164-6-17**] 07:10AM TYPE-ART TEMP-33.9 O2-50 PO2-77* PCO2-32*
PH-7.39 TOTAL CO2-20* BASE XS--4 INTUBATED-INTUBATED
[**2164-6-17**] 11:17AM TYPE-ART PO2-130* PCO2-30* PH-7.42 TOTAL
CO2-20* BASE XS--3
[**2164-6-17**] 11:30AM URINE OSMOLAL-402
[**2164-6-17**] 11:30AM URINE HOURS-RANDOM UREA N-342 CREAT-132
SODIUM-10 POTASSIUM-68 CHLORIDE-36
[**2164-6-17**] 02:10PM PT-21.9* PTT-37.7* INR(PT)-2.0*
[**2164-6-17**] 02:10PM PLT COUNT-179
[**2164-6-17**] 02:10PM WBC-2.5* RBC-4.29 HGB-12.7 HCT-36.4 MCV-85
MCH-29.5 MCHC-34.8 RDW-14.6
[**2164-6-17**] 02:10PM CALCIUM-6.7* PHOSPHATE-3.6 MAGNESIUM-4.4*
[**2164-6-17**] 02:10PM GLUCOSE-94 UREA N-24* CREAT-1.2* SODIUM-138
POTASSIUM-3.8 CHLORIDE-113* TOTAL CO2-18* ANION GAP-11
[**2164-6-17**] 02:14PM freeCa-1.09*
[**2164-6-17**] 02:14PM GLUCOSE-93 LACTATE-1.2
[**2164-6-17**] 02:14PM TYPE-ART PO2-118* PCO2-28* PH-7.45 TOTAL
CO2-20* BASE XS--2
[**2164-6-17**] 04:57PM TYPE-ART PO2-124* PCO2-31* PH-7.41 TOTAL
CO2-20* BASE XS--3
Brief Hospital Course:
Discharge Summary
The patient was admitted to the General Surgical Service for
evaluation and treatment. After a brief, uneventful stay in the
PACU, the patient arrived on the floor NPO, on IV fluids and
antibiotics, with a foley catheter. The patient was
hemodynamically stable.
Neuro: The patient received a dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient initially had increased upper airway
secretions due to which she would deasaturate especially when
sleeping. The patient was given nebulizers, including albuterol,
mucomyst, and atrovent which improved her symptoms
significantly. She therafter remained stable; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate. 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. The lower pole of the
wound was noted to have drainage. Several staples were removed
and the wound was packed with gauze, in a wet to dry manner,
which was well tolerated by the pateint. The patient was kept on
Cipro flagyl for a total of seven days. This was stopped prior
to discharge.
Endocrine: The patient's blood sugar was monitored throughout
here stay.
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; she was encouraged to
get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
benadryl 75', klonopin 0.5"', motrin 800"', robaxin 1500"',
Atripla 1 tab daily, methadone wean (? off), bentyl, xanax,
clonidine
Discharge Medications:
1. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 2 weeks.
Disp:*25 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 3 weeks.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation for 2 weeks.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation for 2 weeks.
7. Xanax 0.5 mg Tablet Oral
8. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed.
9. Benadryl 25 mg Capsule Sig: Three (3) Capsule PO once a day
as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
peforated duodenal ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-22**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
please follow up with Acute Care Surgery clinic in [**Hospital **] Medical
Building 3A by calling ([**Telephone/Fax (1) 2537**] in [**1-15**] weeks.
Completed by:[**2164-6-27**]
|
[
"V08",
"070.54",
"304.21",
"532.10",
"300.00",
"568.89",
"V10.11",
"304.01",
"305.1",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.42"
] |
icd9pcs
|
[
[
[]
]
] |
8312, 8327
|
4942, 7270
|
318, 438
|
8396, 8396
|
1889, 4919
|
10415, 10596
|
1377, 1382
|
7451, 8289
|
8348, 8375
|
7296, 7428
|
8547, 10005
|
10021, 10392
|
1397, 1397
|
1636, 1870
|
264, 280
|
466, 974
|
1411, 1622
|
8411, 8523
|
996, 1194
|
1210, 1361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
165
| 170,252
|
52762+59462
|
Discharge summary
|
report+addendum
|
Admission Date: [**2170-10-3**] Discharge Date: [**2170-10-5**]
Date of Birth: [**2084-4-9**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Penicillins / Ciprofloxacin Hcl / Warfarin / Cozaar /
Norvasc / Lisinopril / Rosuvastatin
Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 yo male h/o CAD, CHF, COPD presents with dyspnea. Reports
cough x3 weeks, denies hemoptysis. Noted dyspnea which awoke him
from sleep on the night prior to presentation. Patient denies
chest pain, fevers and chills. Patient endorses worsening
orthopnea over past month, previously slept with 1-2 pillows now
requires 3 pillows. Has additionally experienced PND. Has not
noted swelling of his lower extremities or increased weight. His
weight on admission of 154 is down from his most recent clinic
weight of 168. He has noted swelling of his abdomen starting on
the morning of admission. He reports this swelling was present
prior to presentation in the ED and states it is not a problem
he has previously experienced.
In ED patient's initial VS were T 98.6, HR 88, 154/96, Resp 22
98% RA, patient then experienced decompensation of his
respiratory status, desaturated to 92% on room air requiring
placement on BiPAP. Patient received a CXR which showed
increased vascular congestion and questionable pneumonia.
Patient received Azithro, ceftriaxone, nebs x3 and solumedrol.
On arrival to the MICU, patient was noted to be saturating well
on BiPAP, experienced increased shortness of breath when taken
off of BiPAP.
Past Medical History:
CAD: cath [**6-17**] w/ 90% LAD, 90% ramus intermedius lesions,
both stented w/ Cypher DES; OM1 w/ 50-60% lesion; repeat cath
[**9-17**] and [**3-23**] showed patent stents
- combined ischemic/non-ischemic cardiomyopathy: LVEF 30-40%
- CHF: 30-40%
- HTN
- Hypercholesterolemia
- CKD: baseline creat 1.7- 2.0
- GERD
- Cataracts: bilateral, not repaired
- Sleep apnea
- Lower back pain
- Osteoarthritis
- Hemorrhoid repair 20 years ago
- Hernia repair (epigastric, [**2161**]; inguinal [**2164-1-26**])
- BPH
- restless leg syndrome
Social History:
Patient works as a minister at this point. Denies EtOH and
illicit drug use. Quit smoking many years ago.
Family History:
+ for multiple siblings with heart disease. Sister with ESRD.
Physical Exam:
Admission Exam:
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: Normal S1 and S2 without murmurs/rubs/gallops
Peripheral Vascular: well perfused peripherall with pulses in
all extremities
Respiratory / Chest: symmetric expansion, crackles at bases,
mild wheezes
Abdominal: Distended, tense abdominal wall, no tenderness to
palpation, tympanitic to percussion
Extremities: no lower extremity edema
Skin: Warm
Neurologic: Responds to: Verbal stimuli, Movement: Purposeful,
Tone: Normal
Discharge Exam:
Tc 98.0 Tm 98.0 BP 120/75 HR 62 RR 18 O2 98%RA
General Appearance: Lying comfortably in bed, breathing easily
HEENT: PERRL, EOMI, MMM
Cardiovascular: Normal S1 and S2 without murmurs/rubs/gallops
Respiratory / Chest: Good air movement, crackles at bases, mild
wheezes
Abdominal: Distended, tense, soft, nontender. Hyperactive bowel
sounds.
Extremities: No appreciable lower extremity edema, warm,
peripheral pulses present bilaterally radial and pedal.
Pertinent Results:
Admission labs:
[**2170-10-3**] 11:20AM BLOOD WBC-8.3 RBC-4.72 Hgb-14.5 Hct-44.3 MCV-94
MCH-30.7 MCHC-32.7 RDW-13.4 Plt Ct-131*
[**2170-10-3**] 11:20AM BLOOD Neuts-80.9* Lymphs-11.0* Monos-4.8
Eos-2.8 Baso-0.5
[**2170-10-3**] 12:07PM BLOOD PT-10.7 PTT-26.5 INR(PT)-1.0
[**2170-10-3**] 11:20AM BLOOD Glucose-192* UreaN-34* Creat-1.9* Na-145
K-3.7 Cl-108 HCO3-28 AnGap-13
[**2170-10-3**] 11:20AM BLOOD proBNP-1275*
[**2170-10-3**] 11:20AM BLOOD cTropnT-<0.01
[**2170-10-3**] 07:31PM BLOOD cTropnT-<0.01
[**2170-10-3**] 07:29PM BLOOD Type-ART pO2-161* pCO2-48* pH-7.35
calTCO2-28 Base XS-0
[**2170-10-3**] 07:29PM BLOOD Lactate-2.6*
[**2170-10-3**] 05:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2170-10-3**] 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Micro:
Blood culture [**10-3**]- No growth
Urine cutlure [**10-3**]- No growth
Urine legionella antigen [**10-3**]- Negative
Imaging:
CXR [**10-3**] IMPRESSION: Findings suggesting mild vascular
congestion. In the appropriate clinical setting, atypical
pneumonia could also be considered. Also, although it is
difficult to exclude focal pneumonia at the lung bases, patchy
basilar opacities with low lung volumes could also be seen with
atelectasis.
Cardiac Echo [**2170-10-4**]
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is mildly depressed (LVEF=
35-40 %) with regional hypokinesis in basal-mid lateral
hypo/akinesis and apical hypokinesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. Moderate to severe (3+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2169-8-4**],
the wall motion abnormalities and overall ejection fraction are
similar. The degree of mitral regurgitation has increased but
was probably underestimated on the prior study.
IMPRESSION: Regional wall motion abnormalities in the inferior,
lateral and apical territories with reduced ejection fraction to
30-35%. Moderate to severe mitral regurgitation. Mild aortic
regurgitation.
CXR [**2170-10-4**]
COMPARISON: [**2170-10-3**].
FINDINGS: As compared to the previous radiograph, the lung
volumes have
minimally increased, likely reflecting improved ventilation.
Otherwise, the
radiograph is unchanged, including the pre-existing
mild-to-moderate
cardiomegaly. No pleural effusions are seen. No evidence of
pneumonia.
Discharge labs:
[**2170-10-5**] 09:00AM BLOOD WBC-12.2* RBC-4.70 Hgb-14.3 Hct-43.5
MCV-92 MCH-30.4 MCHC-32.8 RDW-13.5 Plt Ct-126*
[**2170-10-5**] 09:00AM BLOOD Glucose-127* UreaN-50* Creat-2.0* Na-143
K-4.3 Cl-100 HCO3-30 AnGap-17
[**2170-10-5**] 09:00AM BLOOD Calcium-8.6 Phos-3.0 Mg-3.2*
Brief Hospital Course:
MICU Course:
87 year old male with productive cough x3 weeks and new onset of
dyspnea on day prior to presentation who was admitted to the
MICU originally for BIPAP and quickly weaned off of it and
transferred to the medical [**Hospital1 **].
# Dyspnea: most likely represents CHF exacerbation in setting of
progressive orthopnea as well as contribution from concurrent
COPD exacerbation. Likely exacerbated by abdominal wall tension
with large amounts of bowel gas. ABG on bipap shows mild
respiratory acidosis. Patient has previous spirometry results
indicative of underlying restrictive pathology as well. His
respiratory status improved after diuresis and he was weaned off
fo Bipap and stable on NC and transferred to the medical [**Hospital1 **].
On the floor he continued saturate comfortably on room air. In
addition, he was placed on steroid burst and azithromycin x 5
days for COPD flare.
# CHF: Last echo [**7-/2169**] shows LVEF of 35-40%. Patient received
repeat echo on hospital day 2 with final report pending upon
call out from ICU. Patient was continued on home CHF medications
of Diovan, metoprolol and Lasix. Echo without marked interval
change, EF 30-35%.
# Abdominal distension: KUB shows diffuse bowel gas, no air
fluid levels or signs of obstruction. Abdominal exam currently
without tenderness or rebound, not concerning for acute abdomen.
Distension preceded Bipap initiation per the patient. Patient
endorses normal BMs and continues passing some gas per rectum.
Patient received Simethicone overnight with minimal improvement
in bowel gas, also received aggressive bowel regimen.
# CKD: Cr noted to be at high end of patient's baseline, trended
down.
Transitional Issues:
Medication Changes:
INCREASED prednisone to 40mg a day for [**10-6**] and [**10-7**], then
continue taking your home dose of 5mg daily
STARTED Azithromycin (last day [**10-7**])
STARTED Advair twice daily and STOPPED Flovent
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Acetaminophen w/Codeine [**2-12**] TAB PO Q6H:PRN Pain
2. Albuterol Inhaler [**2-12**] PUFF IH Q6H:PRN respiratory distress
3. Allopurinol 100 mg PO DAILY
4. Lorazepam 0.5 mg PO HS:PRN restless legs
5. Atorvastatin 20 mg PO DAILY
6. Calcitriol 0.25 mcg PO 1X/WEEK (TU)
7. ZYRtec *NF* 10 mg Oral daily
8. Clopidogrel 75 mg PO DAILY
9. Clotrimazole Cream 1 Appl TP [**Hospital1 **]
10. cycloSPORINE *NF* 0.05 % OU [**Hospital1 **]
11. Felodipine 5 mg PO DAILY
12. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
13. FoLIC Acid 1 mg PO DAILY
14. Furosemide 60 mg PO DAILY
15. Gabapentin 300 mg PO BID
16. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
17. Metoprolol Succinate XL 25 mg PO BID
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
19. Potassium Chloride 8 mEq PO DAILY Duration: 24 Hours
Hold for K >
20. PredniSONE 5 mg PO DAILY
21. Valsartan 320 mg PO DAILY
22. Aspirin 81 mg PO DAILY
23. Docusate Sodium 100 mg PO BID constipation
24. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Calcitriol 0.25 mcg PO 1X/WEEK (TU)
5. Clopidogrel 75 mg PO DAILY
6. Clotrimazole Cream 1 Appl TP [**Hospital1 **]
7. cycloSPORINE *NF* 0.05 % OU [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID constipation
9. Felodipine 5 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 60 mg PO DAILY
12. Gabapentin 300 mg PO BID
13. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO BID
15. Albuterol Inhaler [**2-12**] PUFF IH Q6H:PRN respiratory distress
16. ZYRtec *NF* 10 mg Oral daily
17. Potassium Chloride 8 mEq PO DAILY Duration: 24 Hours
Hold for K >
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
19. Multivitamins 1 TAB PO DAILY
20. Lorazepam 0.5 mg PO HS:PRN restless legs
21. Acetaminophen w/Codeine [**2-12**] TAB PO Q6H:PRN Pain
22. Azithromycin 250 mg PO Q24H Duration: 2 Days
last day [**10-7**]
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
23. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose 1
puff(s) inh twice a day Disp #*1 Unit Refills:*0
24. Simethicone 40-80 mg PO QID:PRN gas/bloating
RX *simethicone 80 mg 1 tab by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
25. Valsartan 320 mg PO DAILY
26. PredniSONE 40 mg PO DAILY Duration: 2 Days
after [**10-7**], resume 5mg daily
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Chronic obstructive pulmonary disease exacerbation
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 108821**],
It was a pleasure participating in your care at [**Hospital1 771**].
You were admitted to the hospital because you were short of
breath due to a flare up of your chronic obstructive pulmonary
disease. You were given inhalers and nebulizers, as well as
steroids and antibiotics that both reduce inflammation and
protect against potential infection.
Medication Changes:
INCREASED prednisone to 40mg a day for [**10-6**] and [**10-7**], then
continue taking your home dose of 5mg daily
STARTED Azithromycin (last day [**10-7**])
STARTED Advair twice daily and STOPPED Flovent
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2170-10-9**] at 12:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2170-10-17**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr None
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: FRIDAY [**2170-12-14**] at 9:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Known lastname 17823**],[**Known firstname **] Unit No: [**Numeric Identifier 17824**]
Admission Date: [**2170-10-3**] Discharge Date: [**2170-10-5**]
Date of Birth: [**2084-4-9**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Penicillins / Ciprofloxacin Hcl / Warfarin / Cozaar /
Norvasc / Lisinopril / Rosuvastatin
Attending:[**First Name3 (LF) 15534**]
Addendum:
Clarification: The patient had an acute exacerbation of his
chronic CHF. It is unlikely that he had pneumonia because he was
afebrile.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15535**] MD [**MD Number(2) 15536**]
Completed by:[**2170-11-29**]
|
[
"V58.65",
"585.3",
"414.01",
"V70.7",
"491.21",
"428.0",
"276.7",
"712.30",
"276.0",
"787.3",
"414.8",
"518.81",
"276.2",
"425.4",
"327.23",
"428.23",
"275.49",
"403.90",
"599.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13803, 14020
|
6600, 8283
|
368, 375
|
11374, 11374
|
3466, 3466
|
12195, 13780
|
2319, 2383
|
9672, 11199
|
11300, 11353
|
8556, 9649
|
11557, 11946
|
6302, 6577
|
2398, 2977
|
2993, 3447
|
8304, 8304
|
11966, 12172
|
321, 330
|
403, 1624
|
3482, 6285
|
11389, 11533
|
1647, 2180
|
2196, 2303
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,087
| 163,133
|
33766
|
Discharge summary
|
report
|
Admission Date: [**2136-5-17**] Discharge Date: [**2136-5-22**]
Date of Birth: [**2055-3-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Mitral regurgitation
Major Surgical or Invasive Procedure:
Mitral valve replacement(31mm St. [**Male First Name (un) 923**] tissue), closure of
patent foramne ovale, ligation of left atrial appendage [**2136-5-18**]
History of Present Illness:
This 81 year old white female has chronic diastolic heart
failure with progressive dyspnea. Prior workup has revealed
severe mitral regurgitation without coronary artery disease. She
as well has chronic, refractory atrial fibrillation with
associated pulmonary toxicity from Amiodarone therapy. She was
admitted for elective surgery.
Past Medical History:
chronic atrial fibrillation
hypothyroidism
s/p right total hip replacement
s/p bilateral cataract extractions
h/o multiple basal cell carcinomas
chronic renal insufficiency
probable pulmonary Amiodarone toxicity
hyperlipidemia
hypertension
chronic diastolic heart failure
Social History:
Race: Caucasian
Last Dental Exam: edentulous, upper /lower full dentures
Lives with: son
Occupation: retired insurance underwriter
Tobacco: 1ppd x 25 yrs, quit 30-35 yrs ago
ETOH: none
Family History:
Non contributory
Physical Exam:
Admission:
Pulse: 71 Resp: 16 O2 sat: 100%RA
B/P Right: 121/64 Left:
Height: 5'4" Weight: 132 Lbs
General:
Skin: Dry [x] intact [x] well healed scar s/p thyroid surgery
HEENT: PERRLA [] EOMI [x] right- RRL, left- sluggish s/p
cataract
[**Doctor First Name **].
Neck: Supple [x] Full ROM [x]
Chest: bilateral Exp.Wheezes
Heart: RRR [] Irregular [x] Murmur 3/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema/Varicosities:
trace pedal edema bilaterally, moderate varicosities
bilaterally,
early venous stasis changes bilateral
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit -none, pulses 2+ (B)
Pertinent Results:
[**2136-5-20**] 09:02PM BLOOD WBC-12.0* RBC-3.11* Hgb-9.6* Hct-29.0*
MCV-93 MCH-31.0 MCHC-33.2 RDW-15.0 Plt Ct-132*
[**2136-5-20**] 04:02AM BLOOD WBC-11.7* RBC-2.99* Hgb-9.6* Hct-27.5*
MCV-92 MCH-32.2* MCHC-35.0 RDW-15.6* Plt Ct-118*
[**2136-5-20**] 09:02PM BLOOD Glucose-105* UreaN-35* Creat-1.7* Na-132*
K-4.9 Cl-99 HCO3-25 AnGap-13
[**2136-5-20**] 04:02AM BLOOD Glucose-113* UreaN-36* Creat-1.5* Na-134
K-4.6 Cl-102 HCO3-22 AnGap-15
[**2136-5-17**] 10:30AM BLOOD Glucose-116* UreaN-50* Creat-1.5* Na-138
K-4.4 Cl-109* HCO3-21* AnGap-12
[**2136-5-17**] 05:15PM BLOOD ALT-11 AST-20 LD(LDH)-249 AlkPhos-142*
Amylase-107* TotBili-0.6
[**2136-5-17**] 10:30AM BLOOD ALT-7 AST-14 AlkPhos-129* Amylase-100
TotBili-0.7 DirBili-0.3 IndBili-0.4
Brief Hospital Course:
She was taken to the Operating Room on [**5-18**] where mitral valve
replacement, closure of an incidental patent foramen ovale and
ligation of the left atrial appendage was performed. She
tolerated the procedure well and weaned from bypass on Propofol
alone. She remained stable, was weaned from the ventilator and
extubated.
CTs and wires were removed per protocols and she was begun on
Carvedilol and diuresed. her renal function remained stable, she
was in electrical sinus rhythm. Coumadin was not given due to
her high fall risk and prior intolerance from bruising.
She continued to do well, Physical therapy worked with her for
mobility and strengthening. Wound were healing well and
surgical staples remained in place. She was placed on oral
diuretics for an indefinite period to be addressed as needed.
On POD 4 she was alert and oriented, vital signs were stable and
she was ready for rehab. Arrangements were made for followup,
including removal of skin staple on the sternal wound.
Medications on Admission:
Metoprolol tartrate 37.5 t.i.d., Cozaar 25
daily, Lasix 80 daily, digoxin 0.0625, EC ASA 81, potassium
chloride 20 mEq daily, Allopurinol 100 daily, Advair Diskus
250/50 1 puff b.i.d., L-thyroxine 25 mcg, Fosamax with D, ativan
0.5 HS prn
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days.
2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **]
Discharge Diagnosis:
Mitral regurgitation
patent foramne ovale
s/p mitral valve replacement,ligation of left atrial appendage
and closure of patent foramen ovale
paroxysmal atrial fibrillation
hypothyroidism
s/p right total hip replacement
s/p bilateral cataract extractions
h/o multiple basal cell carcinomas
chronic renal insufficiency
probable pulmonary Amiodarone toxicity
hyperlipidemia
hypertension
chronic diastolic heart failure
urinary tract infection
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with assistance,unsteady gait.
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema:
Discharge Instructions:
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.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**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:
Surgeon: Dr. [**Last Name (STitle) 914**],([**Telephone/Fax (1) 170**]) on [**2136-6-19**] at 1:45
[**Hospital Ward Name 121**] 6 wound clinic in 10 days- nurse will sch3edule appointment
for check and staple removal.
Please scedule appointments with:
primary Care: dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8446**] ([**Telephone/Fax (1) 17753**]) in 2 weeks
cardiologist: Dr. [**First Name8 (NamePattern2) 1026**] [**Name (STitle) 1016**] in [**2-22**] weeks
Completed by:[**2136-5-22**]
|
[
"272.4",
"585.9",
"745.5",
"V43.64",
"403.90",
"428.32",
"427.31",
"599.0",
"424.0",
"244.9",
"424.2",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.36",
"37.23",
"35.23",
"35.71",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5389, 5567
|
2977, 3980
|
297, 456
|
6051, 6300
|
2216, 2954
|
7157, 7673
|
1334, 1352
|
4270, 5366
|
5588, 6030
|
4006, 4247
|
6324, 7134
|
1367, 2197
|
237, 259
|
484, 819
|
841, 1115
|
1131, 1318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,135
| 140,488
|
38604
|
Discharge summary
|
report
|
Admission Date: [**2167-10-2**] Discharge Date: [**2167-10-13**]
Date of Birth: [**2089-4-28**] Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Morphine / Citalopram /
Thiazides
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
SOB, s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78M with history of CAD status post CABG, COPD, presenting after
falling off bed and being found down by neighbor this morning.
He hit his head but denies LOC. On arrival to ED by EMS, he
complained of some shortness of breath, but denieed chest pain,
cough, dysuria. He denies abdominal pain. Triggered on arrival
for tachypnea.
Initial vitals: T 99.4F, P 104, BP 135/86, RR 36, SpO2 95%4L
In the ED, CXR showed interstitial edema w/o consolidation. CBC
showed elevated white count w/ left shift. Chem7, LFTs wnl. Trop
negative. Pt improved w/ nebs. Given azithromycin 250mg and
prednisone 20mg. Pt was admitted to medicine.
Vitals prior to transfer: T 98.7F, P 97, BP 108/68, RR 16, SpO2
96%4L
Currently, the patiet has no pain. He reports recent worsening
dyspnea, indicating that he can only walk 1.5 blocks before
getting short of breath. He was unable to quantify his baseline
exercise capacity but was sure that his breathing is worse than
normal. The dyspnea is worse w/ ambulation. He endorses
epigastric pain has been ongoing for the past year and is not
recently worse. There is no radiation of pain to the shoulder or
jaw. He endorses yellow sputum production but denies it is worse
than baseline.
Over the past month, he reports vomiting food and liquids
whenever he takes them in by mouth. He is nauseated after
eating. His last BM was 4 days ago. He denies flatus over the
past 3 days. Other than the longstanding epigastric pain, he
denies abdominal pain.
He is also complaining of numbness in his hands, R>L. The
numbness is intermittent, in the palmar aspects of his fingers,
and worse w/ extension/abduction.
Reports urinary urgency for 1 year. Denies dysuria.
.
10 point ROS is otherwise negative
Past Medical History:
CAD s/p CABG '[**64**] (Coronary artery bypass grafting x4 with left
internal mammary artery to left anterior descending artery, and
reverse saphenous vein grafts to the distal right coronary
artery, obtuse marginal artery and diagonal artery.)
paroxysmal A. fib
HTN
Hyperlipidemia
Glucose intolerance
COPD
esophageal dysmotility/spasm - percutaneous enterojeujunal
placement
GERD
? BPH with urinary incontinence
depression/anxiety
Insomnia
Hepatitis C.
Anemia
B/L Hip pain - MRI LS-spine '[**65**] - DJD & Left L4-5 severe
foraminal stenosis
PAD showing ABI's
h/o EtOH
s/p hernia repair
s/p shoulder surgery
Social History:
Lives alone in [**Hospital3 **]. Divorced twice. 6 children in
[**Country 6607**]. Total of 30 years in prison. Released in [**2163**]. 120+ pack
years of smoking, quit 12 years ago. Reports is former
alcoholic.
Family History:
Father died of MI in his 60s. Brother #1 died of DM. Brother #2
died of lung cancer.
Physical Exam:
Admission physical exam:
VS - Temp 98.1F, BP 104/90, HR 93, R 20, O2-sat 91% 2L
GENERAL - NAD, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, irreg irreg, nl S1-S2, ii/vi systolic
cresc-decresc murmur at L/RUSB
LUNGS - poor air movement, barrel chest, crackles b/l worse at
right base, no wheezes, resp mildly labored
ABDOMEN - hypoactive bowel sounds, abd distended, tympanitic,
non-tender
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-25**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
.
Discharge PE:
Patient was CMO-no VS being taken other then RR which was in the
low 20's
Lungs-unchanged per above except for the fact the patients was
breathing comfortably
-exam otherwise unchanged
Pertinent Results:
Admission labs:
[**2167-10-2**] 11:11AM WBC-15.1*# RBC-5.01 HGB-15.3 HCT-44.6 MCV-89
MCH-30.5 MCHC-34.2 RDW-14.2
[**2167-10-2**] 11:11AM NEUTS-93.7* LYMPHS-3.2* MONOS-2.9 EOS-0.2
BASOS-0.1
[**2167-10-2**] 11:11AM PLT COUNT-195
[**2167-10-2**] 11:11AM ALBUMIN-4.2
[**2167-10-2**] 11:11AM proBNP-461
[**2167-10-2**] 11:11AM cTropnT-<0.01
[**2167-10-2**] 11:11AM LIPASE-14
[**2167-10-2**] 11:11AM ALT(SGPT)-28 AST(SGOT)-38 CK(CPK)-47 ALK
PHOS-78 TOT BILI-0.9
[**2167-10-2**] 11:11AM GLUCOSE-174* UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17
[**2167-10-2**] 11:16AM LACTATE-1.8
[**2167-10-2**] 10:00PM CK-MB-2 cTropnT-<0.01
[**2167-10-2**] Chest X-ray:
IMPRESSION: Increased interstitial markings in the lungs
bilaterally,
asymmetrically more so on the right than on the left. These
findings could be related to either pulmonary edema versus
atypical infection. Clinical correlation suggested.
[**2167-10-2**] Abdomen/pelvis X-ray:
IMPRESSION: No evidence of obstruction or perforation.
[**2167-10-5**] CTA
IMPRESSION:
1. No evidence of pulmonary embolism. Ascending thoracic aorta
is top normal in size without evidence of dissection.
2. On a background of COPD and pulmonary edema, there are
bilateral multifocal opacifications which may represent
infectious process and/or aspiration.
3. Significant esophageal dilatation, with retained fluid and
food contents. If this has not already been further assessed,
recommend evaluation.
4. Mediastinal, retroperitoneal, and mesenteric root
lymphadenopathy with 1.7 cm necrotic subcarinal lymph node.
Differential diagnosis for this is extensive, but does include
malignancy. Recommend further evaluation or correlation with
clinical history.
5. Nodularity of the bilateral adrenal glands. Attention on
followup.
.
Brief Hospital Course:
.
This is 78yoM h/o CAD and COPD now w/ 3 days of worsening
dyspnea in the setting of [**12-22**] months of daily post-prandial
vomiting in the setting of esophageal dysmotility. Patient was
found to have hypoxic on admission and was treated empirically
for COPD exacerbation with steroids and nebulizer treatments. On
HOD#3, patient developed acute desaturation requiring increased
oxygen. CTA was completed and ruled out PE however showed
bilateral diffuse airspace disease concerning for aspiration as
well as food compaction in the esophagus. Patient was
transferred to the ICU for further interventions and close
monitoring. While in MICU, discussion occurred regarding
patient's preferences and goals. Patient in the past has had G/J
tube for feeding because of esophageal dysmotility and it was
his desire to not pursue that option again. Additionally, it
order to reverse the underlying issue, he would have needed an
EGD which would have required intubation and patient was against
intubation. Given these goals, his care was reoriented around
comfort, which allowed him to eat. He understands that by
eating, he is at equisitely high risk for aspiration, which
could ultimately lead to death. He was started on pain
medications and ativan for anxiety. Given his stable picture, he
was transferred to a skilled nursing facility for hospice care.
.
Transitional Issues:
-Follow up per [**Hospital1 1501**], given goals of care are comfort, no specific
follow up at this time
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Zolpidem Tartrate 5 mg PO HS
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Senna 1 TAB PO BID:PRN constipation
7. Ezetimibe 10 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Fluoxetine 60 mg PO DAILY
13. Clonazepam 1 mg PO BID
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
2. Acetaminophen 650 mg PR Q6H:PRN pain/fever
3. Albuterol 0.083% Neb Soln 2 NEB IH Q4H wheezing, SOB
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Bisacodyl 10 mg PR DAILY constipation
6. Haloperidol 0.5 mg IM Q4H:PRN agitation, anxiety
7. Ipratropium Bromide Neb 2 NEB IH Q6H
8. Lidocaine Viscous 2% 10 mL PO QID:PRN mouth pain
9. Lorazepam 0.5-2 mg SL Q4H:PRN anxiety/agitation
RX *lorazepam 2 mg/mL 0.5-2.0 mg by mouth every four (4) hours
Disp #*50 Milliliter Refills:*0
10. Nicotine Patch 7 mg TD DAILY
11. Fentanyl Patch 37 mcg/h TP Q72H
RX *fentanyl 25 mcg/hour 1 patch q72h Disp #*10 Unit Refills:*0
RX *fentanyl 12 mcg/hour 1 patch q72h Disp #*10 Unit Refills:*0
12. Morphine Sulfate (Concentrated Oral Soln) 10-15 mg PO
Q2H:PRN pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 10-15 mg by
mouth q2h Disp #*300 Milliliter Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
Aspiration Pneumonitis
Esophageal Dysmotility
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after you had fallen and you
were found to have difficulty breathing. You required a stay in
the ICU because your oxygen levels dropped to you low. After
some investigation, we found out that food is not passing into
your stomach and as a result, you are choking on your food.
After a long discussion with you, it was decided to focus your
care on comfort. You are being discharged to a facility that
will help you with your symptoms.
Followup Instructions:
The doctors at your facility will follow up you there.
Completed by:[**2167-10-13**]
|
[
"427.31",
"507.0",
"070.54",
"E884.4",
"V45.81",
"272.4",
"530.5",
"780.52",
"401.9",
"V49.86",
"493.22",
"788.30",
"285.9",
"530.81",
"300.00",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8898, 8990
|
5883, 7240
|
348, 354
|
9080, 9080
|
4028, 4028
|
9751, 9838
|
2980, 3068
|
7959, 8875
|
9011, 9059
|
7395, 7936
|
9258, 9728
|
3108, 3809
|
7261, 7369
|
3823, 4009
|
295, 310
|
382, 2101
|
4044, 5860
|
9095, 9234
|
2123, 2734
|
2750, 2964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,600
| 122,142
|
12992
|
Discharge summary
|
report
|
Admission Date: [**2137-3-22**] Discharge Date: [**2137-4-1**]
Service: GYNECOLOGIC ONCOLOGY
HISTORY OF PRESENT ILLNESS: An 84-year-old G3, P2-0-1-2
presents with a one to two week history of abdominal
distention, nausea and diarrhea who was found to have ascites
at [**Hospital6 2561**] that was tapped and was found to be
positive for papillary adenocarcinoma. She was transferred
from [**Hospital3 **] and was planned for surgery on [**3-22**].
She initially presented at [**Hospital3 **] on the 5th with
bloating, decreased appetite in five days, without nausea or
abdominal pain. She also noticed some discomfort and loose
stools for about six days. There was no heme in the stool.
She noted increased fatigue, leg swelling. No chest pain,
shortness of breath. Initially at [**Hospital3 **], they noticed
anemia, hyponatremia and elevated liver function tests as
well as ascites. A CT revealed ascites with omental caking
and bilateral probable ovarian masses. Paracentesis on
[**2137-3-20**] revealed papillary adenocarcinoma. A gynecologic
oncology consult was obtained as the patient complained of
increased nausea and decreased bowel movement and was
transferred to [**Hospital3 **] for an operative procedure due to
her symptoms.
PAST MEDICAL HISTORY:
1. Mitral regurgitation
2. Hypertension
3. Paroxysmal atrial fibrillation
4. Left leg claudication
5. High cholesterol
6. History of Helicobacter pylori
7. Uterine prolapse
SURGICAL HISTORY:
1. Mitral valve repair in '[**31**]
2. Angiocath in '[**32**] for mild coronary artery disease
MEDICATIONS:
1. Tylenol 25 mg po q day
2. Lipitor 20 mg po q day
3. Hydrochlorothiazide 25 mg po q day
4. Zantac 150 mg po bid
5. Univasc 15 mg po q day
ALLERGIES: NONE
SOCIAL HISTORY: She lives alone in [**Hospital3 4634**]. Denies
drug use. She did smoke for about 10 years and she drinks
about a glass of wine a day.
GYNECOLOGIC HISTORY: No gynecologic infections, fibroids,
abnormal bleeding. She has a past history for prolapse.
OBSTETRIC HISTORY: Two normal spontaneous vaginal deliveries
and one stillbirth.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 95.0??????, 122/60, 98, 20.
HEAD, EARS, EYES, NOSE AND THROAT: Normal. Extraocular
muscles are intact. No lymphadenopathy.
GENERAL: In no apparent distress.
HEART: Regular.
LUNGS: Clear.
ABDOMEN: Soft, distended, grossly uncomfortable, no
localized tenderness.
EXTREMITIES: Within normal limits.
VAGINAL: Deferred.
LABS FROM OUTSIDE HOSPITAL: CA-125 of 15,510. White count
7.3, hematocrit 32.0, platelets 302. Sodium 127, potassium
5.1, chloride 93, bicarbonate 23.5, BUN 15, creatinine 1.2.
Calcium 8.3, albumin 3.6, total protein 4.2, total bilirubin
0.8, direct bilirubin 0.2, alkaline phosphatase 56, lipase
210.
IMAGING: CT showed multiple mediastinal lymph nodes, ascites
with omental caking. Right adnexa showed a 4.3 x 2.8 cm
tissue mass. There is a right pleural effusion, atrophic
left kidney.
ASSESSMENT AND PLAN: On admission, 84-year-old G3, P2-0-1-2
with ascites. CT consistent with omental caking and right
ovarian and CA-125 that was extremely elevated consisted with
ovarian cancer, here for exploratory laparotomy.
SUMMARY OF HOSPITAL COURSE: On [**2137-3-23**], the patient underwent
a total abdominal hysterectomy/bilateral
salpingo-oophorectomy, omentectomy and tumor debulking.
Findings including 3 liters of ascites, tumor throughout the
entire pelvis and abdomen. The transverse colon is entirely
enveloped in tumor of the omentum. The patient lost about
700 cc and she received 5000 cc of fluid and about 2 units of
packed red blood cells.
Postoperative, the patient had hypotension in the PACU, 70s
to 80s/30s to 40s of unclear etiology and she was requiring
pressors. An electrocardiogram was done that showed no
significant changes, however there was a significant right
bundle branch block in atrial fibrillation which was
unchanged. Her central venous pressure was 9 and it was felt
that she was going to be necessary to rule out MRI. She was
at this point transferred to the SICU on the [**Hospital Ward Name **] for
closer monitoring. The patient remained in the SICU over the
course of the next four days. She was able to be taken off
pressors by postoperative day #2. Her pulmonary status
remained tenuous, however and she required Albuterol and
Atrovent nebulizers.
By postoperative day #4, she was actually not requiring any
more pain medications. She was out of bed to a chair and her
she was maintaining her blood pressure without pressors and
was transferred to the [**Hospital Ward Name **] for further management.
By this point, the patient was significantly debilitated.
She was slowly able to start eating food and was able to get
out of bed and ambulate. PT and social work were consulted
here and the feeling was that she would be best taken care of
at a rehabilitation facility. On [**2136-4-1**] she was deemed
stable to be transferred to the rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Percocet 5 1 to 2 po q 4 to 6 hours prn
2. Motrin 600 mg po q6h prn
3. Atenolol 25 mg po q day
4. Lipitor 20 mg po q day
5. Hydrochlorothiazide 25 mg po q day
6. Zantac 150 mg po bid
7. Univasc 15 mg po q day
PLAN: The patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5166**].
DISCHARGE DIAGNOSES: As above and ovarian cancer, status
post total abdominal hysterectomy/bilateral
salpingo-oophorectomy debulking and omentectomy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26060**]
Dictated By:[**Name8 (MD) 39815**]
MEDQUIST36
D: [**2137-4-1**] 08:45
T: [**2137-4-1**] 09:09
JOB#: [**Job Number **]
|
[
"424.0",
"401.9",
"272.0",
"427.31",
"183.0",
"197.6",
"458.2",
"198.82",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"68.4",
"65.61",
"54.4"
] |
icd9pcs
|
[
[
[]
]
] |
5385, 5769
|
5028, 5363
|
2128, 3208
|
3237, 5005
|
134, 1262
|
1284, 1758
|
1775, 2113
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,657
| 157,390
|
53993
|
Discharge summary
|
report
|
Admission Date: [**2155-3-21**] Discharge Date: [**2155-4-12**]
Date of Birth: [**2108-1-7**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
status epilepticus
Major Surgical or Invasive Procedure:
intubation and extubation
History of Present Illness:
[**Known firstname 3403**] [**Known lastname 110699**] is a 47 year-old man with a history of severe
intellectual disabilty (non-verbal at baseline) who was
transferred from home to [**Hospital 8641**] Hospital in NH after reportedly
having whole body shaking (unknown duration). Records indicate
that he was given 1 mg of Ativan in addition to a load of
Fosphenytoin at 1200 PE x1. He continued to having shaking
movements and was intubated and sedated on propofol and
medflighted to [**Hospital1 18**]. In the ED off of propofol he continues to
have rhythmic shaking of his left arm more than the right.
Neurosurgery was consulted regarding his VP shunt and could not
palpate a reservoir. A shunt series was ordered, but CT from
outside showed a stable level of hydrocephalus from prior
images.
A stat portable EEG was done in the ED which showed frequent
rhythmic right fronto-temporal discharges. ED ordered Flagyl and
Levaquin in the ED - but these infusions were stopped prior to
administration. He was started on Vancomycin and ceftriaxone.
In the chart it indicates that he was most recently admitted to
[**Location (un) 8641**] with a pseudomonas UTI. He has no known history of
seizures and is not currently on any AEDs as per medical
records.
Past Medical History:
Severe intellectual disability - nonverbal, reportedly
understands when spoken to.
Hydrocephalus
? Stroke in [**2153**] - unknown details
Total colectomy and end ileostomy
Scoliosis
Osteoarthritis
Anemia
Endocardial cushion defect
Hypogonadism
Vitiligo
Hiatal Hernia
GERD
Chronic UTIs
Narcolepsy
Polydipsia
MRSA infections
Social History:
Lives with his [**Doctor Last Name **] mother. Nonverbal at baseline. Able to
walk
short distances to wheelchair.
Family History:
unknown and unable to obtain
Physical Exam:
At admission:
Vitals: 98.3 P 72 BP 134/82 R 16 SpO2 100%
General: intubated and sedated wi rhythmic movement of left arm
off sedation
HEENT: macrocephalic, patchy discoloration of hair
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: colostomy bag, soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: some movements of head and grimacing to sternal
rub
-Cranial Nerves:
pupils 2 - 1.5 b/l, + Doll's eyes, + corneals, + gag
-Motor: rhythmic movements of the left arm off of propofol. Some
spontaneous movement of the right arm. Wasting of LE b/l with
increased flexor tone.
-Sensory: some withdrawal to pinch on the right, no withdrawal
on
the left.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: unable to test
-Gait: unable to test
At transfer out of NeuroICU:
Doesn't react well with male examiners (hx of trauma by males in
past), macrocephaly/dysmorphic facial features. Eyes spon open,
track occasionally, dysconjugate gaze, nonverbal and does not
follow commands. moves b/l arms and feet spontaneously, resists
passive leg movement (appear spastic, may be realted to trauma
hx) but pt is able to move legs voluntarily, bilateral hands
also spastic.
AT DISPO:
Vitals: 98.2, 106/59, 60, 19, 93% on RA
General: sitting in bed in NAD
HEENT: macrocephalic, patchy discoloration of hair
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: colostomy bag, soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: tracks examiner, smiles, follows some commands
-Cranial Nerves: pupils 2 - 1.5 b/l, EOMI, face baseline
asymetrical with missing teeth bilaterally
-Motor: MAEE, hands appear spastic
-Sensory: intact to tickle on feet and hands
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: reaches for examiner bilaterally
-Gait: unable to test
Pertinent Results:
[**2155-3-21**] 02:35PM BLOOD WBC-7.4 RBC-3.88* Hgb-12.0* Hct-40.0
MCV-103* MCH-30.8 MCHC-29.9* RDW-14.6 Plt Ct-220
[**2155-3-21**] 02:35PM BLOOD Neuts-86.7* Lymphs-7.8* Monos-4.5 Eos-0.9
Baso-0.1
[**2155-3-21**] 02:35PM BLOOD Plt Ct-220
[**2155-3-21**] 11:29PM BLOOD Glucose-86 UreaN-18 Creat-0.6 Na-142
K-3.7 Cl-103 HCO3-37* AnGap-6*
[**2155-3-22**] 04:16AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-139
K-4.3 Cl-102 HCO3-29 AnGap-12
[**2155-3-21**] 02:35PM BLOOD ALT-29 AST-37 AlkPhos-110 TotBili-0.2
[**2155-3-21**] 02:35PM BLOOD Lipase-28
[**2155-3-21**] 02:51PM BLOOD cTropnT-<0.01
[**2155-3-21**] 02:35PM BLOOD Albumin-3.8 Calcium-9.4 Phos-2.2* Mg-1.8
[**2155-3-29**] 01:53AM BLOOD 25VitD-22*
[**2155-3-26**] 06:20AM BLOOD Vanco-19.1
[**2155-3-22**] 04:16AM BLOOD Phenyto-12.0
[**2155-3-31**] 03:51AM BLOOD Phenyto-4.4*
[**2155-3-21**] 02:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-3-21**] 02:47PM BLOOD Type-ART PEEP-5 pO2-39* pCO2-59* pH-7.42
calTCO2-40* Base XS-10 -ASSIST/CON Intubat-INTUBATED
[**2155-3-22**] 04:57AM BLOOD Type-ART Rates-14/0 Tidal V-500 PEEP-5
FiO2-50 pO2-81* pCO2-44 pH-7.48* calTCO2-34* Base XS-8
Intubat-INTUBATED
[**2155-4-2**] 09:23AM BLOOD Type-ART Temp-36.5 O2 Flow-2 pO2-58*
pCO2-56* pH-7.46* calTCO2-41* Base XS-13 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2155-3-21**] 02:47PM BLOOD Lactate-2.9*
[**2155-3-23**] 02:07AM BLOOD freeCa-1.20
[**2155-3-21**] 02:35PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2155-3-21**] 02:35PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
[**2155-3-21**] 02:35PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
[**2155-3-21**] 02:35PM URINE RBC-2 WBC-119* Bacteri-FEW Yeast-NONE
Epi-0
[**2155-3-29**] 11:46AM URINE CastHy-10*
[**2155-4-2**] 02:44AM URINE Hours-RANDOM Creat-46 Na-143 K-38 Cl-121
[**2155-4-2**] 02:44AM URINE Osmolal-479
[**2155-3-21**] 02:35PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2155-3-21**] 2:35 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2155-3-23**]**
URINE CULTURE (Final [**2155-3-23**]):
MORGANELLA MORGANII. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORGANELLA MORGANII
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2155-3-21**] 7:30 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2155-3-23**]**
MRSA SCREEN (Final [**2155-3-23**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2155-3-23**] 4:47 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2155-3-29**]**
GRAM STAIN (Final [**2155-3-23**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2155-3-29**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
VANCOMYCIN Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2155-3-25**] 12:50 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2155-3-27**]**
GRAM STAIN (Final [**2155-3-25**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2155-3-27**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 344-8753W ON
[**2155-3-23**].
[**2155-3-29**] 11:46 am URINE Source: Catheter.
**FINAL REPORT [**2155-3-31**]**
URINE CULTURE (Final [**2155-3-31**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
EEG LTM: [**Date range (1) 110700**]
[**3-21**]:
FINDINGS:
ABNORMALITY #1: This 30 minute recording, the primary background
was
low, at about 7 Hz posteriorly. There was also a superimposition
of
widespread faster activity. There were a few bursts of
generalized
slowing.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal EEG due to a mild slowing of the background
posteriorly, indicating a widespread encephalopathy. There were
also
widespread faster rhythms, suggesting medication effect. There
were no
prominent focal abnormalities but encephalopathies and
medications may
obscure such findings. There were no clearly epileptiform
features or
any electrographic seizures in this recording.
[**3-22**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background through most of the beginning of the
recording
and then a very widespread rapid rhythm during the early hours
of [**3-23**]. Both signify a widespread encephalopathy. The faster
widespread
rhythms, especially toward the end of the recording, are
primarily
suggestive of medication effect. There were no areas of
prominent focal
slowing but encephalopathies may obscure focal findings. There
were no
epileptiform features or electrographic seizures.
[**3-23**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background remained with a very slow base and with superimposed
faster
beta activity throughout. The widespread faster activity
generally
indicates medication effect. There were no areas of prominent
focal
slowing, but encephalopathies may obscure focal findings. There
were no
epileptiform features or electrographic seizures.
[**3-24**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow and low to moderate voltage background throughout
indicating a widespread encephalopathy. There was minimal
additional
slowing in the right hemisphere. The faster beta and alpha
rhythms with
a widespread distribution generally indicate medication effect.
There
were no clearly epileptiform features, and no electrographic
seizures
were recorded.
[**3-25**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background remained slow and of low voltage throughout,
especially after
10:30 on the morning of the 17th. This suggests medication
effect. The
bradycardia began around the same time. There were no clearly
epileptiform features or any electrographic seizures in the
recording.
[**3-26**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background rhythm was usually mildly slow or consisted of faster
alpha
and beta rhythms with a widespread distribution. The faster
rhythms
usually represent medication effect. There were some more
suppressed
periods. There were no epileptiform features or electrographic
seizures. The bradycardia was noted for most of the recording.
[**3-27**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed an encephalopathic background throughout. The early
rapid, beta
activity is strongly suggestive of medication effect. Later,
other
widespread uniform frequencies were also reflective of an
encephalopathy. There were no prominent focal findings. There
were no
clearly epileptiform features or any electrographic seizures.
[**3-28**]:
IMPRESSION: This is an abnormal EEG telemetry with no pushbutton
activations. It showed occasional isolated bifrontal or
generalized
epileptic discharges indicative of several areas of cortical
irritability. In addition, background was disorganized and
diffusely
slow indicative of moderate encephalopathy. No electrographic
seizures
were present.
[**3-29**]:
IMPRESSION: This is an abnormal EEG telemetry with one
pushbutton
activation for right shoulder twitching with no electrographic
seizures.
There were occasional isolated independent bifrontal or
generalized
epileptic discharges indicative of areas of cortical
irritability. In
addition, background was disorganized and diffusely slow
suggestive of
moderate encephalopathy with non-specific etiology. No
electrographic
seizures were present. Compared to prior day's recording, there
are no
significant differences.
[**3-30**]:
IMPRESSION: There were two pushbutton events for similar
trembling of
the right shoulder and forearm which clinically appeared likely
to be
seizure activity but did not have an identifiable EEG correlate.
The
record itself continues to show moderately severe diffuse
encephalopathy.
[**3-31**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of the continued presence of a diffuse encephalopathy. The
trends
analysis tends to suggest that the right hemisphere was slightly
more
involved than the left. Additionally, isolated interictal
epileptic
activity was seen from the right frontal and, to a lesser
degree, left
frontal regions. Short duration bursts of rhythmic activity were
also
seen that may represent projected abnormalities or briefly
limited
electrographic seizure activity with no clear clinical
accompaniments.
Additionally, the staff detected possible seizures clinically
that did
not appear to have a clear electrographic correlate even though
they
appeared to be highly suggestive of a clinical seizure activity.
Compared to the prior day's recording, there were no significant
changes.
[**4-1**]:
IMPRESSION: This is an abnormal waking EEG because of diffuse
slowing
of background activity compatible with a diffuse encephalopathic
process. Superimposed upon this were relatively focal interictal
epileptic spike and spike wave discharges in the right frontal
region.
ECG:
Sinus rhythm. Rightward axis. Baseline artifact.
Intraventricular conduction
delay. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 176 116 372/384 60 86 65
[**3-21**] CXR:
IMPRESSION: Hazy appearance of left upper lung with suspected
volume loss, an appearance suggesting extensive atelectasis of
the left upper lobe.
[**3-21**] Shunt series Xray:
IMPRESSION:
1. Per patient's history, patient has a VA (ventricular atrial)
shunt;
however, tubing is only seen to the level of the distal right
neck. No tubing seen over the thorax.
2. Interval removal of nasogastric tube with now marked gaseous
distention of the stomach.
[**3-25**] CXR:
There is unchanged evidence of a relatively extensive left lung
parenchymal opacity that is exaggerated on today's radiograph
given patient positioning. The pre-existing right middle and
lower lung opacity is constant. Unchanged position of the
vertebral stabilization devices. The contour of the cardiac
silhouette cannot be delineated on the current image.
[**3-26**] NCHCT:
IMPRESSION:
Study limited by patient motion and positioning.
Right posterior approach ventriculostomy catheter tip projects
in the right lateral ventricle. Ventriculomegaly may be
unchanged compared to the prior examination, however, difficult
to get accurate measurements at reliable comparable levels given
differences in positioning between this study and the outside
hospital CT of [**2155-3-21**]. Findings discussed with Dr.
[**Last Name (STitle) 110701**] at 4:48 a.m. on [**2154-3-25**] via telephone.
[**3-28**] CT Chest without contrast:
IMPRESSION: Moderate-to-severe upper mediastinal
lymphadenopathy. Extensive left lung consolidation with
subsequent volume loss, moderate left pleural effusion.
Mild-to-moderate right pleural effusion with dependent
atelectasis and several non-characteristic ground-glass nodules
in the upper-to-mid lung. Moderate dilatation of the pulmonary
artery, potentially indicative of pulmonary hypertension.
Moderate cardiomegaly without evidence of relevant coronary
calcifications. Status post vertebral fixation devices.
Assessment of the lung parenchyma is limited by severe
respiratory motion artifacts.
[**4-2**] Video Oropharyngeal swallow:
FINDINGS: Barium passed freely through the oropharynx and
esophagus without evidence of obstruction. There was penetration
with thin liquids but no gross aspiration. For details, please
refer to speech and swallow division note in OMR.
IMPRESSION: Penetration with thin liquids, no evidence of gross
aspiration.
Brief Hospital Course:
[**Known firstname 3403**] [**Known lastname 110699**] is a 47 year-old man with severe intellectual
disabilty, VP shunt for hydrocephalus, and chronic UTIs who was
at home and had a generalized seizure reported as whole body
shaking by his [**Doctor Last Name **] mother. [**Name (NI) **] was taken to [**Hospital 8641**] hospital
loaded with fosphenytoin and intubated, then medflighted to
[**Hospital1 18**]. In the ED he had persistent left arm shaking and a
stat-net which showed right frontal rhythmic discharges. He was
loaded with Keppra and propofol was uptitrated to motor
supression. His exam off propofol was notable for macrocephaly,
dysmorphic facial features, intact cranial nerves, and rhythmic
left arm shaking. His CT done at [**Location (un) 8641**] showed stable
hydrocephalus. His labs were grossly positive for a UTI. Given
the current infection and poor substrate it is possible that
these seizures were purely in the setting of infection. There
was a questionable history of a stroke in [**2153**] which would also
be a plausible explanation for seizure focus, although infection
was more likely. During his 12 day NeuroICU course, the patient
was primarily seizure free until a short R shoulder twitching
witnessed on [**3-31**] prior to transfer to the floor. His primary
issue was pulmonary with mucus plugging when attempted
extubation. Patient again self-extubated [**3-31**] (for the 3rd time)
and after this his respiratory status remained stable and he was
able to be transferred to the regular neuro floor.
.
# Neuro: Given pt had been primarily seizure free during his
stay, he was started to be weaned off pheyntoin. On [**3-31**] 3am
the only seizure activity that was seen involved right shoulder
twitching with probable EEG correlate which was limited and
self-resolved. His phenytoin was held at 100mg [**Hospital1 **] with plans
to possibly wean in the future. He was continued on keppra
1,000mg TID, which was transitioned to 1500mg [**Hospital1 **]. However, on
[**4-5**] he again had some twitching of his R shoulder that
self-resolved after 5-10 seconds. His phenytoin level was
checked and it was <0.6. Therefore, he was given a loading dose
and his mantenance was increased to 150mg [**Hospital1 **]. His level
increased, but on [**4-7**] he had another very brief episode of R
shoulder twitching and his phenytoin level was again very low.
He was given a nother loading dose and his maintenance was
increased to 200mg [**Hospital1 **]. However, his level on [**4-9**] was 8.2 so he
was increased to 250/250mg of phenytoin and has done well.
He will need his phenytoin level checked 3 days after dispo.
# ID: pt remained afebrile throughout most of his course, but
during his ICU stay he had a Morganella UTI, MRSA PNA and a
psuedomonas UTI all of which were treated with ABx the cultures
showed sensitivities to prior to his being discharged from the
hospital.
.
# Renal: patient was noted on admission to have etabolic
alkalosis with compensatory resp CO2 retainment. We suspected a
chronic etiology as patient's HCO3 elevated at admission and on
prior labs obtained from OSH. Per PCP, HCO3 has ranged 29-38 for
the past year. We consulted renal, who had some fluid recs, but
once it becema apparent that this was likely a chronic issue,
they recommended that pt f/u with a nephrologist closer to NH as
an outpatient. In addition, we got a renal US that showed a
small kidney, which they recommended could be followed as an
outpatient also.
# Pulm: Pt self-extubated for 3rd time on [**3-31**] and thereafter
remained stable on NC, then was weaned to RA successfully
without incident.
.
#GI: patient passed a speech and swallow video for a diet of
nectar thick liquid and puree. He was initially on TF's ntil he
could take in enough calories on the above regimen, which were
then stopped once he met the required calorie counts.
# CODE/CONTACT: full code as per [**Doctor Last Name **] mother [**Name (NI) **]
([**Telephone/Fax (1) 110702**]
PENDING RESULTS:
None
TRANSITIONAL CARE ISSUES:
Patient will need his phenytoin level checked 3 days after
discharge to ensure that he isn't sub or supratherapeutic.
Medications on Admission:
Zyprexa
Citalopram 10 daily
Provigil 100 mg daily
Nexium 40 mg QHS
Nexium
Miralax
Vit D
MVI
Tylenol PRN
Discharge Disposition:
Home With Service
Facility:
Amedisys NH HH & Hospice
Discharge Diagnosis:
Seizure
Mucous Plugging
Pneumonia
UTI
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 110699**],
You were seen in the hospital for seizures. You were admitted
to the ICU because you had to be intubated to stop your
seizures. There, it was difficult to extubate you. However,
once you were successfully extubated you did well and were able
to be sent home.
We made the following changes to your medications:
1) We STOPPED your PROVIGIL.
2) We STOPPED your ZYPREXA.
3) We STARTED you on KEPPRA 1500mg twice a day.
4) We STARTED you on PHENYTON 250mg every 12 hours.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Please follow these seizure safety guidelines:
SEIZURE SAFETY
________________________________________________________________
The following tips will help you to make your home and
surroundings as safe as possible during or following a seizure.
Some people with epilepsy will not need to make any of these
changes. Use this list to balance your safety with the way you
want to live your life.
Make sure that everyone in your family and in your home knows:
- what to expect when you have a seizure
- correct seizure first aid
- first aid for choking
- when it is (and isn't) necessary to call for emergency help
Avoid things that are known to increase the risk of a seizure:
- forgetting to take medications
- not getting enough sleep
- drinking a lot of alcohol
- using illegal drugs
In the kitchen:
- As much as possible, cook and use electrical appliances only
when someone else is in the house.
- Use a microwave if possible.
- Use the back burners of the stove. Turn handles of pans toward
the back of the stove.
- Avoid carrying hot pans; serve hot food and liquids directly
from the stove onto plates.
- Use pre-cut foods or use a blender or food processor to limit
the need for sharp knives.
- Wear rubber gloves when handling knives or washing dishes or
glasses in the sink.
- Use plastic cups, dishes, and containers rather than breakable
glass.
In the living room:
- Avoid open fires.
- Avoid trailing wires and clutter on the floor.
- Lay a soft, easy-to-clean carpet.
- Put safety glass in windows and doors.
- Pad sharp corners of tables and other furniture, and buy
furniture with rounded corners.
- Avoid smoking or lighting fires when you're by yourself.
- Try to avoid climbing up on chairs or ladders, especially when
alone.
- If you wander during seizures, make sure that outside doors
are
securely locked and put safety gates at the top of steep stairs.
In the bedroom:
- Choose a wide, low bed.
- Avoid top bunks.
- Place a soft carpet on the floor.
In the bathroom:
- Unless you live on your own, tell a family member or [**Name2 (NI) 8317**]
before you take a bath or shower.
- Hang the bathroom door so it opens outward, so it can be
opened
if you have a seizure and fall against it.
- Don't lock the bathroom door. Hang an "Occupied" sign on the
outside handle instead.
- Set the water temperature low so you won't be hurt if you have
a seizure while the water is running.
- Showers are generally safer than baths. Consider using a
hand-
held shower nozzle.
- If taking a bath, keep the water shallow and make sure you
turn
off the tap before getting in.
- Put non-skid strips in the tub.
- Avoid using electrical appliances in the bathroom or near
water.
- Use shatterproof glass for mirrors.
At work:
- Consider telling your co-workers that you have epilepsy and
the
correct first aid for seizures.
- Climb only as high as you can fall without injuring yourself.
- When working around machinery, make sure that safety features
are in place, and consider wearing protective clothing.
- Try to keep consistent work hours so you don't have to go a
long time without sleep.
- Try to limit your exposure to flashing lights if this can
trigger your seizures.
Out and about:
- Carry only as many medications with you as you will need, and
2
spare doses.
- Wear a medical alert bracelet to let emergency workers and
others know that you have epilepsy.
- Stand well back from the road when waiting for the bus and
away
from the platform edge when taking the subway.
- If you wander during a seizure, take a friend along.
- Don't let fear of a seizure keep you at home.
Sports:
- Use common sense to decide which sports are reasonable.
- Exercise on soft surfaces.
- Wear a life vest when you are close to water.
- Avoid swimming alone. Make sure someone with you can swim
well
enough to help you if you need it.
- Wear head protection when playing contact sports or when there
is a risk of falling.
- When riding a bicycle or rollerblading, wear a helmet, knee
pads, and elbow pads. Avoid high traffic areas; ride or skate
on
side roads or bike paths.
Driving:
- You may not drive in [**State 350**] unless you have been
seizure- free for at least 6 months.
- Always wear a seatbelt.
Parenting:
- Childproof your home as much as possible.
- If you are nursing a baby, sit on the floor or bed with your
back supported so the baby will not fall far if you should lose
consciousness.
- Feed the baby while he or she is seated in an infant seat.
- Dress, change, and sponge bathe the baby on the floor.
- Move the baby around in a stroller or small crib.
- Keep a young baby in a playpen when you are alone, and a
toddler in an indoor play yard, or childproof one room and use
safety gates at the doors.
- When out of the house, use a bungee-type cord or restraint
harness so your child cannot wander away if you have a seizure
that affects your awareness.
- Explain your seizures to your child when he or she is old
enough to understand.
Followup Instructions:
Department: NEUROLOGY
When: WEDNESDAY [**2155-5-14**] at 1 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please also call your PCP to have him arrange an appointment
with a nephrologist (a kidney doctor) near to your home.
|
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80,187
| 154,261
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15519
|
Discharge summary
|
report
|
Admission Date: [**2186-4-27**] Discharge Date: [**2186-4-28**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
cholangitis s/p [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] s/p gall bladder stent placement
History of Present Illness:
[**Age over 90 **]yo female with multiple medical problems including type 2
diabetes, CVA, hypertension, chronic kidney disease, atrial
fibrillation, and CHF was admitted from the [**Age over 90 **] suite s/p [**Age over 90 **]
for cholangitis.
She initially presented to the OSH with a mechanical fall for
which she was found to have a right hip fracture. Surgical
repair of her hip was delayed due to multiple complicating
medical issues, including parotiditis, cholecystitis, and
urinary tract infection. Regarding her parotiditis, she
developed a right parotiditis on [**2186-4-26**] for which she was
evaluated by ENT. They drained her right parotid gland which
grew staph aureus and she was started on vancomycin. Regarding
her cholecystitis, she was transferred to [**Hospital1 18**] for [**Hospital1 **] and
received rocephin and flagyl. Regarding her urinary tract
infection, she was started on rocephin. She was then transferred
to [**Hospital1 18**] urgently for an [**Hospital1 **].
[**Hospital1 **] demonstrated a "filling defect that appeared like
sludge/stone in the lower third of the common bile duct. A
moderate diffuse dilation was seen at the main duct with the CBD
measuring 15mm" and a stent was placed. Her procedure was
performed under MAC and was relatively uncomplicated. Upon
arrival to the floor, she reports mild abdominal pain and
fatigue.
Past Medical History:
1. Diabetes
2. CVA
3. Hypertension
4. CKD
4. Pulmonary hypertension
5. Peripheral Vascular Disease
6. Atrial fibrillation
7. Mitral regurgitation
8. Mitral stenosis
9. History of rheumatic bowel
10. Gout
11. Chronic venous stasis
12. Bilateral lower extremity edema
13. Recurrent lower extremity cellulitis
14. CHF
15. Moderate TR
16. Hyperlipidemia
17. Anemia
18. bradycardia tachycardia syndrome
19. sick sinus syndrome,
20. history of sinus pauses
Social History:
- Home: lives at home, walks with a walker, supportive daughter;
husband passed away roughly 4 weeks
- Occupation: unknown
- EtOH: Unknown
- Drugs: Unknown
- Tobacco: Unknown
Family History:
Daughter with diabetes.
Physical Exam:
HEENT: Clear OP, dry mucous membranes, enlarged right parotid
gland with erythema and tenderness
NECK: Supple, No LAD, elevated JVD to the angle of the jaw
CV: tachycardic, irregularly irregular, no murmurs, rubs, or
gallops
LUNGS: increased upper respiratory sounds with bibasilar
crackles
ABD: + BS, soft, slightly tender to deep palpation diffusely, no
rebound or guarding
EXT: 1+ bilateral pitting edema, right lower extremity
externally rotated
SKIN: No lesions
NEURO: A&Ox3. Lethargic but answers questions. CN 2-12 grossly
intact. 5/5 strength throughout. Normal coordination. Gait
assessment deferred
Pertinent Results:
[**2186-4-27**] - [**Hospital1 **] labs
WBC 21 / Hct 34.2 / Plt 200 / MCV 101
INR 1.5
Na 147 / K 4 / Cl 110 / CO2 23.2 / BUN 33 / cr 1.5 / BG 240
Alb 2.9 / TP 6.6 / TB 6.71 / DB 5 / Alk Phos 210 / ALT 88 / AST
100
Amylase 490 / Lipase 174
[**2186-4-27**] - [**Hospital1 18**] Post-[**Hospital1 **] labs
Na 150 / K 3.6 / Cl 114 / CO2 22 / BUN 35 / Cr 1.2 / BG 152
ALT 81 / AST 134 / LDH 353 / Alk Phos 174 / Amylase 1149 / TBili
6.7
Lipase 1689
Alb 3.2 / Ca 8.5 / Mg 2.7 / Phos 2.6
WBC 23.7 / Hct 35.8 / Plt 197
INR 1.5
[**Hospital1 **] MICROBIOLOGY:
- [**2186-4-21**] - Urine Cx - no growth
- [**2186-4-25**] - Urine Cx - E. coli - resistant to ampicillin,
sensitive to cefazolin, cefuroxime, ciprofloxacin, gent,
nitrofurantoin, tetracycline, and bactrim
- [**2186-4-26**] - Skin Lesion - Staph aureus - sensitivities pending
.
[**Hospital1 **] STUDIES:
- [**2186-4-21**] CT Head without contrast
1. NO ACUTE INTRACRANIAL PROCESS.
2. CHRONIC SMALL VESSEL ISCHEMIC DISEASE.
- [**2186-4-21**] CT C Spine -
1. NO EVIDENCE OF FRACTURE OR MALALIGNMENT.
2. PATCHY AIR SPACE OPACITIES WITH INTERLOBULAR SEPTAL
THICKENING WITHIN THE VISUALIZE LUNG APICES, [**Month (only) **] BE INFECTIOUS,
INFLAMMATORY, OR COULD REPRESENT FLUID OVERLOAD. RECOMMEND
CLINICAL CORRELATION.
- [**2186-4-21**] Right Hip XR
There is a fracture involving the right femoral neck at its
junction
with the femoral head. There is minimal varus angulation at the
fracture site. There is generalized osteopenia. No additional
fractures are seen.
- [**2186-4-25**] CXR - PERSISTENT VASCULAR CONGESTION
- [**2186-1-5**] Echo - moderately dilated LA; moderately dilated RA; EF
55%; moderate MS; moderate MR; moderate TR; severe PA systolic
HTN
.
[**Hospital1 18**] Radiology:
Final Report
HISTORY: Right foot swelling.
Three radiographs of the right foot demonstrate air projecting
along the
dorsum of the forefoot, seen on all three views. Assessment of
the finding is markedly limited by overlying dressing material.
Mild, diffuse,
demineralization limits assessment for osseous fragmentation,
none is seen. There is evidence of ovoid lucencies involving
the second and third metatarsal shafts. Mild degenerative change
involves the first MTP joint. No tibiotalar joint effusion is
seen.
IMPRESSION:
Air projecting over the dorsum of the forefoot. The finding
likely represents subcutaneous emphysema, although assessment is
markedly limited by overlying dressing material.
Equivocal lucencies involving the second and third metatarsal
shafts. This
finding might also be attributable to the overlying air, but
osseous lesions are not excluded.
These findings would be better assessed with cross-sectional
imaging. CT
examination would better delineate the extent of air and
potential cortical destruction. MRI might be more useful for
evaluation of the regional soft tissues.
[**Hospital1 18**] [**Hospital1 **] Report:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome. Contrast medium was injected
resulting in complete opacification. A 0.035in in diameter and
260cm in length straight tip glidewire was placed. The existing
guidewire was replaced with a jagwire.
Cannulation of the pancreatic duct was successful and
superficial with a sphincterotome. Contrast medium was injected
resulting in partial opacification.
Biliary Tree: There was a filling defect that appeared like
sludge/stone in the lower third of the common bile duct. A
moderate diffuse dilation was seen at the main duct with the CBD
measuring 15mm. The cystic duct appeared patent. Two stones were
visualized in the gall bladder. Full cholangiogram not obtained
due to patient's history of cholangitis. A 10FR by 8 cm Cotton
[**Doctor Last Name **] biliary stent was placed successfully.
Pancreas: A moderate dilation of the main pancreatic duct was
seen in the head of the pancreas.
Impression: There was a filling defect that appeared like
sludge/stone in the lower third of the common bile duct.
A moderate diffuse dilation was seen at the main duct with the
CBD measuring 15mm.
The cystic duct appeared patent. Two stones were visualized in
the gall bladder.
A 10FR by 8 cm Cotton [**Doctor Last Name **] biliary stent was placed
successfully.
A moderate dilation of the main pancreatic duct was seen in the
head of the pancreas
Recommendations: Admit to the [**Hospital Unit Name 153**] for further management
Follow for response/complications
Please call if develop jaundice, abdominal pain or black stools.
Continue broad spectrum antibiotics
Repeat [**Hospital Unit Name **] in 3 months for stent removal and re-evaluation
Follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 44970**]
CHEST PORTABLE AP
REASON FOR EXAM: [**Age over 90 **]-year-old woman with multiple medical
problems including AFib, CHF, recent right hip fracture,
cholecystitis and UTI. Presents with hypoxia, evaluate.
Since [**2184-10-4**], cardiomegaly is likely unchanged. Left
retrocardiac
opacities increased, at least partly due to atelectasis, but
could also be
aspiration. Left pleural effusion increased, now small to
moderate. Mild
pulmonary edema is present. There is no other change.
[**Hospital1 18**] LABS:
[**2186-4-27**] 11:50PM BLOOD WBC-23.7*# RBC-3.47* Hgb-11.4* Hct-35.8*
MCV-103* MCH-33.0* MCHC-32.0 RDW-18.1* Plt Ct-197
[**2186-4-28**] 04:42AM BLOOD WBC-21.4* RBC-3.42* Hgb-11.5* Hct-35.2*
MCV-103* MCH-33.7* MCHC-32.7 RDW-18.1* Plt Ct-198
[**2186-4-27**] 11:50PM BLOOD Neuts-90.3* Lymphs-3.5* Monos-6.0 Eos-0.1
Baso-0.1
[**2186-4-28**] 04:42AM BLOOD Neuts-88.8* Lymphs-3.8* Monos-7.0 Eos-0.2
Baso-0.1
[**2186-4-27**] 11:50PM BLOOD PT-16.5* PTT-28.2 INR(PT)-1.5*
[**2186-4-28**] 04:42AM BLOOD PT-16.1* PTT-25.1 INR(PT)-1.4*
[**2186-4-27**] 11:50PM BLOOD Ret Aut-2.1
[**2186-4-27**] 11:50PM BLOOD Glucose-152* UreaN-35* Creat-1.2* Na-150*
K-3.6 Cl-114* HCO3-22 AnGap-18
[**2186-4-28**] 04:42AM BLOOD Glucose-186* UreaN-36* Creat-1.2* Na-150*
K-3.5 Cl-114* HCO3-23 AnGap-17
[**2186-4-27**] 11:50PM BLOOD ALT-81* AST-134* LD(LDH)-353*
AlkPhos-174* Amylase-1149* TotBili-6.7*
[**2186-4-28**] 04:42AM BLOOD ALT-82* AST-124* AlkPhos-177*
Amylase-1168* TotBili-6.2*
[**2186-4-28**] 04:42AM BLOOD Lipase-1344*
[**2186-4-27**] 11:50PM BLOOD Lipase-1689*
[**2186-4-27**] 11:50PM BLOOD Albumin-3.2* Calcium-8.5 Phos-2.6*
Mg-2.7*
[**2186-4-28**] 04:42AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.5
[**2186-4-27**] 11:50PM BLOOD VitB12-998* Folate-15.5
[**2186-4-28**] 12:07AM BLOOD Type-ART pO2-179* pCO2-31* pH-7.45
calTCO2-22 Base XS-0
[**2186-4-28**] 03:02AM BLOOD Type-ART pO2-70* pCO2-36 pH-7.46*
calTCO2-26 Base XS-1
[**2186-4-28**] 12:07AM BLOOD Lactate-1.3
[**2186-4-28**] 12:07AM BLOOD O2 Sat-98 MetHgb-0
Brief Hospital Course:
[**Age over 90 **]yo female with multiple medical problems including congestive
heart failure, atrial fibrillation, type 2 diabetes mellitus,
and stroke was admitted from [**Age over 90 **] for cholangitis and stent
placement in the setting of right parotiditis, right hip
fracture and urinary tract infection.
# Cholangitis
Patient has evidence of cholangitis per [**Age over 90 **] and underwent
placement of a biliary stent. [**Age over 90 **] recommendations were to have
the stent removed in three months. She was maintained on
meropenem while hospitalized here.
# Right Foot Pain
Patient has right foot swelling concerning for osteomyelitis. We
would recommend CT scan or MRI for further evaluation.
# Right Hip Fracture
Patient is a very high risk candidate for moderate risk
procedure. She developed right hip fracture after mechanical
fall. Will defer surgical management of hip pending further
management of infection and hypoxia.
# Urinary Tract Infection
Patient has urinary tract infection with E. coli resistant to
ampicillin only and most likely covered by meropenem for
cholangitis.
# Type 2 Diabetes Mellitus
Stable. Patient's HbA1c suggests excellent control of her
diabetes mellitus.
She was maintained on a humalog insulin sliding scale
# She was continued on her regimen of metoprolol and digoxin IV
while hospitalized for management of her atrial fibrillation.
Her allopurinol, zocor, niacin, statin, and aldactone were hold
due to concerns of aspiration. Her synthroid was held due to
these concerns.
# Parotiditis
Patient has parotiditis and is s/p drainage by ENT. Per report,
culture demonstrated staph aureus, and sensitivities are still
pending.
- will need CT neck once oxygenation and heart rate are improved
- ENT follow up needed.
.
# Anemia
Appears stable within her baseline range. B12, folate levels
checked, within normal limits. Reticulocute index consistent
with hypoproliferation at 1.1, continued iron and folate
repletion.
# Renal insufficiency
Her baseline creatinine is 1.6-1.9, which appears stable and
within her baseline.
At time of discharge pt's VS: 98.9 121/54 83 10 98% 2L NC
She was responding to questions, denied pain or other
complaints. Per the patient's family's wishes she was transfered
back to [**Hospital1 **] [**Location (un) 620**], her hospital of origin for further care.
Medications on Admission:
HOME MEDICATIONS:
1. Glyburide 2.5 mg p.o. daily
2. Aspirin 81 mg p.o. daily
3. Ferrous sulfate 325 mg p.o. daily
4. Prilosec 20 mg p.o. daily
5. Allopurinol 100 mg p.o. daily
6. Niacin 500 mg p.o. b.i.d.
7. Zocor 10 mg p.o. at bedtime
8. Lasix 80 mg once or twice daily
9. Aldactone 25 mg 1 tablet midday.
10. Coumadin 3 mg corrected to INR
11. Metoprolol 12.5 mg daily
12. Digoxin 0.125 mcg daily
13. Synthroid 5.5 mcg daily.
.
TRANSFER MEDICATIONS:
1. Rocephin 1 gram IV daily
2. Flagyl 500 mg IV t.i.d.
3. Vancomycin 750 mg IV daily
4. Synthroid now on hold due to her afib with RVR
5. Digoxin 0.125 mg IV q.
6. Lopressor 5 mg IV q.4 h.
7. Lantus 3 units at bedtime. hold when NPO
8. Nexium 20 mg IV daily
9. daily nasal spray
10. Morphine p.r.n.
11. Haldol p.r.n.
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous Q12H
(every 12 hours).
4. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q48H (every 48 hours).
5. Digoxin 250 mcg/mL Solution Sig: One (1) Injection DAILY
(Daily).
6. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q4H (every 4 hours).
7. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Cholangitis
.
SECONDARY DIAGNOSIS:
1. Right Hip Fracture
2. Urinary Tract Infection
3. Foot Infection
4. Type 2 Diabetes Mellitus
Discharge Condition:
Stable. Patient is at her baseline condition.
Discharge Instructions:
You were admitted to this hospital for [**Location (un) **] evaluation of your
gall bladder infection. You had a bile duct stent placed. The
gastroenterology team recommended that you have a repeat [**Location (un) **] in
3 months for stent removal. You are now returning to [**Hospital1 **]
for further evaluation of your hip fracture, parotid gland
infection, and foot infection.
.
Please continue to take all of your medications as prescribed.
Followup Instructions:
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2186-7-27**] 11:00
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2186-7-27**] 11:00
|
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"285.9",
"250.00",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
13770, 13785
|
9971, 12319
|
255, 313
|
13981, 14029
|
3070, 9948
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14524, 14759
|
2399, 2425
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13139, 13747
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13806, 13806
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14053, 14501
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2440, 3051
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12363, 12775
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176, 217
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12797, 13116
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341, 1715
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13863, 13960
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13825, 13842
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1737, 2190
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2206, 2383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,640
| 119,379
|
15203
|
Discharge summary
|
report
|
Admission Date: [**2106-4-9**] Discharge Date: [**2106-4-26**]
Date of Birth: [**2050-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
Abdominal Pain, Fevers, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 55 year old male with ulcerative colitis,
primary sclerosing cholangitis, and cirrhosis who presents s/p
pullback cholangiogram today to evaluate for biliary drain
leakage with fever and abdominal pain. Developed pain around
biliary drain 4-5 days ago, worsening as the week progressed.
Called [**Hospital **] clinic and was electively scheduled for [**4-9**] for
cholnagiogram to evaluate for possible biliary leak. Last night
had fever to 101 and multiple episodes of watery diarrhea.
Awoke this a.m. with lower quadrant abdominal pain, different
from the evolving pain over the past week. Presented to GI
suite where pullback cholangiogram was performed which showed
free passage of bile into jejunum without evidence of leak.
However, has had continued lower crampy abdominal pain every 30
minutes with max fever of 102.4 and continued diarrhea.
Diarrhea is much more frequent when compared to his UC
exacerbations (30 episodes since last night vs [**6-30**] with UC flare
vs 4 when under control). Additionally, he never has this type
of abdominal pain with UC exacerbations. No BRBPR or melena.
Nausea/vomited x 1 last night at MN with no repeat episodes.
Currently not nauseated.
ROS: Notes 40 pound weight loss over past 4 yrs. No HA, URI
sxs, cough, sore throat, chest pain, SOB, orthopnea, PND,
dysuria, hesitancy, urgency. + decreased appetitie.
Past Medical History:
# Primary sclerosing cholangitis - s/p CBD excision and
Roux-en-Y hepaticojejunostomy. PET scan with multiple areas of
FDG1 avidity concerning for malignancy
# Cirrhosis - Thought to be secondary to PSC; complicated by
esophageal varices - three cords with grade I varices - and
splenomegaly (liver biopsy showed bridging fibrosis, but varices
and splenomegaly suggestive of cirrhosis).
# S/p cholangiogram [**11-27**] which demonstrated irregular dilation
and stricture of the left-sided intrahepatic bile duct with no
communication to the right side. Biliary drain placement in
[**11-27**] with biopsies that revealed fibrosis, but no evidence of a
tumor. Replacement of his biliary tube x 1 in [**2-25**].
# ETOH abuse
# Cholecytectomy
Social History:
history of heavy alcohol abuse, quit in [**2095**].
Family History:
NC
Physical Exam:
VS: 100.8,132/58,100,18, 97% RA
gen: NAD, cachetic, jaundiced, resting comfortably in bed.
HEENT: PERRL/EOM intact, +scleral icterus, OP clear, MMM, no
JVD, no carotid bruit.
Neck: no masses, no LAD.
Cardiac: RRR, nl s1s2, no MRGs
Lungs: CTA b/l, no crackles or wheezes.
Abd: diffusely jaundiced, soft, +BS, very tender to palpation in
lower quadrant diffusely, not tender around catheter drainage
site, dressing in place and clean and dry, no rebound or
guarding, no ascites
extr: warm well perfused, 2+ dp pulses, no cyanosis, no LE
edema.
neuro: a&ox3, cn ii-xii intact; motor, sensory, coordination,
and language grossly non-focal.
Pertinent Results:
Admission:
[**2106-4-9**] 08:20AM WBC-12.5*# RBC-3.89* HGB-13.0* HCT-38.6*
MCV-99* MCH-33.4* MCHC-33.6 RDW-13.9
[**2106-4-9**] 08:20AM PLT COUNT-291
[**2106-4-9**] 08:20AM PT-13.7* PTT-27.4 INR(PT)-1.2*
[**2106-4-9**] 08:20AM GLUCOSE-138* UREA N-15 CREAT-0.7 SODIUM-135
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-24 ANION GAP-18
[**2106-4-9**] 08:20AM ALT(SGPT)-62* AST(SGOT)-110* ALK PHOS-941*
TOT BILI-8.3*
[**2106-4-9**] 08:20AM ALBUMIN-3.5
.
Discharge:
[**2106-4-26**] 05:20AM BLOOD WBC-7.9 RBC-3.22* Hgb-10.3* Hct-31.2*
MCV-97 MCH-32.0 MCHC-33.1 RDW-16.0* Plt Ct-171
[**2106-4-21**] 05:05AM BLOOD PT-14.3* PTT-30.3 INR(PT)-1.3*
[**2106-4-26**] 05:20AM BLOOD Glucose-98 UreaN-10 Creat-0.5 Na-137
K-4.0 Cl-101 HCO3-25 AnGap-15
[**2106-4-26**] 05:20AM BLOOD ALT-47* AST-56* LD(LDH)-255* AlkPhos-669*
TotBili-6.2*
[**2106-4-26**] 05:20AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
.
[**2106-4-9**] CXR: No effusions. No infiltrates. No free air under the
diaphragm.
.
[**2106-4-9**] Cholangiogram:
IMPRESSION:
1. Pullback cholangiogram via the existing percutaneous biliary
access into the left intrahepatic biliary duct demonstrated no
dilatation of the left intrahepatic biliary duct, minimal
filling of the nondilated side branches, and free passage of
contrast past the biliary/enteric anastomosis. No
leaking/extravasation of contrast was demonstrated.
2. Replacement of an 8 French external-internal biliary drain
with a 10 French external-internal biliary drain which was
capped.
3. The case was discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**].
.
[**4-10**] CT Abd/pelvis:
1. New colonic thickening involving the cecum and ascending
colon up to the proximal transverse colon most consistent with
inflammation or infection. The adjacent appendix is enlarged
with intraluminal fluid and peripheral enhancement concerning
for associated appendicitis. Clinical correlation is requested.
2. New mild intraabdominal ascites.
3. [**Name (NI) 44264**] PTC drain extending from stably dilated left-sided
intrahepatic ducts into the proximal duodenum. A left-sided
periductal cystic region has increased in size from prior exam
as described above.
.
[**4-11**] CXR: Moderate-sized right pneumothorax.
.
[**4-11**] CT Abd pelvis:
1. Interval improvement in colonic wall thickening of the cecum
and ascending colon consistent with inflammation or infection.
Interval decrease in size of appendix and reduction of free
pelvic fluid.
2. New small-to-moderate right pneumothorax.
3. [**Name (NI) 44264**] PTC drain in an unchanged position, with stable
intrahepatic biliary ductal dilatation.
.
[**4-12**] CXR: Marked interval improvement in previously identified
right hydropneumothorax with small residual right pneumothorax.
.
[**4-12**] Chest tube placement CXR: Moderate-to-large right
hydropneumothorax, increased in size following chest tube
replacement. Unusual cystic lucencies in right perihilar region
which could represent additional loculated areas of
pneumothorax.
.
[**4-12**] Pleural drain placement CXR: After placement of pleural
drain, there is now a combination of moderate right pneumothorax
with layering pleural effusion or hemothorax. Increase in right
basilar atelectasis
.
[**4-13**] CXR: AP chest compared to 7:35 a.m. and [**4-12**]. The tip of
the right apical pleural tube projects over a triangular lucent
area, which is probably residual pleural space containing air,
although hyperlucency in aerated lung apex distal to a row of
suture could give exactly the same appearance. The right lung is
otherwise clear. Left lung is clear. Mild rightward mediastinal
shift is stable. Heart size normal.
.
[**4-14**] CXR: Right apical pleural tube unchanged in position
projecting over a small apical pleural air collection. Small
fissural right pleural effusion increased slightly. Mild
rightward mediastinal shift stable. Left lung clear.
.
[**4-15**] CXR: Small right apical pneumothorax persists, apical
pleural tube in place. Atelectasis at the base of the right lung
which may be considerable in the lower lobe has increased since
[**4-14**]. Small right pleural effusion is unchanged. Left lung
hyperinflated and clear. Heart is top normal size.
.
[**4-16**] CXR: Persistent small, unchanged right pneumothorax
.
[**4-19**] CT Abd/pelvis: 1. Interval marked improvement in
inflammation of the right lower quadrant. 2. Dilated left-sided
biliary ducts. This is stable when compared to prior studies and
consistent with the history of PSC
3. Splenomegaly.
4. Multiple prominent mesenteric lymph nodes, some may be
slightly more prominent than before.
.
[**4-19**] CXR after removal of chest tube: Comparison to prior chest
x-ray of [**2106-4-18**] at 11:38 a.m. shows no appreciable change in
the appearance of the chest with a small persistent right apical
pneumothorax
.
[**4-21**] cholangiogram: 1. Pullback cholangiogram via the existing
percutaneous biliary access into the left intrahepatic biliary
duct demonstrates no dilatation of the main left intrahepatic
biliary ducts. There is minimal filling of side branches in the
left lobe and this raises the likelihood of progression of the
PSC with significant obstruction to many more intrahepatic
ducts, Clinical correlation recommended to decide if additional
duct drainage should be attempted. Remotely, an attempt could be
made to subselect branches via the current tract and perform
dilatation of the stenoses. Free passage of contrast was noted
through the biliary/enteric anastomosis without evidence for
biliary leakage.
2. Replacement of the 10 French external-internal biliary drain
with a 10 French external-internal biliary drain, which was
capped
.
[**4-23**] MRCP: 1. Multifocal areas of mild-to-moderate intrahepatic
segmental biliary dilatation, most prominent in the left lobe in
keeping with background of primary sclerosing cholangitis. This
is stable in appearance compared to recent CTs [**2105**]. Appearances
in the left lobe are mildly more prominent than earlier MRI of
[**2104-10-7**]. No mass lesion.
2. Splenomegaly, small amount of intra-abdominal ascites. Patent
portal and hepatic veins.
3. Moderate right basal pleural effusion and some associated
right basal atelectasis similar to recent CT.
.
[**4-12**] RUL wedge resection specimen: Emphysema with bleb formation
and subpleural fibrosis.
.
[**4-21**] EGD/colonoscopy biopsies:
Gastrointestinal mucosal biopsies, six:
A. Antrum: Fragment of unremarkable superficial gastric
foveolar epithelium.
B. Cecum: Fragment of unremarkable superficial intestinal
mucosa.
C. Transverse colon: Chronic inactive colitis.
D. Ascending colon: No diagnostic abnormalities identified.
E. Splenic flexure: No diagnostic abnormalities identified.
F. Descending colon: Chronic inactive colitis.
Note: No granulomas or dysplasia seen.
Brief Hospital Course:
.
# Abdominal pain: Cholangiogram had no evidence of biliary leak
as a possible cause of abdominal pain. CT abdomen showed
infectious vs. inflammatory colitis. He had evidence of
appendicitis, which was thought to be secondary to inflammation
from the colitis. He was started on empiric Unasyn and
maintained on his outpatient Colazal and metronidazole. He
continued to spike fevers and was subsequently started on Zosyn
to increase gram negative coverage to cover Pseudomonas, and
oral vancomycin for the possibility of C. diff resistant to
Flagyl. He was also kept NPO for bowel rest. Repeat CT abdomen
showed improvement in the inflammation. Stool studies were
negative for C. diff. toxin. His exam improved and he was
subsequently afebrile. He subsequently underwent colonoscopy on
[**4-20**] that showed chronic inflammation and esophageal varices,
but no acute UC flare. He was able to resume eating with no
complications, and his diarrhea decreased in frequency. It was
decided to give him a trial off ursodiol to see if this may be
contributing to his diarrhea. If this is not successful, he will
restart ursodiol, as well as starting budesonide as an
outpatient. He completed a course of ciprofloxacin and was
discharged on no antibiotics.
.
# Pneumothorax: Spontaneous right pneumothorax was incidentally
found on CT abdomen on [**4-11**]. He was initially asymptomatic, but
subsequently had some respiratory distress. His pneumothorax
was increasing on chest x-ray. A chest tube was placed by
Thoracic Surgery. He subsequently developed a hemopneumothorax.
He was taken for VATS with blebectomy and pleurodesis on [**4-12**].
His chest tube was discontinued on [**4-18**] after it stopped
draining. Chest x-ray the next day showed stable residual small
apical pneumothorax.
.
# PSC: He is s/p biliary drain placement, found to be
functioning well without leak. He was continued on his ursodiol
initally. His elevated bilirubin gradually tranded down, but his
alkaline phosphatase continued to trend up. Eventually the T
bili began to rise again as well, and he underwent a second
cholangiogram with replacement of the biliary stent. The live
could not be fully visualized, and so he underwent an MRCP. This
did not reveal any acute process or obstruction. As discussed
above, his ursodiol was temporarily stopped at time of discharge
to see if this may be contibuting to his diarrhea. If it has no
effect in reducing his diarrhea, it will be restarted in [**12-25**]
days.
.
# Ulcerative Colitis: He was initially continued on colazol and
flagyl at his outpatient doses. The flagyl was then discontinued
after a long course. He had a colonoscopy and EGD with 6
biopsies taken. No acute UC was found, only chronic
inflammation, pan-colonic diverticulosis, and esophageal
varices.
.
# Cirrhosis: This is secondary to PSC. His cirrhosis is
complicated by esophageal varices and splenomegaly. He was
continued on his outpatient propranolol and rifaximin. He had a
small amount of ascites of CT abdomen. He was treated with daily
vitamin K, and discharged on every other day vitamin K.
.
# FEN: He has had poor PO intake with chronic weight loss.
Nutrition was consulted. He was initially NPO with D5 1/2 NS. He
was later able to advance his diet to solids with supplemental
shakes. His electrolytes were monitored and repleted prn.
.
# Ppx: He was on a PPI while not eating, and heparin SQ while
not ambulating.
.
# Code: Full
Medications on Admission:
Colazol 750 mg tabs, 3 tabs PO TID
[**Last Name (un) **] 600 mg PO TID
Flagyl 250 mg PO TID
Propranolol 10 mg PO BID
Vitamin D 50,000 units
Mephyton 5 mg PO QD
Calcium with vit D
Discharge Medications:
1. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*15 Tablet(s)* Refills:*2*
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO DAILY (Daily).
6. Balsalazide 750 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
8. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day): please take this medication 2 hours before, or
2 hours after your other medications.
Disp:*60 Packet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Budesonide 3 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO once a day: please start this
medication only if a trial off ursodiol does not decrease your
diarrhea.
Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerative colitis flare
Hemopneumothorax
End-stage liver disease/Cirrhosis
Primary sclerosing cholangitis
Discharge Condition:
Stable, afebrile, eating and drinking
Discharge Instructions:
Please seek medical attention for fevers > 100.5, for worsening
jaundice, for abdominal or chest pain, for shortness of breath,
or for anything else concerning to you.
Please take all of your medications as directed. Note that we
are asking you not to take ursodiol right now for several days.
If no difference in your diarrhea after 2-3 days, please restart
ursodiol. At that time if that has not helped, please start the
new medication called budesonide. You have been given a
prescription for this.
.
Please record the output of your biliary drain each day, and
being this information to your next appointment with Dr. [**Last Name (STitle) 497**]
next week.
Followup Instructions:
1) An appointment with Dr. [**Last Name (STitle) 497**] and small bowel follow through
procedure are being arranged for you for next week, you will be
called with the appointment time. The number at Dr.[**Name (NI) 948**]
office is [**Telephone/Fax (1) 673**]
2) Provider: [**Name10 (NameIs) **] [**Hospital **] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2106-5-11**] 1:20
3) Please call Dr. [**Last Name (STitle) **] for an appointment. He would like to
see you in the next 2-3 weeks. [**Telephone/Fax (1) 1954**]
Completed by:[**2106-4-26**]
|
[
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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15043, 15049
|
10136, 13593
|
349, 355
|
15200, 15240
|
3295, 10113
|
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|
2619, 2623
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13823, 15020
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15070, 15179
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13619, 13800
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15264, 15928
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2638, 3276
|
276, 311
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383, 1767
|
1789, 2533
|
2549, 2603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,060
| 193,317
|
24310
|
Discharge summary
|
report
|
Admission Date: [**2182-10-10**] Discharge Date: [**2182-10-11**]
Date of Birth: [**2144-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
alcoholic intoxication and heroin abuse
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 24927**] is a 38 yo M with PMH of polysubstance abuse who
presents with acute alcoholic intoxication and heroin abuse. He
was found around [**Location (un) **] station and brought to [**Hospital1 18**]. On
arrival to [**Hospital1 18**], he reported also snorting heroin.
In the ED, VS: T 99 BP 98/73 HR 102 RR17 99%RA. He was initially
alert and awake, then became somnolent with RR of 6 and O2 sat
of 70%. He received naloxone with immediate awakening. RR
normalized and O2sat was normal. After several hours in [**Name (NI) **], pt
became increasingly agitated and received multiple doses of
valium for elevated CIWA scale, receiving total of 50mg PO.
Pt has frequent visits to [**Hospital1 18**]. Was recently admitted to MICU
Green on [**2182-10-5**]. At that time, seen by psychiatry who left
recommendation regarding administration of benzos as patient
frequently is administered high doses of benzodiazepines for
drug seeking behavior.
Past Medical History:
Per Discharge Summary ([**2182-6-18**])
Poly Substance Abuse: Benzo/Opiates/IVDU
2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated
in the past.
3. Hepatitis C
4. Hepatitis B
5. Compartment Syndrom RLE, [**2171**]
6. OCD and Anxiety
7. Depression with hx of suicidal ideations
8. Sever Peripheral Neuropathy
Social History:
From previous DC summary. States he does not speak to any family
members, never married, no children. Homeless, states he does
not like shelters because he gets "nervous around all the
people."
Family History:
Father with depression, OCD and alcoholism. Mother died of DM
complications
Physical Exam:
VS: T 96 HR 86 BP 128/79 02sat 97% RR 12
GEN: Disheveled, appears older than stated age
HEENT: EOMI, PERRL
NECK: Supple
CHEST: CTABL
CV: RRR, S1S2, no m/r/g
ABD:Soft, NT, ND
EXT: No c/c/e
Skin: Pruritic papular rash on trunk, groin, ankles bilaterally
NEURO: speech slurred, unsteady gait, CN ii-xii intact; able to
answer questions appropriately
.
Pertinent Results:
[**2182-10-10**] 03:10PM GLUCOSE-83 UREA N-12 CREAT-0.8 SODIUM-143
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
[**2182-10-10**] 03:10PM estGFR-Using this
[**2182-10-10**] 03:10PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2182-10-10**] 03:10PM ASA-NEG ETHANOL-244* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2182-10-10**] 03:10PM WBC-5.1# RBC-4.36* HGB-12.5* HCT-37.7* MCV-87
MCH-28.6 MCHC-33.0 RDW-16.5*
[**2182-10-10**] 03:10PM NEUTS-33.2* BANDS-0 LYMPHS-58.8* MONOS-5.5
EOS-1.6 BASOS-0.9
[**2182-10-10**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2182-10-10**] 03:10PM PLT COUNT-239
Brief Hospital Course:
A/P: 38 yo M with PMH of ETOH abuse/withdrawal and multiple
hospitalizations presented with acute intoxication and heroin
use requiring naloxone in ED.
.
ETOH intoxication: ETOH level 244. Speech somewhat slurred on
exam. Pt admits to drinking rum and Listerine. Received Valium
50mg total in ED for CIWA >10. Had 5mg x 3 of Valium in the
MICU. Given thiamine, folate, MVI. Social work was contact[**Name (NI) **] and
paperwork for a section 35 was started. Pt left AMA before
paperwork could be completed (will take several days). Will need
to continue paperwork if pt returns in near future.
Scabies: Pt was treated with permethrin cream and Ivermectin x
1.
Pt left AMA before further care was done for pt.
Medications on Admission:
Per Discharge Summary ([**2182-6-18**]), Unknown Compliance
1. Folic Acid 1mg Daily
2. Thiamine 100mg Daily
3. MVT One tab Daily
4. Ferrous Sulfate 325mg One Tab Daily
5. Oxcarbazepine 300mg one tablet [**Hospital1 **]
6. Gabapentin 200mg PO Q8H
7. Prozac 40mg Once Daily
Discharge Medications:
left AMA
Discharge Disposition:
Home
Discharge Diagnosis:
left AMA
Discharge Condition:
left AMA
Discharge Instructions:
left AMA
Followup Instructions:
left AMA
Completed by:[**2182-10-11**]
|
[
"331.9",
"070.32",
"300.00",
"300.3",
"V60.0",
"070.54",
"291.81",
"305.50",
"133.0",
"357.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4135, 4141
|
3065, 3779
|
313, 319
|
4193, 4203
|
2348, 3042
|
4260, 4300
|
1885, 1962
|
4102, 4112
|
4162, 4172
|
3805, 4079
|
4227, 4237
|
1977, 2329
|
234, 275
|
347, 1314
|
1336, 1658
|
1674, 1869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,156
| 119,617
|
43730
|
Discharge summary
|
report
|
Admission Date: [**2141-12-6**] Discharge Date: [**2142-1-2**]
Date of Birth: [**2074-4-26**] Sex: M
Service: SURGERY/BLUE
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old
male who presented to the [**Hospital1 188**] Emergency Department on [**2141-12-6**], complaining of
crampy abdominal pain that had worsened during the previous
ten days. The patient was status post cardiac catheterization on
[**2141-11-29**] for atypical chest pain, during which he had been noted
to have three vessel coronary disease with no intervention
performed. The patient reported having intermittent less severe
pain over the previous weeks to months. The patient reported the
pain was worse after meals. The patient had lost fifteen pounds
of weight in the previous one and one half weeks. The patient
had food fear. The patient denied having any recent [**Doctor Last Name **] or
bloody bowel movements or melena. The patient had had no
hematemesis. The patient had no lower extremity claudication or
rest pain since is aortobifemoral bypass.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post cardiac
catheterization [**2141-11-29**] without intervention
2. Peripheral vascular disease, status post aorto-bifemoral
bypass in [**2131**].
3. Hypertension.
4. Achalasia s/p dilation
5. Hypercholesterolemia.
MEDICATIONS ON ADMISSION:
1. Lipitor 10 mg p.o. once daily.
2. Pepcid 20 mg p.o. twice a day.
3. Lisinopril 40 mg p.o. once daily.
4. Aspirin 325 mg p.o. once daily.
5. Toprol XL 75 mg p.o. once daily.
6. Imdur sustained release 30 mg p.o. once daily.
7. Plavix 75 mg p.o. once daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient occasionally drank alcohol and
smoked one to two cigarettes per day. The patient denied
intravenous drug use.
PHYSICAL EXAMINATION: On presentation, the patient's
temperature was 98.9, heart rate 78, blood pressure 220/90,
respiratory rate 18 and oxygen saturation 95% in room air.
Physical examination was notable for abdomen that was softly
distended and diffusely tender to palpation with the
tenderness greatest to the right of the midabdomen. On
rectal examination, the patient was guaiac positive.
LABORATORY DATA: The patient's white blood cell count was
18.8, hematocrit 44.0, platelet count 424,000. He had 80%
neutrophils and 12% lymphocytes, as well as 5% monocytes.
His INR was 1.1. with a prothrombin time of 13.1 and partial
thromboplastin time of 26.8. His serum sodium was 134, serum
potassium 5.0, chloride 98, bicarbonate 24, blood urea
nitrogen 26, creatinine 1.5, glucose 104. Liver function
tests were normal.
HOSPITAL COURSE: While in the Emergency Department, general
surgery and vascular surgery consultations were requested.
The patient's presentation was strongly suspicious for
mesenteric ischemia. A CAT scan was obtained showing
occlusion of the proximal superior mesenteric artery with
distal reconstitution. There was mild narrowing of the
proximal celiac axis. There were no secondary signs of
mesenteric ischemia on this imaging study. The patient was also
noted to have an appendix that was borderline in size with some
thickening (0.8 cm) with no definite surrounding inflammatory
changes. Suspicion was still strong for mesenteric ischemia. The
patient was started on empiric antibiotic coverage with
Levofloxacin and Flagyl. Plans for mesenteric catheterization
were initiated. The decision was made to continue performing
serial examinations through the night of [**2141-12-6**]. On the
morning of [**2141-12-7**], the patient had an increase in his abdominal
pain. CAT scan at 7:25 a.m. on the morning of [**2141-12-7**], revealed
a large amount of mesenteric venous and portal venous gas with
pneumatosis of the cecum. The occlusion of the patient's
superior mesenteric artery and the high grade stenosis of the
proximal celiac axis was stable from previous CAT scan. The
appendix remained dilated with minimal stranding. Given the
concerning findings on the CT scan, the patient was emergently
taken to the operating room for exploration. The patient was
found to have ischemic small bowel with necrotic colon secondary
to superior mesenteric artery occlusion and thrombus. The
patient underwent lysis of adhesions, subtotal abdominal
colectomy, partial omental resection, creation of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**]
pouch, superior mesenteric artery thrombectomy and patch
angioplasty. Estimated blood loss was 400cc and the patient
received three liters of lactated ringer's. Please refer to
the dictated operative notes for further details.
Postoperatively, the patient was kept intubated with a plan
to return for second look operation on [**2141-12-8**]. In the
postoperative period, the patient was noted to have
electrocardiographic changes and increasing cardiac enzymes
and ultimately ruled in for a postoperative myocardial
infarction. Cardiology involvement was requested and
obtained. The patient was taken to the operating room as
planned on [**2141-12-8**], for a second look. Intraoperatively,
the patient was noted to have approximately 700ml of old
blood in the right and left gutters as well as the pelvis.
This was irrigated out. The liver was found to be normal in
appearance. There was some oozing at the previous site of the
superior mesenteric artery dissection. Bleeding was ultimately
controlled. The distal tip of the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 3379**] pouch
appeared dusky and a segment of this was resected. An ileostomy
was also performed. Intraoperatively, the patient also had a
transesophageal echocardiogram performed which was notable
for identifying a large mobile thrombus in the descending
arch of the patient's aorta. Jejunostomy tube was also
placed. The patient received two liters of intravenous
fluids, one unit of blood and two units of fresh frozen
plasma. Estimated blood loss was 750ml. In the
postoperative period, the patient developed rapid atrial
fibrillation to the 140s which ultimately required
intravenous Amiodarone for control. The patient was
continued on Levaquin, Ampicillin and Flagyl. The patient
was transferred to the Intensive Care Unit intubated. The
patient was started on Heparin drip and was also on
Nitroglycerin drip per cardiology. On postoperative day
number three and two, the patient's mean arterial pressures
were noted to increase and diuresis was initiated. The
patient was also started on TPN. Cardiac catheterization was
also performed on postoperative day three and two which
revealed severe three vessel disease with vasospasm. No
intervention was performed due to the risk of reocclusion and
the diffuse nature of his disease. Trophic tube feeds were
started on [**2141-12-11**]. The patient continued to have intermittent
episodes of rapid atrial fibrillation. The patient's ileostomy
put out occasional old blood and clots but appeared viable. By
[**2141-12-13**], the patient appeared stable and ready for extubation
and ventilator weaning was initiated. By this point, the patient
remained sedated on a Fentanyl drip but was easily arousable and
following commands. On [**2141-12-14**], the patient self extubated by
tonguing out his endotracheal tube. The patient appeared to
tolerate being off the ventilator and was kept on a face mask.
Decision was made not to reintubate at that time. The patient
was also started on a Clonidine patch for his high blood
pressure. On [**2141-12-18**], the decision was made to obtain CAT scan
of the patient's abdomen to rule out an abscess when the patient
developed a fever and a rising white count. No evidence of an
intra-abdominal abscess was identified. The celiac and superior
mesenteric arteries were patent. On [**2141-12-19**], the patient
experienced desaturation in his oxygenation to between 70 and 80
and was also tachypneic, tachycardic and hypertensive. The
patient was suctioned without effect and the decision made to
reintubate. A chest x-ray obtained revealed a white out of the
patient's right lung lower lobe. The patient was believed to
have mucous plugging. A bronchoscopy was performed with thick
copious mucus suctioned from the patient's right lower lobe. A
chest x-ray obtained after the bronchoscopy revealed reexpansion
of the patient's right lower lobe lung. The patient was
empirically started on Ceftriaxone. On [**2141-12-20**], a repeat
bronchoscopy was performed with further suctioning of mucus.
The patient was started on Mucomyst to assist in clearing his
secretions. Around that period, the patient's hematocrit was
occasionally noted to be decreased to the high 20s and he
received occasional units of blood. On [**2141-12-21**], the patient
was successfully extubated. His hematocrit was once again
noted to be decreased and the patient's Plavix was held. The
patient also complained of some abdominal pain and a CAT scan
of the patient's abdomen as well as CT angiogram were ordered
and performed. The CT angiogram revealed that the patient's
vessels were patent with no evidence of bleeding. A right
upper quadrant ultrasound was also ordered given a slight
increase in the patient's liver function tests. This showed
no evidence of cholecystitis or biliary outlet obstruction.
The patient experienced some chest pain on transfer back from
radiology following his CAT scan and was restarted on
Diltiazem, Nitroglycerin and was also briefly on an Esmolol
drip to control his heart rate. The patient's symptoms
resolved and he had minimal electrocardiographic changes. On
[**2141-12-23**], the patient's tube feeds were restarted. Shortly
after the patient's tube feeds were restarted, the patient
had a large melanotic output from his ileostomy. The
decision was made to request gastroenterology consultation
for possible esophagogastroduodenoscopy and ileoscopy. The
esophagogastroduodenoscopy was performed on [**2141-12-27**],
revealing just some mild gastritis with no evidence of active
bleeding. The ileoscopy revealed diffuse erythema and
inflammation of the distal ileum but no evidence of acute
bleeding. In the day or two following this study, the
patient's ileostomy output became nonbloody and his
hematocrit stabilized. By [**2141-12-29**], the patient was deemed
stable enough for transfer to the Stepdown Unit. The patient
was started on clears and his diet later advanced to regular
food. Physical therapy was initiated. The patient's tube
feeds were cycled. A calorie count was initiated. By
[**2141-12-29**], which was postoperative day twenty-two, the
patient's TPN was discontinued and rehabilitation placement
initiated. The patient had by this time been transitioned to
oral Amiodarone with his heart rate in sinus rhythm. The
patient continued on Coumadin dosed once daily. The
patient's Heparin drip had been stopped. By [**2142-1-2**], the
patient was deemed ready for discharge.
At the time of discharge, the patient's midline incision
appeared to be healing well with no evidence of infection.
The patient also had a groin incision that appeared to be
healing well.
The patient complained of a worsening in his vision shortly
prior to discharge. A visual examination by the house
officer revealed no visual field deficits and no scotoma.
The decrease in the patient's visual acuity appeared to be
bilateral. Neurologic examination revealed intact
extraocular muscular function and symmetric strength with no
evidence of a stroke. Outpatient follow-up was deemed to be
appropriate.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Coumadin 5 and 2.5 mg alternating.
2. Dilaudid 2 to 4 mg p.o. q4hours p.r.n.
3. Protonix 40 mg p.o. twice a day.
4. Loperamide 2 mg p.o. four times a day.
5. Amiodarone 200 mg p.o. once daily.
6. Lisinopril 10 mg p.o. once daily.
7. Paxil 20 mg p.o. once daily.
8. Diltiazem 90 mg p.o. four times a day.
9. Plavix 75 mg p.o. once daily.
10. Metoprolol 50 mg p.o. twice a day.
11. Clonidine patch q.week.
12. Albuterol one to two puffs every six hours as needed for
wheezing.
13. Albuterol nebulizer every six hours as needed.
14. Aspirin 325 mg p.o. once daily.
FOLLOW-UP: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2819**] one to two weeks following discharge. The patient is
also to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the vascular
service following discharge. The patient is expected to
continue receiving cardiology care. The patient will need to
follow-up with his primary care physician within one to two
weeks following discharge. The patient will need follow-up
with an optician for visual acuity testing.
DISCHARGE DIAGNOSES:
1. Superior mesenteric artery occlusion secondary to
thromboembolis with mesenteric ischemia/infarction and portal
venous gas
2. Congestive heart failure
3. Myocardial infarction and coronary vasospasm
4. Hypertension
5. Vancomycin resistant Enterococcus colonization (this was
noted on routine weekly Intensive Care Unit VRE screening on
[**2141-12-25**])
6. Lower GI bleed
7. Anemia requiring multiple blood transfusions
8. Malnutrition requiring parenteral and enteral nutrition
9. Atrial Fibrillation
10. Respiratory failure requiring reintubation
11. Cholestatic Jaundice
12. Mental Status Delirium from acute illness
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2142-1-1**] 18:24
T: [**2142-1-1**] 19:13
JOB#: [**Job Number 93983**]
Y
|
[
"557.0",
"428.0",
"263.9",
"518.81",
"997.1",
"410.71",
"540.9",
"427.31",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.4",
"38.06",
"54.59",
"45.13",
"47.19",
"46.01",
"99.05",
"46.39",
"88.56",
"37.22",
"45.79",
"45.76",
"45.12",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12845, 13737
|
11683, 12824
|
1408, 1713
|
2701, 11623
|
1877, 2683
|
162, 179
|
208, 1102
|
1124, 1382
|
1730, 1854
|
11648, 11657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,482
| 115,044
|
4888
|
Discharge summary
|
report
|
Admission Date: [**2151-5-14**] Discharge Date: [**2151-5-21**]
Date of Birth: [**2084-11-24**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: A 66-year-old male presenting
with left arm tingling and neck pain. The patient has been
seen by his physician. [**Name10 (NameIs) **] has been having left shoulder pain
and an outpatient workup showed that he had a spinal cord
tumor, and he also has thyroid cancer not associated to the
spinal vertebral body, and the patient admitted for resection
of the tumor.
PAST MEDICAL HISTORY: Significant for hypertension, kidney
cancer, and also renal cell cancer and thyroid CA (he is SP
radiation therapy in [**2147**]). Hypothyroidism. He had an
appendectomy and also had a left nephrectomy and left
thyroidectomy in [**2147**].
PREOPERATIVE MEDICATIONS: Levoxyl 150 mcg, Norvasc 5 mg once
a day, folic acid 1 mg once a day, lorazepam 1 mg at bedtime.
PHYSICAL EXAMINATION: In general, in no acute distress. His
vital signs are a temperature of 98.6, blood pressure 149/76,
heart rate of 78, respirations 16, and saturation is 97% on
room air. He weighs 160 pounds and height of 5 feet 7 inches.
Chest is clear to auscultation AP bilaterally. Heart regular
rate and rhythm. No murmur. No gallop or bruits. Abdomen
soft, nontender, and nondistended. Bowel sounds positive.
Extremities with no edema. No cyanosis. Neurologic exam
reveals patient is oriented. No cervical tenderness. Muscle
strength is [**6-10**] in all extremities, and toes are upward. His
DTRs are 1+ on the right brachial radialis; otherwise 2+
throughout. No sensory deficits.
LABORATORY DATA: White count is 7.6, hematocrit is 29.9,
platelets are 104. His PT is 14, PTT is 31, INR is 1.2. His
chemistries reveal sodium is 142, potassium is 4.1, chloride
is 104, bicarbonate is 25, BUN is 13, and creatinine is 1.1.
Blood glucose is 137. His ABG is 7.38, PCO2 is 44, PO2 is
157.
RADIOLOGIC STUDIES: The patient's preoperative chest x-ray
showed no acute cardiopulmonary process identified.
BRIEF SUMMARY OF HOSPITAL COURSE: This 66-year-old male
underwent a C7 vertebral body embolization on [**2151-5-14**].
On [**5-15**] he underwent resection of a T1 tumor with a
posterior fusion from C5 to T2 which was separate from his
thyroid cancer which was resected in [**2147**]. After his
procedure he reported some radicular pain down to his fingers
but denied any headache, nausea, vomiting. No double vision.
No ataxia or urinary incontinence. Postoperatively, he did
well. Neurologically, he was alert and oriented x 3. His
motor function was [**6-10**] throughout. Sensation remained intact.
The patient stayed overnight in PACU and then transferred to
the unit on the 10th. He remained neurologically stable, and
his labs remained stable. He was able to be extubated on
[**5-16**] and remained well. He was on Kefzol postoperatively.
The patient was transferred to [**Hospital Ward Name 121**] 5 which is the
neurosurgery floor.
On postoperative day 1, try to increase activity, ambulate
with PT. Also, check postoperative x-rays plain AP and
lateral which were on the lateral radiograph really limited
due to inadequate under-penetration and only showed C1
through C4. On the AP radiograph there has been fusion of C5
through T2 via posterior pedicle screws and rods. An
additional horizontal metallic construct connects the
posterior fixation device at T1. Patient evaluated by PT for
safety for home needs and felt the patient was able to go
home without any services, and he is able to tolerate diet
well and ambulate independently and did well throughout
hospital course. Patient discharged on [**2151-5-21**] without
any complications postoperatively.
MAJOR SURGICAL AND INVASIVE PROCEDURES: He had a T1 tumor
resection and C5 to T2 posterior fusion, and prior to that he
had spinal tumor embolization on the 8th.
DISCHARGE STATUS: The patient neurologically stable.
DISCHARGE MEDICATIONS: Acetaminophen 325 mg 1 to 2 tablets
q.4-6 hours as needed for pain, Levoxyl 150 mcg once a day as
preoperative, Norvasc 5 mg once a day, folic acid 1 mg once a
day, Prilosec 20 mg once a day, Colace 100 mg twice a day,
Keflex 500 mg p.o. q.i.d. for 7 days, oxycodone/acetaminophen
5/325 mg tablets 1 to 2 tablets q.4-6 hours for pain.
FOLLOW-UP PLANS: Follow up with Dr. [**Last Name (STitle) 1132**] on [**2151-5-25**]
for removal of staples. Change dressing Xeroform gauze twice
a day and wound check for redness or any swelling or any
other concerns.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 20397**]
MEDQUIST36
D: [**2151-8-4**] 12:15:43
T: [**2151-8-4**] 13:09:45
Job#: [**Job Number 20398**]
|
[
"401.9",
"198.5",
"198.4",
"193",
"V10.52",
"V45.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"81.63",
"88.49",
"81.03",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
3957, 4293
|
830, 928
|
2076, 3933
|
951, 2047
|
4311, 4766
|
174, 539
|
562, 803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,125
| 189,643
|
19892+57092
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-12-9**] Discharge Date: [**2193-12-13**]
Service: Neurology
CHIEF COMPLAINT: Unresponsiveness.
HISTORY OF PRESENT ILLNESS: This is an 86-year-old gentleman
with a history of melanoma, who presented with
unresponsiveness and seizures on the evening of admission.
As according to the patient's son, he had a resection of
melanoma from his armpit about three weeks prior.
About 10 days prior to admission, his son and daughter noted
that he was not his usual self. He was weak all over and had
less energy than usual. His primary care physician drew
some blood and this revealed only a mild anemia. Apparently
on the evening of admission shortly before midnight, his son
heard labored breathing coming from the room. When he went
into father's bedroom, he noted that he was lying in bed with
his eyes open, and that when he blinked, his eyes were not
closing all the way. He was not responsive to voice, but he
was able to grip his son's hands on both sides. He could not
get him out of bed. EMS was called and while in the
ambulance, he remained unresponsive and a generalized seizure
was witnessed.
He became unresponsive with gaze fixed to the left with a
left pupil fixed and a flaccid left arm and leg. He was
incontinent. He was given 5 mg Diazepam IV push and this
resolved the seizure activity. The EMS did note that during
that seizure also that he had facial tic progressing to full
body seizure activity. He was brought to the [**Hospital1 346**] Emergency Room for further
evaluation. He received vecuronium, Fentanyl, etomidate, and
succinylcholine for intubation.
PAST MEDICAL HISTORY:
1. Multiple melanomas.
2. CABG [**00**] years ago.
3. Coronary stents x3.
4. Hypertension.
5. Diabetes.
6. Normal cholesterol.
7. Lung cancer about 12 years ago which was treated somehow
and details are not clear, however, is in remission.
MEDICATIONS UPON ADMISSION:
1. Plavix 75 mg p.o. q.d.
2. Toprol 100 mg p.o. q.d.
3. EC-ASA 325 mg p.o. q.d.
4. Allopurinol 300 mg p.o. q.d.
5. Imdur 60 mg p.o. q.d.
6. Flomax 0.4 mg p.o. q.d.
7. Lipitor 20 mg p.o. q.d.
8. Diltiazem 60 mg p.o. q.d.
ALLERGIES: Antihistamines supposedly.
FAMILY HISTORY: No history of strokes or seizures. His
brothers all died of myocardial infarctions in their 50's and
60's.
SOCIAL HISTORY: He lives at home with his son. [**Name (NI) **] is self
sufficient and still drives. He is a lawyer and is still
working full-time per his family. There is no smoking
history. He does drink 1-2 drinks per night.
EXAM UPON PRESENTATION: Temperature 97.8, heart rate 100,
blood pressure 130/100, respiratory rate 20, and O2
saturation 100% while intubated. In general, this is an
elderly man in no apparent distress and no signs of trauma.
HEENT: A large lesion on the nose that appears to be either
a basal cell carcinoma or a melanoma. Lungs are clear to
auscultation bilaterally. The cardiovascular examination
reveals a slightly tachycardic rate with a regular rhythm.
There are no murmurs that are appreciated. Abdomen is soft,
nontender, and positive bowel sounds. Extremities: Large
lesion on the right leg, which again appears to be a skin
dysplasia that is somewhat dark and necrotic.
NEUROLOGIC EXAMINATION: He is intubated. He does not appear
to be breathing without the vent. He does not respond to
voice. His pupils are symmetric at 2.5 mm and reactive to
light. His corneas are present bilaterally. There is gag.
He pronates to painful stimulation in the left arm. He
withdrew somewhat more briskly to pain on the right side in
the upper and lower extremities. There is slight withdraw in
the legs bilaterally, but they seem less brisk than the upper
extremities. His deep tendon reflexes are 3+ throughout and
symmetric with no ankle clonus. The toes were equivocal, but
appear to go up on the left and down on the right.
LABORATORIES UPON PRESENTATION: White count 11.5, hematocrit
34.7, platelets 246, MCV 104. Chem-7 revealed a sodium of
142, potassium of 4.2, chloride 103, bicarb of 16, BUN 18,
creatinine 0.8, and glucose 137. Her calcium was 9.8, his
magnesium was 1.6, and the phosphate was 3.8. ABG on the
ventilator was 7.30/48/306. His coagulation studies were
normal with an INR of 1.1, PT of 12.8, and PTT of 24.5. His
urinalysis was negative for urinary tract infection.
A head CT upon admission showed multiple areas of
intraparenchymal hemorrhage, the largest of which was in the
thalamus on the right. There were multiple cortically based
hyperintensities bilaterally. There was a large amount of
edema associated with the lesions, especially in the frontal
lobes bilaterally with right greater than left.
HOSPITAL COURSE: Patient was admitted to the Neuro ICU for
frequent neuro checks and blood pressure management. He was
given 1 gram of Dilantin in the Emergency Room as well as 10
mg of decadron. He gradually woke up the next day of
admission, but was not weaned off the vent until the third
hospital day after it was noted some secretions were
appearing from the trache.
1. Hyperdense cerebral lesions: These were most
likely metastatic melanoma, and they had a hemorrhagic
component to them. His blood pressure was kept no higher
than systolic of 160. He was continued on maintenance
Dilantin at 100 mg p.o. t.i.d. and had a gradual decrement in
his Dilantin levels while taking famotidine. His Dilantin
level was increased to 150 mg in the morning and 200 mg IV at
night. He had no further seizure activity.
He had an EEG performed early in the hospital course which
showed only encephalopathy bilaterally, and no epileptiform
features. He was also continued on decadron 6 mg q.6h. for
the management of edema, while the family was deciding
whether the patient would undergo radiation treatment for
metastatic melanoma.
The patient gradually woke up and was extubated on [**2193-12-11**],
and did rather well with chest PT and suctioning. His level
of alertness improved, and he is able to follow most commands
intermittently, but was still noted to be somewhat drowsy.
His speech was somewhat understandable, but was always
hypophonic and it appeared that he was oriented at least to
place and time.
His neurologic examination improved to where he was moving
all four extremities symmetrically, and again as noted, he
appeared to follow commands intermittently depending on his
level of consciousness.
2. Cardiovascular: He was ruled out for myocardial
infarction by cardiac enzymes. He was continued on his
metoprolol and atorvastatin for his cardiac disease.
3. Pulmonary secretions: As noted, the patient had many
secretions and on the day of extubation, required continuous
suctioning every one hour. By the day before discharge, the
patient had decreased secretions and responded well to chest
physical therapy. He was saturating 99% on room air without
any supplemental O2.
4. FEN/GI: The patient was given nasogastric tube for tube
feeds and he tolerated these well. He was also continued on
insulin-sliding scale while on the steroids for treatment of
steroid induced hypoglycemia. His electrolytes remained
stable throughout the hospital course.
5. Infectious disease: The patient did spike one temperature
to 101 with blood cultures and sputum cultures sent off which
are still negative growth to date. He has not spiked any
further temperatures and was not given any antibiotics, and
has done well.
Radiologic studies: Series of portable chest x-rays on
[**12-9**] and [**12-10**] show appropriate placement of
the nasogastric feeding tube as well as no evidence of any
focal consolidations in the lung parenchyma. There was noted
to be some slight left lower lobe atelectasis. There were
also noted probable small bilateral pleural effusions with a
slight increase in upper zone redistribution of the pulmonary
vasculature.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: [**Hospital3 **] Medical Center.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg p.o./ng q.4-6h. prn fever or pain.
2. Metoprolol 50 mg nasogastric b.i.d.
3. Atorvastatin 20 mg nasogastric q.d.
4. Dexamethasone 6 mg IV q.6h.
5. Regular insulin-sliding scale.
6. Famotidine 20 mg IV q.12h.
7. Phenytoin 150 mg IV q.a.m. and 200 mg IV q.p.m.
8. Normal saline at 80 cc an hour.
9. Impact tube feeds with fiber full strength at goal rate of
75 cc an hour with residual checks q.4h. and hold for feeding
or residual greater than 150 cc.
CONSULTS OBTAINED: Neuro-Oncology consult was done by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. The family should consider whether he would like
radiation treatment for these hemorrhagic metastases thought
to be likely melanoma. The family was informed of this
recommendation, and they proceeded to watch the patient's
clinical course to determine his neurologic status after
resolution of his acute alterations of level of consciousness
due to seizure and edema. They requested the transfer to [**Hospital6 **], where all of his care is given and the
accepting facility has accepted the patient pending an
available bed.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2193-12-13**] 08:26
T: [**2193-12-13**] 08:25
JOB#: [**Job Number 53720**]
Name: [**Known lastname 9971**], [**Known firstname **] Unit No: [**Numeric Identifier 9972**]
Admission Date: [**2193-12-9**] Discharge Date: [**2193-12-13**]
Date of Birth: [**2107-5-21**] Sex: M
Service:
ADDENDUM: The patient did have a leukocytosis during his
hospital stay of up to 20,000. A source was never found for
infection including blood cultures, urine cultures, and
sputum cultures. As mentioned before in the Discharge
Summary, he did spike only once. His white blood cell count
did come down to 17,000 on [**2193-12-13**]. This was
thought possibly due to a stress response/steroids.
The patient also received a peripherally inserted central
catheter because peripheral intravenous access was difficult
on this gentleman. He went down to Interventional Radiology
for a fluoroscopically-guided peripherally inserted central
catheter placement, and this is now being used for access and
blood draws as well.
[**First Name8 (NamePattern2) 2121**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9973**]
Dictated By:[**Name8 (MD) 74**]
MEDQUIST36
D: [**2193-12-13**] 08:33
T: [**2193-12-13**] 08:43
JOB#: [**Job Number 9974**]
|
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"250.00",
"518.81",
"198.3",
"V10.11",
"401.9",
"780.39",
"V10.82",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7890, 7950
|
2198, 2307
|
7973, 10624
|
4713, 7868
|
114, 133
|
162, 1629
|
1920, 2181
|
3255, 4695
|
1651, 1906
|
2324, 3230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,699
| 146,761
|
54343
|
Discharge summary
|
report
|
Admission Date: [**2150-3-26**] Discharge Date: [**2150-4-1**]
Date of Birth: [**2091-4-23**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Sulfonamides / Avandia / Combivir / Lasix
Attending:[**Attending Info 65513**]
Chief Complaint:
bilateral complex cystic adnexal masses and thickened
endometrium
Major Surgical or Invasive Procedure:
s/p TAH-BSO [**2150-3-26**]
History of Present Illness:
58yo F with h/o DM2, obesity (270lbs), restrictive and
obstructive pulmonary disease on O2 at night and with exertion,
diastolic dysfunction with EF 65% (with 1+MR), renal
insufficiency, and OSA who underwent TAH for complex pelvic mass
and was admitted to the [**Hospital Unit Name 153**] for weaning of intubation. Mrs.
[**Known lastname **] had bilateral complex adnexal masses and a thickened
endometrium seen on pelvic ultrasound. She was evaluated by Dr.
[**Last Name (STitle) 5797**] and recommended to undergo a TAH and BSO for removal
and diagnosis of masses to r/o cancer. She underwent an
extensive pre-op evaluation, including evaluation by Dr. [**Last Name (STitle) **]
who recommended aggressive IS after the OR given her restrictive
disease. She underwent her TAH/BSO and was intubated in the OR
and because of her complicated medical status she was not
extubated post-surgery. Intraop pathology was benign. She has
been admitted to the ICU for weaning off the ventilator. On
arrival to the floor the patient wa intubated but awake and
initial risbi was <100 on PS 5/5. She complained of some pain at
the incision site which was relieved with IV morphine. She was
extubated and remained on 3L NC.
Review of sytems: As above.
Past Medical History:
Restrictive lung disease [**2-10**] Obesity per Dr. [**Last Name (STitle) **] notes
IDD
CAD (RCA stent)
CHF (EF 55% [**2148**])
[**1-18**] stable MIBI and neg stress test
Pulm HTN
mitral regurg
HLD
HTN
OSA
CRI
GERD
DJD
depression
iron deficiency anemia
glaucoma
COPD per report in Dr.[**Name (NI) 1985**] earlier notes but spirometry
consistent with restriction only - uses 2L O2 with ambulation
and at night
.
PSHx: Breast bx, tonsillectomy, angioplasty x2, bladder
suspension/collagen injection for stress incontinence
Social History:
Brother is EP doctor here. Patient works as a manager at Pap
[**Male First Name (un) 45193**] and spends a great deal of time on her feet. She does not
smoke, but has
smoked [**1-10**] pack per day for 5-6 years. She has not smoked for
3-4 years now. She denies alcohol use. She denies use of illicit
drugs or non-prescription medications. She is a widdow and has
two sons, the [**Name2 (NI) 1685**] of which has autism and lives with her.
Family History:
Significant for coronary artery disease and arrhythmia in both
parents and diabetes mellitus in mother.
Physical Exam:
Vitals: T:97.4 BP:126/67 P:63 R: 18 O2: 96% on 2L NC
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM,
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. incision
c/d/i
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2150-3-26**] 03:13PM TYPE-ART TEMP-36.6 O2-50 PO2-121* PCO2-42
PH-7.32* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED
[**2150-3-26**] 11:58AM TYPE-ART PO2-143* PCO2-47* PH-7.33* TOTAL
CO2-26 BASE XS--1 INTUBATED-INTUBATED
[**2150-3-26**] 11:58AM GLUCOSE-112* LACTATE-1.9 NA+-139 K+-4.3
CL--105
[**2150-3-26**] 11:58AM HGB-12.1 calcHCT-36
[**2150-3-26**] 11:58AM freeCa-1.15
.
ABG: 7.33/47/143/26
.
PFTs [**2-18**]:
Her pulmonary function tests today continue to show moderate
restriction, albeit improved compared to her last visit. Her
FEV1 is 61% of predicted at 1.32 liters. Her FVC is 59% of
predicted, at 1.73 liters. These values are actually up,
compared with the last two visits.
[**2150-4-1**] 06:30AM BLOOD WBC-12.7* RBC-3.92* Hgb-10.8* Hct-33.3*
MCV-85 MCH-27.6 MCHC-32.5 RDW-15.0 Plt Ct-285
[**2150-3-31**] 06:40AM BLOOD WBC-13.2* RBC-3.96* Hgb-10.7* Hct-32.9*
MCV-83 MCH-26.9* MCHC-32.4 RDW-15.2 Plt Ct-293
[**2150-3-30**] 09:15AM BLOOD WBC-14.0* RBC-3.94* Hgb-10.8* Hct-33.4*
MCV-85 MCH-27.3 MCHC-32.2 RDW-15.0 Plt Ct-276
[**2150-3-30**] 07:10AM BLOOD WBC-13.2* RBC-3.97* Hgb-10.8* Hct-34.0*
MCV-86 MCH-27.2 MCHC-31.8 RDW-15.1 Plt Ct-281
[**2150-3-29**] 06:50AM BLOOD WBC-17.2* RBC-4.08* Hgb-11.2* Hct-34.5*
MCV-85 MCH-27.4 MCHC-32.4 RDW-15.2 Plt Ct-236
[**2150-3-28**] 02:35PM BLOOD WBC-23.2* RBC-4.26 Hgb-11.4* Hct-36.1
MCV-85 MCH-26.9* MCHC-31.7 RDW-15.3 Plt Ct-315
[**2150-3-28**] 05:55AM BLOOD WBC-19.8* RBC-4.05* Hgb-11.1* Hct-34.4*
MCV-85 MCH-27.5 MCHC-32.3 RDW-15.0 Plt Ct-256
[**2150-3-27**] 03:10AM BLOOD WBC-15.1* RBC-4.16* Hgb-11.5* Hct-35.1*
MCV-84 MCH-27.6 MCHC-32.7 RDW-14.9 Plt Ct-233
[**2150-4-1**] 06:30AM BLOOD Glucose-120* UreaN-30* Creat-1.2* Na-142
K-3.9 Cl-105 HCO3-28 AnGap-13
[**2150-3-31**] 06:40AM BLOOD Glucose-142* UreaN-38* Creat-1.2* Na-138
K-4.1 Cl-104 HCO3-25 AnGap-13
[**2150-3-30**] 09:15AM BLOOD Glucose-172* UreaN-43* Creat-1.4* Na-134
K-4.4 Cl-101 HCO3-25 AnGap-12
[**2150-3-29**] 06:50AM BLOOD Glucose-212* UreaN-44* Creat-1.5* Na-132*
K-4.8 Cl-99 HCO3-23 AnGap-15
[**2150-3-28**] 05:55AM BLOOD Glucose-197* UreaN-40* Creat-1.7* Na-136
K-5.1 Cl-100 HCO3-24 AnGap-17
[**2150-3-27**] 03:10AM BLOOD Glucose-129* UreaN-26* Creat-1.2* Na-140
K-5.1 Cl-106 HCO3-25 AnGap-14
[**2150-3-26**] 09:31PM BLOOD Glucose-157* UreaN-28* Creat-1.3* Na-139
K-5.5* Cl-106 HCO3-22 AnGap-17
[**2150-3-27**] 10:03AM BLOOD CK-MB-43* MB Indx-1.6 cTropnT-<0.01
[**2150-3-27**] 03:10AM BLOOD CK-MB-48* cTropnT-<0.01
[**2150-4-1**] 06:30AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0
[**2150-3-31**] 06:40AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.1
[**2150-3-30**] 09:15AM BLOOD Calcium-9.2 Phos-2.3* Mg-2.1
[**2150-3-29**] 06:50AM BLOOD Calcium-9.6 Phos-2.2* Mg-2.0
[**2150-3-28**] 02:35PM BLOOD Mg-2.1
[**2150-3-28**] 05:55AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
Brief Hospital Course:
58yo female with h/o restrictive (likely from obesity) and
obstructive pulmonary disease, diastolic CHF, OSA, morbid
obesity who underwent a uncomplicated TAH/BSO for intraoperative
benign disease on [**2150-3-26**]
.
# PostOp Care: The patient was initially transferred to the ICU
immediately post-operatively for monitoring of her fluid shifts
given her multiple medical co-morbidities. She did well post op
and was transferred to the gyn floor on POD1. The patient's
pain was initially controlled with a Dilaudid PCA until her diet
was advanced to regular. At this time the patient was
transitioned to oral dilaudid. The patient was ambulating
independently. Physical therapy was consulted to assist the
patient with ambulation but she was doing well on her own.
.
# Restrictive Lung disease: The patient was extubated in arrival
to the [**Hospital Unit Name 153**] without complication. She did well post-intubation
on O2 by NC. CPAP and 2L NC ordered for night per her home
regimen. Post-operative chest xray showed atelectasis vs.
aspiration, but no evidence of pneumonia. Home bronchodilators
were continued. Respiratory therapy worked with the patient and
she received nebulizer treatments while in house.
.
#GU: The patient has a history of chronic renal insufficiency.
I/O's were strictly monitored. Fluid boluses were kept a
minimum. Daily Cr was followed. The patient's foley was
discontinued on post-operative day 5. The patient voided
spontaneously. Prior to discontinuation of foley catheter a
urine culture was sent. The results of this are still pending
and will need to followed up on as an outpatient. At time of
discharge the patient's urine output was excellent and creatine
was at baseline.
.
# FEN/GI: Daily electrolytes and CBC were checked for the
patient. Her electrolytes were repleated as needed. Her diet
was gradually advanced to regular with passage of flatus. At
time of discharge, the patient was tolerating a regular diet and
in good condition.
.
# CAD: Patient has a history of PTCA and BMstent placement in
RCA in [**2143**] and cath in [**2146**] showing diffsue disease (no
intervention) and is on statin, plavix, imdur, toprol, asa at
home. The patient's aspirin was restarted on post-operative day
#1. She was continued on her statin, metoprolol throughout her
hospital course. Her blood pressures remained in normal range.
Her valsartan was restarted on POD #5 and her plavix was
restarted on POD#6.
.
# OSA: CPAP and 2L NC at night per home regimen.
.
# IDDM: Patient on glargine [**Hospital1 **] at home. Monitored on ISS and
bedtime glargine which was titrated up as patient's diet was
advanced. [**Last Name (un) **] was consulted and gave daily recommendations
for insulin. The patient was discharged home on 60 units of
glargine QHS in addition to a humolog sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**]
recommendations.
.
# Hyperlipidemia: The patietn is on statin and zetia at home.
Her home medications were restarted on post-operative day #1.
Medications on Admission:
Meds at home (per chart):
bumetanide 1mg daily
clopidogrel 75mg daily
ezetimibe 10mg daily
fluoxetine 20mg daily
advair 1 puff [**Hospital1 **]
aspart
glargine
isosorbide mononitrate 60mg daily
clonopin 0.5mg prn
metoclopramide 10mg daily
metoprolol XL 100mg daily
KCl 10 mEq every other day
pravastatin 80mg daily
ranitidine 300mg daily
valsartan 160mg daily
tylenol/codeine#3 30/300mg tid prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for prn pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous at bedtime.
Disp:*1000 units* Refills:*2*
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Adnexal masses
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You underwent a total abdominal hysterectomy and bilateral
salpingo-oophorectomy. Please keep all of you follow up
appointments as instructed. Please take all of your discharge
medications as directed. Please call the office for fever
>100.4, chills, nausea, vomiting, heavy vaginal bleeding,
shortness of breath, chest pain, strong abdominal pain not
controlled by your medications, or any other concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2150-4-20**] 11:30
Staple removal appt [**2150-4-9**], 3:00pm, [**Hospital Ward Name 23**] Bldg [**Location (un) **].
[**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]
|
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icd9cm
|
[
[
[]
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[
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|
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|
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|
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|
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436, 1650
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|
2241, 2682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
864
| 138,624
|
29066
|
Discharge summary
|
report
|
Admission Date: [**2114-11-25**] Discharge Date: [**2114-12-2**]
Date of Birth: [**2043-9-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2114-11-26**]
Coronary Artery Bypass Graft x3 (saphenous vein graft -> left
anterior descending, saphenous vein graft -> right coronary
artery, saphenous vein graft->posterior lateral branch)[**2114-11-27**]
History of Present Illness:
71 year old male with new onset chest pain. He was awoken from
sleep at approximately 2AM with chest "burning" in the left
parasternal area, that radiated to his left jaw, relieved with
SL NTG at [**Hospital3 **] and then reoccured. Was transferred
for further cardiac management. He denied SOB or diaphoresis,
but did admit to some mild nausea with his chest pain. He
denies any prior history of chest pain or chest pressure in the
past. He does admit to some mild SOB while walking up stairs as
well as calf pain when walking distances.
Past Medical History:
- Type II DM
- HTN
- Hypothyroidism
- Hyperlipidemia
- Depression
- GERD
- TIAs
- s/p Right carotid endarterectomy [**9-28**]
- s/p hip replacement
- s/p left mastectomy 3 years ago for breast cancer (breast
cancer diagnosed after patient noted bleeding from left nipple)
Social History:
Patient lives with his wife in southern [**Name (NI) 3914**]. Formerly
operated a bed and breakfast.
- Quit smoking 50 years ago, smoke 1 ppd x 6-8 years
- Occasional EtOH use, 1-2 times/month
- No recreational drug use
Family History:
Father- MI at age 63
Mother- MI at age 80
Physical Exam:
Vitals T 97.7, BP 132/51, HR 77, RR 18, O2 sat 99% on 4L
Gnl: NAD, Alert and oriented x 3
HEENT: PERRLA, Anicteric, MMM, JVP to angle of jaw; Well healed
right carotid endarterectomy scar along right neck
CV: RRR, Normal S1 + S2, No murmurs, rubs or gallops
Chest: Left mastectomy scar, well healed
Resp: Clear to auscultation bilaterally, No wheezes or crackles
Abd: Soft, Nontender, NABS, No hepatosplenomegaly
Extremities: No cyanosis, or clubbing; 1+ LE edema on shins;
DT/PT intact, feet warm, hairless lower legs
skin/nails: no rashes/no jaundice/no splinters
Neuro: AAOx3
Discharge
Vitals 98.1, 70 sr, 130/70, 20, 99% RA
Gen A/Ox3 NAD
Cards RRR
Lungs CTAB
Abd +BS
Inc sternum stable
Ext no edema
Pertinent Results:
CXR [**11-28**]
Lung volumes are preserved following extubation. Mild
enlargement of the postoperative cardiomediastinal silhouette is
comparable. Lungs are clear and there is no pleural effusion or
pneumothorax.
TEE [**11-27**]
PRE-CPB No atrial septal defect is seen by 2D or color Doppler.
There is mild
symmetric left ventricular hypertrophy. Regional left
ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are
simple atheroma in the aortic arch. There are complex (>4mm)
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 leaflets are mildly thickened. Mild (1+) mitral
regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
POST-CPB Normal biventricular systolic function. No other
changes from pre-CPB
findings. Thoracic aorta appears intact.
[**2114-12-2**] 04:28AM BLOOD WBC-10.6 RBC-2.62* Hgb-7.9* Hct-22.4*
MCV-86 MCH-30.0 MCHC-35.1* RDW-15.0 Plt Ct-246
[**2114-11-25**] 10:00AM BLOOD WBC-9.2 RBC-3.70* Hgb-11.0* Hct-32.4*
MCV-88 MCH-29.8 MCHC-34.1 RDW-14.0 Plt Ct-180
[**2114-12-2**] 04:28AM BLOOD Plt Ct-246
[**2114-11-28**] 02:34AM BLOOD PT-13.0 PTT-24.9 INR(PT)-1.1
[**2114-11-25**] 10:00AM BLOOD Plt Ct-180
[**2114-11-25**] 10:00AM BLOOD PT-15.3* PTT-70.7* INR(PT)-1.4*
[**2114-12-2**] 04:28AM BLOOD Glucose-118* UreaN-37* Creat-1.6* Na-136
K-4.5 Cl-101 HCO3-25 AnGap-15
[**2114-11-25**] 10:00AM BLOOD Glucose-195* UreaN-32* Creat-1.4* Na-140
K-4.9 Cl-107 HCO3-21* AnGap-17
[**2114-11-26**] 12:01PM BLOOD ALT-15 AST-32 AlkPhos-41 Amylase-39
TotBili-0.4
Brief Hospital Course:
Presented to [**Location (un) 620**] [**Hospital1 18**] with chest pain and then transferred
to [**Hospital1 18**] for cardiac management. He ruled in for STEMI [**11-25**] and
then underwent cardiac catherization [**11-26**] which revealed 3
vessel coronary artery disease. He underwent cardiac surgery
preoperative workup and [**11-27**] went to the operating room for
coronary artery bypass graft surgery. Please see operative
report for further details. He was transferred to the cardiac
surgery unit on insulin, propofol, and neosynephrine. In the
first 24 hours he awoke neurologically intact, extubated without
difficulty, and weaned off vasopressors. He continued to
progress and was transferred to [**Hospital Ward Name **] 2 on post operative day 1.
He continued to progress except for elevated blood sugars and
returned to the cardiac surgery recovery unit for blood glucose
management and insulin drip. He was transitioned back to NPH
and regular insulin sliding scale with controlled blood sugars.
He was transferred to [**Hospital Ward Name **] 2 were he continued to progress and
was ready for discharge with VNA services on postoperative day
5. Plan for continued glucose monitoring and follow up with Dr
[**Last Name (STitle) 11694**].
Medications on Admission:
Celexa 20mg PO daily
Ritalin 10mg PO BID
Glyburide 5mg PO BID
Synthroid 175mcg PO daily
Trazadone 100mg PO daily
Guaifenesin 600mg PO BID
Insulin NPH 20 units QAM/25 units QPM
Insulin Regular 5 units QAM/ 10 units QPM
Lisinopril 20mg PO daily
Terazosin 5mg PO QHS
Rosigilitazone 4 mg PO daily
Lovastatin 20mg PO daily
Prilosec 20mg PO daily
Hyoscyamine 0.375 PO daily
Aspirin 325mg PO daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
for 5 days
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*175 Tablet(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
NPH insulin resume home dosing varying scale
Regular insulin continue with sliding scale as prior to
admission
Trazadone 100mg once daily
Guaifenisin 600mg twice a day
Hytrin 5mg once daily
Rosiglitazone 4mg twice a day
Zocor 20mg once daily
Prilosec 20mg daily
Hyoscyamine 0.375mg once daily
Discharge Disposition:
Home With Service
Facility:
VNA Alliance NH and [**State 3914**]
Discharge Diagnosis:
Cardiac Catherization [**2114-11-26**]
Coronary Artery Bypass Graft x3 (saphenous vein graft -> left
anterior descending, saphenous vein graft -> right coronary
artery, saphenous vein graft->posterior lateral branch)[**2114-11-27**]
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 poiunds in 24 hours or
5 pounds in one week
No creams, lotions, powders, or ointments to incisions
No driving for one month
No heavy lifting (10 pounds) for 10 week
Call with any questions or concerns
Followup Instructions:
Dr. [**Last Name (STitle) **] in CT surgery clinic in 4 weeks. Please call
[**Telephone/Fax (1) 170**] for an appointment.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2114-12-3**]
|
[
"244.9",
"250.00",
"414.01",
"585.9",
"410.71",
"428.0",
"403.90",
"530.81",
"272.4",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"39.61",
"88.55",
"99.04",
"37.22",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7031, 7098
|
4241, 5504
|
333, 567
|
7374, 7381
|
2472, 4218
|
7825, 8090
|
1688, 1732
|
5945, 7008
|
7119, 7353
|
5530, 5922
|
7405, 7802
|
1747, 2453
|
283, 295
|
595, 1138
|
1160, 1434
|
1450, 1672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,148
| 176,144
|
39916
|
Discharge summary
|
report
|
Admission Date: [**2197-2-28**] Discharge Date: [**2197-3-6**]
Date of Birth: [**2111-9-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
[**3-1**]: diagnostic cerebral angiogram
[**3-2**]: craniotomy and resection of mass
History of Present Illness:
85yo woman known to the neurosurgery service since [**2196-9-10**] when
she presented to the ED with pressure ulcers,rhabdomyolysis and
renal failure after being found down in her bath tub. A head CT
was performed which revealed a frontal parafalcine base avidly
enhancing mass. Pt has been followed closely and recent imaging
revealed interval increase in size.
Past Medical History:
DM type 2
CAD s/p stent and pacer defibrilaltor in [**2194**]
Spondylolisthesis of lower back for which she bas never been
operated on but that it causes her occasional numbness and
weakness of her lower extermities. This has been since an
injury
in [**2146**] when she fell straight down.
Social History:
The patient is a lifelong non-smoker.
She worked in internal accounting at Price Waterhouse. She
admits
to rare alcohol use.
Family History:
NC
Physical Exam:
PHYSICAL EXAM UPON DISCHARGE:
awake, a+o to self, hospital & date
PERRL, EOMI
face symmetric, tongue midline
MAE's with good strengths
following all commands
incision- dissolvable sutures, well healing
Pertinent Results:
[**3-1**] Head CT:IMPRESSION: 4.1 x 4.9 cm extra-axial dural based
mass in the anterior cranial fossa with displacement of the
anterior cerebral arteries. There is no shift of midline
structures.
[**3-2**] Head CT:IMPRESSION: Unchanged appearance of 4 x 5 cm
extra-axial mass in the anterior cranial fossa- redemonstrated
for planning for surgery.
[**3-4**] Head CT:IMPRESSION: Redemonstration of postoperative changes
status post right frontal craniotomy and resection of inferior
frontal mass, with no evidence of postoperative hemorrhage,
infarcts, or other complication.
Brief Hospital Course:
Pt presented electively on [**2-28**] for preop angiogram. Due to
scheduling this was not able to be performed. She was admitted
in anticipation of angiogram the following morning.
On [**3-1**] she underwent a cerebral angiogram without embolization
due to tortuosity of vessels and calcifications. Procedure was
without complication. She was transferred to the PACU for close
neurological monitoring post op. She returned to the floor for
the evening of [**3-1**] and on the morning of [**3-2**] she went to the
operating room for a craniotomy for resection of her meningioma.
Surgery was without complication. She was extubated and
transferred to the ICU. Post operative head CT revealed no
hemorrhage and good resection.
On [**3-3**] she remained neurologically stable and monitored closely
in the ICU. on [**3-4**] she was cleared for transfer to the floor.
Her foley was discontinued and meds were changed to PO. The
patient had a fall and when examined she was noted to have a
small amount of blood over her incision. A stat head CT was
performed and negative for interval change.
On [**3-5**] & [**3-6**] she worked with PT & OT who recommended discharge
to rehab. urine output was closely monitored and labs were
repleted as necessary. She was cleared for discharge pending bed
availability.
Medications on Admission:
Lipitor, Plavix, eplerenone, furosemide, levothyroxine,
lisinopril, Toprol [**Last Name (LF) 8864**], [**First Name3 (LF) **]
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
11. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. heparin (porcine) 5,000 unit/mL Solution Sig: [**11-27**] Injection
TID (3 times a day).
15. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8hrs ()
for 2 days.
16. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8hrs ()
for 2 days.
17. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q8hrs ()
for 2 days.
18. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12hrs ()
for 2 days.
19. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Qdays ()
for 1 days.
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
skull base lesion likely representing a olfactory groove
meningeoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**3-20**]
at 11:30
The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**],
in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2197-5-30**] 10:45
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-5-30**] 10:15
Completed by:[**2197-3-6**]
|
[
"225.2",
"V45.82",
"414.01",
"756.12",
"272.4",
"250.00",
"733.3",
"244.9",
"428.0",
"425.4",
"V45.02",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
5252, 5324
|
2082, 3386
|
285, 371
|
5436, 5436
|
1480, 1490
|
7336, 8052
|
1238, 1242
|
3562, 5229
|
5345, 5415
|
3412, 3539
|
5614, 7313
|
1257, 1257
|
236, 247
|
1287, 1461
|
399, 764
|
1848, 2059
|
5451, 5590
|
786, 1079
|
1095, 1222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,010
| 188,702
|
32787
|
Discharge summary
|
report
|
Admission Date: [**2118-12-30**] Discharge Date: [**2119-1-5**]
Date of Birth: [**2082-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Bloody Stools
Major Surgical or Invasive Procedure:
1. Capsule endoscopy
2. Flexible sigmoidoscopy
History of Present Illness:
36 y/o male with Sarccoidosis presents as a transfer from
[**Doctor Last Name 1263**] Hosptital after presenting on [**2118-12-23**] with nausea, 2
episodes of non bloody vomiting, and four episodes of bloody
bowel movements. He had been using Ibuprofen regularly for pain
from a broken rib. He was admitted to [**Hospital 1263**] hospital with a HCT
of 41, and continued to have [**3-13**] blody bowel movements per day.
On [**12-26**] or [**12-27**], he had a syncopal episode after having a
bloody bowel movement and was transferred to the ICU. He had a
EGD with push enteroscopy, and a colonoscoy which did not reveal
the source of his bleeding. He had a taggged red cell scan which
also did not locate the bleed. He received 2 units PRBC's on
[**2118-12-27**] and 2 units on [**2118-12-28**]. His nadir HCT by record was
22%. He denies alcohol abuse, liver disease, or history of
hematemisis. He denies cocaine abuse. He has not had fevers,
chills, or significant abdominal pain. He denies chest pain,
dyspnea. He does admit to some lightheadedness when walking.
Past Medical History:
Sarcoidosis
Splenectomy s/p stab wound
Asthma
Social History:
Lives in [**Location 16174**] with his fiance and four children. No
tobacco. [**2-12**] drinks of alcohol per week. No cocaine or illicits
other than marijuana.
Family History:
Mother with HTN and Sarcoid. Sister with rectal bleeding
requiring medications.
Physical Exam:
GENERAL: Young, well appreaing african american male.
VITALS: T 98.7 HR 89 BP 152/90 RR 20 SAT 100%RA
HEENT: sclera anicteric, moist mucous membranes.
NECK: NoLAD. No JVP elevation.
CHEST: Lungs clear.
HEART: Regular, soft systolic murmur.
ABD: Soft, NT, ND, good bowel sounds.
EXT: No edema, good pulses.
NEURO: Normal exam.
Pertinent Results:
[**2118-12-31**]
04:47a
139 105 10 80 AGap=16
3.9 22 0.9
89
12.3 10.0 296
29.3
PT: 13.0 PTT: 25.0 INR: 1.1
Comments: PT: Note [**Name (NI) **] Reference Range As Of [**2118-11-23**] 12:00a
[**2118-12-31**]
12:10a
89
13.7 10.1 276
29.5
N:64.2 L:25.5 M:6.7 E:3.4 Bas:0.3
[**2118-12-30**]
11:33p
140 106 9 80 AGap=15
3.7 23 1.0
estGFR: >75 (click for details)
Ca: 9.0 Mg: 1.8 P: 3.2
PT: 12.7 PTT: 19.6 INR: 1.1
CTA ABD W&W/O C & RECONS [**2119-1-5**] 1:08 PM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
Reason: Evaluate for occult sources of GI bleed, including
possible
[**Hospital 93**] MEDICAL CONDITION:
36 year old man with large, occult GI bleed, h/o left rib
fracture and stab wound s/p splenectomy, sarcoid, asthma, with
negative EGD/push enteroscopy/colonoscopy/tagged RBC scan
REASON FOR THIS EXAMINATION:
Evaluate for occult sources of GI bleed, including possible
angiography to evaluate for AV fistulas and ischemia
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL INDICATION: 36-year-old gentleman with large occult GI
bleed. Evaluate for occult sources of possible gastrointestinal
hemorrhage.
TECHNIQUE: 0.625 mm helically acquired images are obtained from
the lung bases to the pubic symphysis both with and without
intravenous contrast. Multiplanar reformations are provided for
interpretation.
FINDINGS: No prior imaging is available for comparison.
The lung bases are grossly clear.
There is evidence of prior splenectomy with splenosis identified
in the region of the surgical bed. The pancreas, adrenal glands,
kidneys, gallbladder, and liver are grossly unremarkable.
Evaluation of the bowel reveals significant circumferential
thickening involving the region of the rectum. Differential
considerations do include neoplasia given this imaging
appearance. Other considerations include inflammatory or
infectious etiologies. Direct visualization is recommended for
further evaluation as clinically indicated. Findings are
discussed with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the time of dictation. Also, there
is a small amount of inspissated oral contrast within the distal
aspect of the appendiceal lumen.
Pelvic structures appear otherwise grossly unremarkable. No
suspicious lytic or blastic bony lesions are seen. Healing
fracture of the right-sided twelfth rib is incidentally noted.
IMPRESSION:
1. Significant thickening of the rectum as noted above.
2. Healing right-sided rib fracture as described above.
3. Findings of prior splenectomy with splenosis in the region of
the surgical bed.
Brief Hospital Course:
Patient was initially observed overnight in the [**Hospital Unit Name 153**] with stable
vital signs and hematocrit and was transferred to the floor. A
bowel prep was performed and capsule endoscopy was performed,
results pending at the time of discharge. A contrast abdominal
and pelvic CT was performed, and the distal rectum was noted to
have hypervascularity. A subsequent flexible sigmoidoscopy was
negative and completely normal. Patient was notably guaiac
negative after bowel prep, with stable hematocrit for 4 days on
discharge. He was scheduled for follow up in [**Hospital **]
clinic.
Medications on Admission:
Ibuprofen prn
Oxycodone prn
Albuterol prn
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*QS * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Gastrointestinal bleed
2. Sarcoidosis
3. Mild intermittent asthma
Discharge Condition:
Stable hematocrit for 5 days
Discharge Instructions:
Please contact your primary care physician if you develop bloody
stools or lightheadedness.
Followup Instructions:
Provider: [**Name10 (NameIs) 8758**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2119-1-31**] 3:00
|
[
"458.9",
"493.90",
"285.9",
"578.1",
"V45.79",
"135"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"44.13"
] |
icd9pcs
|
[
[
[]
]
] |
5804, 5810
|
4769, 5366
|
328, 377
|
5923, 5954
|
2182, 2771
|
6094, 6226
|
1739, 1820
|
5459, 5781
|
2808, 2987
|
5831, 5902
|
5392, 5436
|
5978, 6071
|
1835, 2163
|
275, 290
|
3016, 4746
|
406, 1475
|
1497, 1545
|
1561, 1723
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,158
| 163,428
|
25590
|
Discharge summary
|
report
|
Admission Date: [**2175-7-18**] Discharge Date: [**2175-7-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
c/c: sepsis, gallstone pancreatitis
Major Surgical or Invasive Procedure:
ERCP on [**7-18**].
History of Present Illness:
[**Age over 90 **]F with a history of renal cell CA s/p nephrectomy with lung
mets s/p lobectomy transferred from OSH with sepsis,
trasaminitis, pancreatitis, concerning for gallstone
pancreatitis. Patient originally presented to [**Location (un) 620**] ED the
previous evening with sudden onset of epigastric pain and chest
pain which radiated to the left axillar. The pain was sharp in
nature and she had chills. At [**Location (un) 620**] she was found to have
elevated LFTs, elevated amylase and lipase. A chest/abdominal
CT showed possible pancreatitis changes but limited exam, with
CBD at 7 cm, along with a hiatal hernia, and acute pulmonary
abnormalities. She was initially placed on levoflox and flagyl.
She subsequently had [**5-1**] blood cultures with gram negative
bacilli and some gram positive cocci. Her antibiotics were
broadened to include levoflox, flagyl, zosyn, and vanco. At
admission, her SBP was in the 120s, but overnight dropped to the
80s systolic. She was treated with IV fluids to maintain her BP
which held stable with SBPs in the 80s. A femoral TLC was
attempted unsuccessfully. She continued to mentate with good
urine output, and receivced total of ~5 liters of IVF overnight.
On the day of transfer to [**Hospital1 18**], her LFTs and amylase/lipase
rose dramatically. She had a right subclavian line placed by
Surgery. She was then transferred to [**Hospital1 18**] for further
evaluation and possible ERCP. Patient is without any
complaints. Denied abdominal pain at present, no n/v/d or f/c.
Past Medical History:
1. Renal Cell CA - 8 years ago s/p nephrectomy with lung mets
and rt. lobectomy
2. H/O pancreatitis a few years ago treated at [**Hospital1 2025**]
3. Nephrectomy
4. HTN
5. Glaucoma
6. Asthma/COPD
7. Depression
8. s/p appendectomy
9. hypercholesterolemia
10. GERD
11. PVD
12. s/p TAH
13. h/p GI bleed
Social History:
Social History ?????? lives at [**Doctor Last Name 5749**] Hills. No tobacco or EtOH.
Daughter very involved in care, & is nurse.
Family History:
Family History ?????? non-contributory
Physical Exam:
Physical Exam
VS ?????? T=98.8 P=84 BP=100/35 RR=14 O2sat91% on RA, 98% on 2 liters
n.c.
Gen- pleasant, elderly female, lying in bed comfortably,
speaking in full sentences, in NAD
HEENT- PERRLA, EOMI, o/p clear w/ moist mucus membranes
Neck- soft & supple
CV- RR, no m/r/g
Pulm- decreased BS in right base, bibas crackles
Abd- +BS, s/NT/ND
Ext- W&D, no edema
Neuro- A&Ox3, decreased sensation in bil hands
Brief Hospital Course:
[**Age over 90 **]F with history of renal cell CA, COPD, PVD here with sepsis,
enzymes suggestive of pancreatitis, most likely gallstone vs.
other causes of cholestasis also with possible cholangitis given
elevated LFTs. Pt was transferred from an outside hospital to
the Medical ICU on [**7-18**]. Pt's status deteriorated the morning
of [**7-19**], progressive lethargy & obtundation and acidosis.
Following extensive discussion with the [**Hospital 228**] healthcare
proxy, clearly indicating that the patient did not want
intubation/mechanical ventilation and heroic measures, focus of
care shifted to comfort as primary goal. Patient was made CMO
and expired. Healthcare proxy was present.
1. Sepsis ?????? Upon admission, OSH microbiology data showed gram
negative rod bacteremia and few GPCs. Presumed source was GI
tract, with cholangitis, pancreatitis. Pt had been fluid
resusiciated for hypotension (asymptomatic) at the outside
hospital but, per report, did have persistently low blood
pressures (ranging 70-80 systolic) that eventually responded to
IVFs. She was hemodynamically stable at ariival, with lactate of
0.9, suggesting adequate resusication however became hypotensive
post ERCP so was given additional IVF per sepsis protocol.
Consyntropin stim test showed inadequate response so pt was
started on stress dose steroids (fludrocort and hydrocort).
Patient was continued on broad-spectrum antibiotics ?????? levoflox,
Zosyn, & vanco. Patient was briefly placed on Levophed for a MAP
<60 but this was discontinued after family meeting and decision
was made to make patient comfort-measures-only.
2. Pancreatitis/Cholangitis/Cholestasis ?????? Patient with
obstructive cholangitis per labs, also with pancreatitis,
concerning for gallstone pancreatitis versus acute pancreatitis.
OSH CT showed normal CBD, but her clinical picture was
concerning for obstructing gallstone. Repeat U/S here showed no
ductal dilatation. ERCP was attempted on [**7-18**] but the
specialists were unable to visualize the papilla so this
procedure was stopped. Pt was continued on IVF and antibiotics
as above.
3. DNR/DNI
Medications on Admission:
Medications (home): ASA 81 mg QD, albuterol MDI 2 puffs TID,
ativan .5 mg [**Hospital1 **], Azmacort 2 puffs TID, calcium 500 [**Hospital1 **], colace
100mg TID, etidronate 400mg QD x 10days/mth, klonopin .5 mg [**Hospital1 **],
lipitor 10mg QD, MVI QD, neurontin 100mg QD, nexium 20 mg QD,
pilocarpine opth 1% left eye QID, senna 2 tabs [**Hospital1 **]
Medications (transfer): levoflox 500 IV QD, flagyl 500 IV TID,
vanco 1 gram IV Q24, zosyn 3.375 IV Q6, ASA 81 QD, albuterol MDI
prn, phenergan prn, zofran prn, morphine prn, ativan .5 [**Hospital1 **],
azmarcort TID, colace [**Hospital1 **], klonopin .5 [**Hospital1 **], lipitor 10mg QD,
MVI, neurontin 100 QD, protonix 40 QD, senna [**Hospital1 **], pilocarpine
gttp, sc heparin
Allergies: NKDA
Discharge Medications:
none (deceased)
Discharge Disposition:
Expired
Discharge Diagnosis:
(deceased)
acute pancreatitis
sepsis
bacteremia
hypotension
Discharge Condition:
deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2175-7-19**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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icd9pcs
|
[
[
[]
]
] |
5845, 5854
|
2874, 5000
|
300, 321
|
5957, 6122
|
2386, 2427
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|
5875, 5936
|
5026, 5782
|
2442, 2851
|
223, 262
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349, 1896
|
1918, 2221
|
2237, 2370
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,327
| 176,260
|
30882
|
Discharge summary
|
report
|
Admission Date: [**2135-8-29**] Discharge Date: [**2135-9-27**]
Date of Birth: [**2066-11-25**] Sex: M
Service: MEDICINE
Allergies:
Vidaza / vancomycin
Attending:[**First Name3 (LF) 38616**]
Chief Complaint:
Admitted electively for chemotherapy for MDS in transformation
to AML
Major Surgical or Invasive Procedure:
cardiac cath
thoracentesis
History of Present Illness:
Patient is admitted for Cycle 2 of Decitabine. He has been doing
relatively well at home since his most recent two hospital
admissions: [**Date range (1) 73068**] admitted with progressive weakness due
to pneumonia and UTI and [**Date range (1) 73067**] with fever and found to have
a pansensitive E. coli bacteremia, Vancomycin sensitive
enterococcal bacteremia, and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] blood stream
infection. That hospitalization included marked LFT
abnormalities, and a question of a cholecystitis versus possible
drug reaction. Last had chemotherapy with Cycle 1 Decitabine on
[**2135-6-6**] after a drug challenge with lower doses which he
tolerated well. The drug challenge was performed because he had
a severe reaction to Azacitadine with multiple skin
complications including neutrophilic dermatoses and ischemic
bowel.
He was transferred to the CCU after developing CP while on the
oncology service on the evening of [**9-5**]. He developed sudden
onset SSCP which then radiated to the back, described as a
throbbing sensation, not similar to chronic back pain. He
received 0.4 SL Nitro x 3 and 10 mg IV morphine with some
resolution. There was a thought there may be some ST depressions
in V4-V5, which resolved after the above. BP was symmetric in
BUE at that time. A bedside echo was performed by the cardiology
fellow with new inferolateral hypokinesis so he was transferred
urgently for cath, lab was activated overnight.
Cath revealed single vessel right dominant disease with 70%
stenosis of the RCA. No stent was placed in order to minimize
the risk of interruption of chemotherapy. His CP was attributed
to demand ischemia and troponin peaked at 0.07 before trending
down.
.
Upon arrival to the CCU, pt. was noted to have temp of 104
without localizing symptoms for infection. He was already on
Vancomycin, Cefepime, Fluconazole and Acyclovir at time of
transfer to the CCU (Vanc and Cefepime added just prior to
cath). Vancomycin was changed to Daptomycin today given concern
for allergy. UA showed trace leuks, few bacteria and CXR showed
no evidence of pneumonia. Blood and urine cultures show NGTD. He
also developed asymptomatic hypotension in the CCU with
systolics in the 80s, responsive to fluid. He was afebrile
otherwise throughout CCU stay. He was given 1L NS total with
improvement to the 90s systolic. He had a few hours of [**Last Name (un) **],
transient hypoxia with SaO2 88 on RA which resolved with 2L
nasal O2. He was transferred to the floor on [**9-7**] without any
complications.
On ROS he reports that he is still fatigued, ambulating with a
walker, and has a poor appetite. He denies fevers, rigors,
chills, new pain, cough, dysuria or focal symptoms of infection.
He also denies chest pain, nausea, vomiting, shortness of
breath. All other ROS are negative.
.
Past Medical History:
MDS RAEB type 1, 7% blasts with extensive myelofibrosis, 7q-,
transfusion dependent, s/p azacitadine complicated by ischemic
bowel perforation and multiple ulcers (pyoderma gangrenosum).
Right colectomy [**9-/2134**], for ischemic bowel with slow healing
midline abdominal wound.
Decubitus ulcers.
Neutrophilic dermatosis (pyoderma gangrenosum and Sweets
syndrome).
Carpal tunnel syndrome.
COPD.
Left knee surgery.
Back surgery.
Demand ischemia with 70% stenosis of RCA on cath [**9-5**], elected
to treat with medical therapy alone
Social History:
Retired, used to work for a chemical company. History of
asbestos and other chemical exposure. He has a history of
significant alcohol use, which he stopped approximately seven
years ago. 60 pack year history of tobacco use.
Family History:
Sister - died of scleroderma; Another sister - died of unclear
etiology; Brother - died of EtOH abuse; Daughter with Marfan's;
Two brothers are alive and well; Mother - died of lung cancer;
Father - died in an MVC.
Physical Exam:
VS: T: 99 BP:94/52 P:92 RR:18 in O2Sat: 98 % on 2L
GENERAL: thin appearing, in no apparent distress
Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted
Ears/Nose/Mouth/Throat: Mucous membranes moist,without ulcers or
exudates, good dentition
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: CTA bilaterally without rhonci, without wheezes
Cardiovascular: RRR, S1S2, II/VI systolic murmur on LUSB, no
rubs, no gallops
Gastrointestinal: soft, NT/ND, no rebound, no guarding,
normoactive bowel sounds, no masses or organomegaly noted.
Skin: warm, dry, two right sided abdominal ulcers that are pink
and perfused well, appear to be healing and uninfected,
unstageable sacral decub
Extremities: without cyanosis, without clubbing, mild bilateral
LE edema, without joint swelling
Neurologic:
-mental status: Alert, oriented x 3. Normal attention. Able to
relate history without difficulty. Fluent speech.
Psychiatric: calm, appropriate.
.
Pertinent Results:
[**2135-8-29**] 12:15PM UREA N-30* CREAT-1.2 SODIUM-133 POTASSIUM-4.5
CHLORIDE-99 TOTAL CO2-29 ANION GAP-10
[**2135-8-29**] 12:15PM ALT(SGPT)-13 AST(SGOT)-25 LD(LDH)-311* ALK
PHOS-160* TOT BILI-0.5
[**2135-8-29**] 12:15PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.7
[**2135-8-29**] 12:15PM WBC-3.6* RBC-2.71* HGB-8.0* HCT-22.7* MCV-84
MCH-29.4 MCHC-35.1* RDW-16.0*
[**2135-8-29**] 12:15PM NEUTS-31* BANDS-4 LYMPHS-28 MONOS-11 EOS-2
BASOS-3* ATYPS-2* METAS-3* MYELOS-2* BLASTS-14*
[**2135-8-29**] 12:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2135-8-29**] 12:15PM PLT SMR-VERY LOW PLT COUNT-25*
.
[**2135-9-7**] 04:01PM BLOOD WBC-1.2* RBC-3.20* Hgb-9.5* Hct-27.3*
MCV-85 MCH-29.6 MCHC-34.8 RDW-16.2* Plt Ct-17*
[**2135-9-7**] 04:01PM BLOOD WBC-1.2* RBC-3.20* Hgb-9.5* Hct-27.3*
MCV-85 MCH-29.6 MCHC-34.8 RDW-16.2* Plt Ct-17*
[**2135-9-7**] 05:59AM BLOOD Neuts-36* Bands-2 Lymphs-33 Monos-4 Eos-3
Baso-1 Atyps-0 Metas-9* Myelos-7* Blasts-5*
[**2135-9-7**] 04:01PM BLOOD Plt Ct-17*
[**2135-9-6**] 06:02AM BLOOD PT-16.2* PTT-33.7 INR(PT)-1.4*
[**2135-9-7**] 04:01PM BLOOD Glucose-99 UreaN-38* Creat-1.1 Na-135
K-4.1 Cl-102 HCO3-22 AnGap-15
[**2135-9-6**] 06:02AM BLOOD ALT-11 AST-18 CK(CPK)-20* AlkPhos-77
TotBili-0.3
[**2135-9-7**] 04:01PM BLOOD Calcium-8.6 Phos-4.3 Mg-2.5
Trend for [**Last Name (un) **]:
[**2135-9-24**] 07:10AM BLOOD Glucose-100 UreaN-48* Creat-1.6* Na-136
K-4.3 Cl-104 HCO3-25 AnGap-11
[**2135-9-25**] 04:43AM BLOOD Glucose-88 UreaN-53* Creat-2.3* Na-137
K-5.0 Cl-106 HCO3-22 AnGap-14
[**2135-9-26**] 06:35AM BLOOD Glucose-106* UreaN-65* Creat-3.0* Na-135
K-5.6* Cl-105 HCO3-21* AnGap-15
Hypercalcemia:
PARATHYROID HORMONE RELATED PROTEIN
Test Result Reference
Range/Units
PTH-RP 15 14-27 pg/mL
VITAMIN D [**1-11**] DIHYDROXY
Test Result Reference
Range/Units
VITAMIN D, 1,25 (OH)2, TOTAL <8 L 18-72 pg/mL
VITAMIN D3, 1,25 (OH)2 <8
VITAMIN D2, 1,25 (OH)2 <8
VITAMIN D 25 HYDROXY
Test Result Reference
Range/Units
VITAMIN D, 25 OH, TOTAL 22 L 30-100 ng/mL
VITAMIN D, 25 OH, D3 16 ng/mL
VITAMIN D, 25 OH, D2 6 ng/mL
Pleural Fluid:
[**2135-9-19**] 08:22AM BLOOD freeCa-1.43*
[**2135-9-9**] 05:17PM PLEURAL WBC-144* RBC-4625* Polys-45* Lymphs-35*
Monos-1* Eos-18* Meso-1* Other-0
[**2135-9-9**] 05:17PM PLEURAL TotProt-2.3 Glucose-139 LD(LDH)-91
Albumin-1.5
pH=7.42
NO MALIGNANT CELLS
[**2135-9-5**] Cardiac catheterization
COMMENTS:
1) Selective coronary angiography of this right-dominant system
demonstrated single vessel CAD, with a 70% non-obstructive
ostial lesion of the large RCA. The LMCA and LAD were
large-caliber and
patent vessels; the LCx was diminutive and patent.
2) Ventriculography revealed an estimated EF of 55% with mild
inferior
hypokinesis and mild mitral regurgitation.
3) Limited resting hemodynamics revealed systemic arterial
hypotension,
with a central aortic pressure of 80/38 mmHg. There was no
systolic
pressure gradient between the aorta and the left ventricle, upon
careful
pullback of the pigtailed catheter.
4) Given the patient's acute leukemia, thrombocytopenia, and
plan to
continue with chemotherapy in the setting of being chest
pain-free, we
opted to treat the RCA stenosis medically for now until we have
a
detailed discussion with the oncology team. The patient as well
favored
this approach, understanding that an intervention may interfere
with his
chemotherapeutic plan.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Mild mitral regurgitation.
3. Mild systolic ventricular dysfunction.
[**2135-9-5**] Echo
Very limited views obtained. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function appears
grossly preserved (LVEF>55%). Right ventricular chamber size and
free wall motion are normal. The mitral valve leaflets are
mildly thickened. An eccentric, posteriorly directed jet of
moderate (2+) mitral regurgitation is seen. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
[**2135-9-5**] CXR
FINDINGS: As compared to the previous radiograph, the pleural
effusions have
resolved. Lung volumes have minimally increased, potentially
suggesting
improved ventilation. Moderate cardiomegaly, unchanged evidence
of
mild-to-moderate interstitial fluid overload. No evidence of
pneumonia.
[**9-25**] Head CT: No acute process
[**9-25**] CT Abdomen and Pelvis:
1. No evidence for hematoma.
2. Persistent increased bilateral pleural effusions.
3. Marked splenomegaly.
4. Gallstones.
5. Suspected chronic avascular necrosis involving each femoral
head, with
more prominent findings on the right than left side.
Microbio:
[**2135-09-23**] 4:38 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2135-10-7**]**
GRAM STAIN (Final [**2135-9-24**]):
[**10-11**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2135-9-28**]):
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
AZTREONAM Sensitivity testing per DR [**Last Name (STitle) 73069**]
([**Numeric Identifier 73070**]).
SENSITIVE TO COLISTIN sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
RESISTANT TO AZTREONAM AT >=32 MCG/ML sensitivity
testing
performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
FUNGAL CULTURE (Final [**2135-10-7**]):
YEAST.
BLOOD Cultures all negative
Brief Hospital Course:
The patient is a 68-year-old gentleman with a history of MDS
evolving to AML with increasing transfusion requirement and
severe pancytopenia. Several prolonged and complicated hospital
admissions in last 3 months following his first cycle of
Decitabine as noted above in HPI. His post-treatment course was
complicated by fever, LFT abnormalities, and a question of a
cholecystitis. He is admitted for his second full cycle of
chemotherapy with Decitabine today with the plan to use a 10 day
regimen. Of note, treatment Vidaza (a drug from the same
class)resulted in a prolonged and complicated course in the
past.
# MDS and pancytopenia:
Pt's current cycle 2 of decitabine stopped after 8 days. Pt w/
unstable angina found to have fixed stenotic lesion of the RCA,
thought by cards to be causing demand ischemia and favored
medical mgmt. Overall, pt failed azacitidine and two cycles of
decitabine. He required near daily transfusions with platelets
and pRBC and failed to increase counts appropriately. Pt had a
drop in HCT, which along with his abdominal pain was concerning
for an intraabdominal bleed--CT did not demonstrate hemmorrhage.
Towards the end of patient's care, numerous conversations took
place between patient, patient's family, and medical team.
Given poor performance status, significant medical comorbidities
including obtundation, virulent drug resistant pneumonia, and
ARF, and the patient's goals of care, the patient was made CMO
before his death a few days later.
# Pneumonia and infection: Pt had fever in late [**Month (only) **] to 104
while on fluconazole, flagyl, cipro. Pt then completed abx
course of greater than 2 weeks with linezolid and cefepime. A
source of infection failed to be identified. Per ID, on [**9-22**]
abx were stopped. The next day pt spiked to 104.3, coughing up
green sputum and became increasingly confused and then obtunded.
Pt started on linezolid, meropenem, and acyclovir. Blood
cultures were negative, but sputum culture came back positive
for pan-resistant (except Amikacin) pseudomonal pneumonia.
Given pt's renal failure and goals of care, the infection was
not treated. Medications were withdrawn with the exception of
those to keep the patient comfortable.
# ARF: Toward the end of his life, pt developed ARF,
obtundation, and low blood pressure w/ pseudomonas lung
infection. Blood cultures were negative. The pt's decline in
mental status was most likely [**1-19**] to sepsis and uremia from ARF
which may have been precipitated by sepsis as well as IV
acyclovir. The patient also developed a pericardial friction
rub correlating with his ARF. Given goals of care and patient's
performance status, pt did not undergo dialysis.
#CAD: The pt developed chest pain during the course of this
hospital stay. EKG showed ST depressions in V4-V5 that resolved
with sublingual nitroglycerin and morphine. An echo was
performed with showed new infererolateral hypokinesis. The pt
was taken urgently to cardiac catheterization where a 70% osteal
right coronary artery disease was discovered. The decision was
made not to place a stent due to ongoing chemotherapy and his
likely need for further platelet transfusions. Stent placement
would require the initiation of anti-platelet therapy in order
to maintain stent patency. Medical management was started with
atorvastatin 20mg not the usual 80mg due to medication
interactions and low dose metoprolol. He was observed in the CCU
for approximately 24 hrs where his blood pressures remained
stable and he remained chest pain free. He was then transfered
back to the [**Hospital Unit Name 153**] for further management. In the [**Hospital Unit Name 153**] he
remained pain free, hemodynamically stable. Pt was continued on
low dose statin and metoprolol. Did not start aspirin given
platelets and risk of bleeding.
# Lytes: Hypokalemia/Hypercalcemia/Hypomagnesemia.
Pt had hypercalcemia which improved with fluids and pamidronate
x 1. Pt had low PTH, Vitamin D, Calcitriol, and PTHrP. Pt's
hypokal and hypomag were aggressively repleted with termination
of premature ventricular beats.
Pt passed away the morning of [**2135-9-27**].
Medications on Admission:
acyclovir 400 mg Tablet Q8hr
ciprofloxacin 500 mg Q12hr
fluconazole 400 mg Q24hr
metronidazole 500mg Q8hr
MS Contin 30 mg Q8hr
omeprazole 20 mg daily
oxycodone 5mg Q4HR:PRN pain
Zofran ODT 8mg Q8HR
prochlorperazine maleate 5mg Q6HR:PRN nausea
ascorbic acid 500mg Q12HR
docusate sodium 100mg [**Hospital1 **]
multivitamin one daily
sennosides [senna] one [**Hospital1 **]:PRN constipation
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Myelodysplasia with evolution to AML
Sepsis from pseudomonas penumonia
ARF
Pancytopenia
Decubitus and abdominal ulcers
Chronic back pain
Diabetes
Unstable angina
CAD
multilobar pneumonia
Insomnia
Hearing loss
Discharge Condition:
N/A
Discharge Instructions:
N/A
[**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]
Completed by:[**2135-10-17**]
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"00.14",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
16524, 16533
|
11896, 16057
|
352, 381
|
16786, 16791
|
5306, 8982
|
4088, 4304
|
16496, 16501
|
16554, 16765
|
16083, 16473
|
8999, 9946
|
16815, 16953
|
4319, 5138
|
243, 314
|
409, 3272
|
9955, 11873
|
5153, 5287
|
3294, 3829
|
3845, 4072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,302
| 104,668
|
51630
|
Discharge summary
|
report
|
Admission Date: [**2104-3-3**] Discharge Date: [**2104-3-10**]
Date of Birth: [**2038-5-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male with a chief complaint of persistent nausea, vomiting,
and failure to thrive times one week.
The patient has a significant history of biventricular
failure and coronary artery disease, who was recently
discharged from [**Hospital1 69**] on
[**2104-2-15**] for a congestive heart failure exacerbation.
At the time of admission, the patient denies any chest pain,
palpitations, shortness of breath, fevers, chills, bright red
blood per rectum, melena, and diarrhea. He does describe
nausea and vomiting as well as some anorexia for the past
week prior to admission. In general, the patient has had
decreased oral intake and overall failure to thrive for the
last month. The patient denies any sick contacts. The
patient complains of increasing fatigue as well as a 14-pound
weight gain since his discharge on [**2-15**] despite
recently increasing his Lasix dose from 80 mg to 100 mg in
the morning with an additional 80-mg dose in the afternoon,
as well as the addition of Zaroxolyn administered prior to
Lasix.
The patient was seen by his primary care physician
(Dr. [**First Name (STitle) 1104**] and sent to the [**Hospital1 188**] Emergency Department for further evaluation.
On presentation, he was found to have a blood urea nitrogen
to creatinine ratio of 124 to 2.9 which was significantly
increased from his baseline. Therefore, the patient was
admitted for further management of what was felt to be
congestive heart failure exacerbation.
The patient reported that his cardiac history began in [**2086**].
He did well until the middle [**2092**] when he began having
persistently increasing numbers of congestive heart failure
exacerbation. He developed congestive heart failure
intermittently and was hospitalized in [**2103-1-22**] and
then again in [**2103-4-22**]. At this time, he started having
increasing paroxysmal nocturnal dyspnea, dyspnea on exertion,
and peripheral edema. However, the patient was stabilized
with increasing Lasix dosage. He was subsequently admitted
in [**2104-1-22**] with a congestive heart failure
exacerbation and return now with a 14-pound weight gain,
anorexia, nausea, and vomiting.
PAST MEDICAL HISTORY:
1. Biventricular heart failure/congestive heart failure with
an ejection fraction of 20%; thought secondary to ischemic
cardiomyopathy.
2. Severe pulmonic stenosis.
3. Status post pacemaker implantable
cardioverter-defibrillator placement in [**2098**] secondary to
third-degree heart block.
4. Coronary artery disease, status post myocardial
infarction in [**2086**] with cardiogenic shock at the age of 47;
status post cardiac catheterization in [**2102-5-22**] with 50%
proximal left anterior descending artery, severe pulmonary
hypertension, wedge of 14, and global hypokinesis.
5. History of syncopal episodes.
6. Hypercholesterolemia.
7. Insulin-dependent diabetes mellitus since [**2086**] with
secondary neuropathy and cataracts.
8. Obstructive sleep apnea, on home BiPAP times one year.
9. Chronic renal insufficiency.
MEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d.,
Zaroxolyn 2.5 mg p.o. q.d., captopril (discontinued the week
prior to admission), aspirin 325 mg p.o. q.d., NPH 26 units
in the a.m. and 14 units in the p.m., sublingual
nitroglycerin p.r.n. for chest pain, Protonix 40 mg p.o.
q.d., Pravachol 20 mg p.o. q.d., digoxin 0.125 mg p.o. q.d.,
Isordil 10 mg p.o. t.i.d., K-Dur one tablet p.o. q.d.
ALLERGIES: The patient reports SERAX, AMBIEN, FENTANYL, and
DEMEROL cause him to "feel strange." [**Year (4 digits) **] causes
seizures.
SOCIAL HISTORY: The patient has a distant history of pipe
smoking. He currently lives with his wife and two children
and is a retired security guard. His wife is an Emergency
Department nurse.
FAMILY HISTORY: The patient's brother died of a myocardial
infarction at the age of 47.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 97.4, blood pressure of 116/77, respiratory
rate of 14, saturating 100% on room air. In general, a
rather ill-appearing male, sleeping, lethargic, easily
arousable, in no acute distress. Head, eyes, ears, nose, and
throat revealed mucous membranes were moist. The oropharynx
was clear. Pupils were equal, round, and reactive to light.
Sclerae were anicteric. Cardiovascular examination revealed
soft first heart sound, obliterated second heart sound.
Holosystolic murmur, positive jugular venous distention.
Pulmonary revealed mild bibasilar crackles; otherwise clear
to auscultation bilaterally. The abdomen was distended,
positive bowel sounds, nontender, 2+ pitting edema of the
abdominal wall. Extremities revealed 2+ pitting edema to the
scapulas bilaterally as well as to the bilateral knees.
Neurologically, alert and oriented times three. No focal
deficits.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories at
the time of admission revealed a white blood cell count
of 7.4, hematocrit of 39, platelets of 199. Sodium of 128,
potassium of 3.9, chloride of 83, bicarbonate of 20, blood
urea nitrogen of 124, creatinine of 2.9, blood glucose
of 110. Calcium of 9.1, magnesium of 3.2, phosphate of 7.2.
Digoxin level of 2.8.
RADIOLOGY/IMAGING: A chest x-ray revealed a right pleural
effusion; unchanged, with right-sided atelectasis, dual
chamber pacemaker placed, questionable left lower extremity
opacity, possibly consistent with pneumonia. Stable
cardiomegaly. No increased pulmonary vascular congestion.
Electrocardiogram revealed AV paced at 61 beats per minute
with left axis deviation, QRS of 122 seconds to 200 seconds.
HOSPITAL COURSE: The patient is a 65-year-old male with
severe biventricular failure who was admitted with worsening
renal failure and worsening total body fluid overload thought
secondary to his worsening congestive heart failure.
The patient was initially admitted to the Medicine floor and
then subsequently he was transferred to the Coronary Care
Unit for more intensive hemodynamic monitoring and further
management.
1. CARDIOVASCULAR: The patient was continued on his current
doses of aspirin, Pravachol, and Isordil given his history of
coronary artery disease.
Given that the patient was felt to be significantly fluid
overloaded with poor cardiac output, it was recommended that
a Swan-Ganz catheter be placed and the patient to be placed
on a Milrinone drip. This was performed without
complications once the patient was transferred to the
Coronary Care Unit.
The patient was continued on Lasix which was changed to 40 mg
intravenously b.i.d., and his digoxin was held given elevated
digoxin levels, and captopril was held given his acute renal
failure.
The initial Swan-Ganz placement was performed without
difficulty and demonstrated hemodynamics as follows: Right
atrium 30 mmHg, right ventricle 80/30 mmHg, pulmonary artery
of 80/30 mmHg, wedge of 30 mmHg. Cardiac index of 1.12 with
a cardiac output of 1.9. The patient was subsequently
started on a Milrinone intravenous drip which was renally
dosed given his low creatinine clearance.
The patient continued to demonstrate elevated filling
pressures and a high wedge; however, some benefit of
Milrinone drip was seen by following mixed venous
saturations. The patient's Lasix dose was not felt to be
adequate to promote diaphoresis, and therefore he was
switched to a Lasix drip which was increased to its maximum
dose.
As the patient's blood pressure fell slightly with Milrinone,
a vasopressin was added with subsequent stabilization of his
blood pressure. Given the patient's overall fluid overload
which was not appropriately responding to Lasix therapy, a
Renal consultation was obtained to consider continuous
venovenous hemofiltration.
Over the next few days the patient did not appear to respond
to a Lasix drip with the addition of Zaroxolyn. The
medications were discontinued secondary to his lack of
urinary output. The patient's pacemaker was interrogated by
the Electrophysiology team, and his baseline heart rate was
increased to 80 in an attempt to improve his cardiac output
and cardiac index. As the patient became nearly oliguric, a
femoral vein Quinton catheter was placed, and the patient was
initiated on continuous venovenous hemofiltration.
However, over the next few hospital days, the patient's
cardiac output and cardiac index continued to decrease
despite optimal Milrinone and vasopressin therapy in addition
to continuous venovenous hemofiltration.
The poor prognosis for the patient in view of optimal medical
management was discussed with the patient as well as his
family. The patient's family reported an understanding of
the situation and reflecting on the patient's prior stated
wishes made the patient do not resuscitate/do not intubate.
The patient's subsequently passed away on the following day.
2. RENAL: The patient had a baseline chronic renal
insufficiency with a baseline creatinine of 2.1 which was
increased to 2.9 at the time of admission. A Renal
consultation was obtained at the time of admission to comment
on the appropriateness of initiating hemodialysis given the
patient's overall fluid overload state. An initial attempt
was made to diuresis the patient with a Milrinone, Lasix, and
supportive vasopressin drips; however, as these treatments
failed and the patient became nearly oliguric, a Quinton
catheter line was placed, and the patient was initiated on
continuous venovenous hemofiltration dialysis. In addition,
the patient was maintained on Phos-Lo and Amphojel given his
elevated phosphorous levels, and his electrolytes were
followed carefully on a b.i.d. basis. However, despite
adequate diuresis and hemodialysis the patient continued to
remain oliguric and continued to demonstrate a decrease in
cardiac output and index. The patient was made do not
resuscitate/do not intubate by his family and subsequently
passed away on [**3-10**].
3. PULMONARY: The patient was felt to have a questionable
left lower lobe infiltrate on chest x-ray at the time of
admission. However, the patient had no signs or symptoms
suggestive of a pneumonia on a clinical basis, and therefore
antibiotics were withheld unless the patient had an increase
in a white blood cell count of fever. The patient has a
history of sleep apnea and was continued on BiPAP at night.
The patient was also provided supplemental oxygen therapy as
needed to maintain comfort given his overall fluid overload
status.
The patient had no further pulmonary issues over the
remainder of his hospitalization.
CONDITION AT DISCHARGE: The patient was made do not
resuscitate/do not intubate following a lengthy family
discussion between the patient and the Coronary Care Unit
team on [**3-9**]. The patient subsequently passed away at
6:30 a.m. on [**3-10**]. The family was present in the room
at the time of the death, and an autopsy was refused at that
time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2104-7-23**] 16:35
T: [**2104-7-24**] 10:28
JOB#: [**Job Number 33736**]
|
[
"398.91",
"286.9",
"V53.31",
"V45.02",
"585",
"276.2",
"250.40",
"584.9",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"57.94",
"38.95",
"38.93",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
3945, 5753
|
3223, 3731
|
5772, 10697
|
10712, 11308
|
159, 2336
|
2358, 3196
|
3748, 3928
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,487
| 178,728
|
42227
|
Discharge summary
|
report
|
Admission Date: [**2139-8-30**] Discharge Date: [**2139-9-8**]
Date of Birth: [**2060-12-12**] Sex: F
Service: MEDICINE
Allergies:
sulfa
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Vomiting/Diarrhea
Major Surgical or Invasive Procedure:
Cardiac Cath, s/p DES to RCA
History of Present Illness:
78 y/o woman with a PMH significant for DM and HTN who was
transferred from [**Hospital3 **] for STEMI. She states that
shortly after awaking at 0800 the morning of admission she
experienced sudden onset nausea, vomiting and non-bloody non
melanotic diarrhea with associated diaphoresis. She called her
PCP, [**Name10 (NameIs) 1023**] urged her to go to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where she was found
to have ST elevations in II/III/AVF and reciprocal ST
depressions in V2. VS at the time were: T 97.4 BP 131/61 HR 61
RR 18 O2 Sat 100% RA. She was given ASA 325, Heparin 60U/kg,
Atorvastatin 80 and Plavix 600 and transferred to [**Hospital1 18**] for PCI.
Cardiac cath showed total mid RCA occulsion (R dominant) and a
DES was placed with restoration of flow to the distal RCA and
PDA. Labs on arrival were CKMB 61 Trop 1.81 and Cr 1.7 (baseline
unknown).
On arrival to the CCU she denied CP/SOB/N/V/HA, palpitations or
lightheadedness. She has had no sick contacts and states she can
walk ~30 minutes before becoming SOB. She does not frequently
climb stairs due to degenerative disc disease. She denies
PND/orthopnea and states that she has noticed occasional
swelling in her ankles over the past few months.
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 recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hypertension
2. CARDIAC HISTORY: None
3. OTHER PAST MEDICAL HISTORY:
- cataracts
- GERD
- osteoporosis
- spinal stenosis
- gastric ulcer
- asthma
- hysterectomy
- cholecystectomy
- multiple back surgeries
Social History:
Lives alone in [**Location (un) 26671**], retired office worker.
- Tobacco history: 45 years of second hand smoke exposure, never
smoked herself
- ETOH: Denies
- Illicit drugs: Denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death.
- Mother: Died at age 87, unclear history of CAD
- Father: Stroke at age 65
Physical Exam:
ADMISSION EXAM:
VS: T 98 BP 93/48 HR 63 RR 17 O2 Sat 97% 2L NC
Wt 153 lbs
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP 3cm above the clavicle, thyroid non tender,
mobile. No LAD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. II/VI harsh holosystolic murmur best heard at the apex.
Normal S1/S2, no S3/S4. No lifts of heaves. No carotid bruits.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: WWP, scant pedal edema to the medial malleolus. 2+
pulses bilaterally. Cath site c/d/i, no hematoma or femoral
bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
DISCHARGE EXAM:
GEN: NAD
CV: RRR, III/VI holosystolic murmur heart throughout the
precordium, JVP flat. Normal S1/S2, no S3/S4
PULM: Crackles in dependent lung fields L>R, no increased WOB,
no cyanosis.
ABD: NTND, NABS, no rigidity or rebound.
EXT: WWP, no c/c/e, pulses 2+
NEURO: A/Ox3, non focal.
Pertinent Results:
[**2139-8-30**] 06:27PM GLUCOSE-131* UREA N-44* CREAT-1.6*
SODIUM-131* POTASSIUM-3.9 CHLORIDE-88* TOTAL CO2-28 ANION GAP-19
[**2139-8-30**] 12:22PM CK-MB-102* cTropnT-5.04*
[**2139-8-30**] 05:48AM CK-MB-120* cTropnT-5.18*
[**2139-8-30**] 05:48AM TRIGLYCER-77 HDL CHOL-54 CHOL/HDL-2.9
LDL(CALC)-90
[**2139-8-30**] 01:00AM CK-MB-61* MB INDX-7.5* cTropnT-1.81*
[**2139-8-30**] 01:00AM WBC-11.0 RBC-4.12* HGB-12.2 HCT-34.4* MCV-84
MCH-29.5 MCHC-35.3* RDW-15.5
[**2139-8-30**] 01:00AM NEUTS-86.8* LYMPHS-9.8* MONOS-3.1 EOS-0.1
BASOS-0.1
RELEVANT STUDIES:
Cardiac Cath ([**2139-8-30**]):
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary artery disease. The LMCA,
LAD, and
LCx were free of angiographically significant disease. There was
a
thrombotic total occlusion of the mid-RCA with no
collateralization.
2. Limited resting hemodynamics revealed normal resting systemic
arterial pressure.
[**Month/Day/Year **] ([**2139-8-30**]): The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the inferior and inferolateral walls. There is a
focal defect in the basal inferior septum on 2D and color
Doppler with continuous left-to-right flow c/w a post infarction
ventricular septal defect (VSD). The remaining left ventricular
segments contract normally. (LVEF 50%). Intrinsic left
ventricular systolic function may be more depressed given the
interventricular flow). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**2-8**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
CXR ([**2139-8-30**]): Current study demonstrates top normal heart as
well as bilateral hilar enlargement and pulmonary edema. The
findings might potentially represent a new acute mitral
regurgitation with increasing pulmonary venous pressure and
presence of newly developed pulmonary edema. Small bilateral
pleural effusions are noted. There is no pneumothorax.
[**Month/Day/Year **] ([**2139-8-31**]): The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with severe hypokinesis of the
basal half of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 50-55 %). There is
a ~1cm basal inferoseptal post infarction ventricular septal
defect (VSD) with prominent left-to-right flow. Right
ventricular cavity size is normal with free wall hypokinesis.
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. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
[**Month/Day/Year **] ([**2139-9-3**]): The left atrium is normal in size. There is mild
regional left ventricular systolic dysfunction with hypokinsis
of the basal and mid inferior and inferolateral segmets . There
is a post infarction ventricular septal defect (VSD). Right
ventricular chamber size is normal. with moderate global free
wall hypokinesis. There is no aortic valve stenosis. No aortic
regurgitation is seen. An eccentric, posteriorly directed jet of
Moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
MRI ([**2139-9-7**])
1. Normal left ventricular cavity size with normal global LVEF
of 65% albeit severely depressed effective forward LVEF of 20%.
Severe hypokinesis to akinesis of the mid to basal inferoseptal
and inferior walls.
2. Transmural of late gadolinium enhancement in the inferoseptal
wall, and 45% non-transmural late gadolinium enhancement in the
inferior wall extending into the inferolateral wall, consistent
with myocardial infarction and low (inferoseptal wall) to
intermediate (inferior wall) likelihood of functional recovery
after revascularization. The late gadolinium enhancement
demonstrates a microvascular obstruction-type pattern. The
infarct size was quantified at 18.2 g, which represents 21% of
the total myocardial mass.
3. Increased T2 signal in these segments, consistent with
edema/inflammation and acute/subacute timing of infarction
(within 2 weeks).
4. Myocardial salvage index, representing the difference between
the area at risk (T2) and the infarct size (late gadolinium
enhancement) divided by the area at risk, calculated at 53%.
5. Infarct-related muscular ventricular septal defect in the mid
to basal
inferoseptal wall measuring 7 mm in the long-axis direction, and
6-9 mm in the short-axis direction (9 mm at the mouth on the
left ventricular size of the septum, and slightly tapering to 6
mm on the right ventricular side of the septum).
6. Ischemic mitral regurgitation with mild posterior leaflet
tethering.
7. Normal right ventricular cavity size with depressed RVEF of
39%. Global
right ventricular hypokinesis with dyskinesis of the distal
segments. Late
gadolinium enhancement in the inferior right ventricular wall,
consistent with right ventricular myocardial infarction.
Systolic flattening of the
interventricular septum, consistent with elevated right
ventricular systolic pressure.
8. The indexed diameters of the ascending and descending
thoracic aorta were normal. The indexed diameter of the main
pulmonary artery was normal.
9. Left atrial enlargement.
10. A note is made of dependent patchy areas of consolidation
are identified in the lung bases, right greater than left, with
a focal area of nodularity in the right mid lung measuring 2 cm
in craniocaudal dimension. However, there is no correlate on
prior chest radiograph. Findings are likely the sequelae of
pulmonary edema, though aspiration or pneumonia should be
considered in the appropriate clinical circumstance. Recommend
follow-up chest radiograph after acute illness to document
resolution. A note is also made of punctate non-enhancing
lesions in both kidneys, likely small simple cysts.
Brief Hospital Course:
78 y/o woman with STEMI and total RCA occlusion s/p DES
complicated by post-infarct ventricular septal perforation.
# STEMI: Pt had 100% RCA occlusion just distal to the acute
marginal takeoff, now s/p DES with restoration of flow to the
distal RCA and PDA (R dominant). She was started on ASA, Plavix,
Atorvastatin, metoprolol and lisinopril during her hospital
course. [**Year (4 digits) **] showed mild regional left ventricular systolic
dysfunction with severe hypokinesis of the basal half of the
inferior and inferolateral walls. Immediately following PCI she
was in 2:1 heart block, which subsequently evolved to Wenckebach
and 1:1 conduction. She remained hemodynamically stable
throughout and was discharged home with cardiology and PCP
follow up.
# VSD: Physical exam on admission to the CCU revealed a new
III/VI systolic murmur heard thoughout the precordium concerning
for new VSD/MR. [**Name14 (STitle) **] showed VSD, cardiac MRI later showed 3:1
shunt fraction, normal RV size with free wall hypokinesis and
elevated PA pressures. Her O2 sat remained >93% on RA throughout
her course and she was given diuresis for reducing pulmonary
edema and shunt, and minimizing pulmonary hypertension. Blood
pressure was also optimized to decrease afterload and maximize
forward flow. The definite treatment will require surgical
repair of the interventricular septum defect. Percutaneous VSD
closure may also be an option.
OUTPATIENT ISSUES:
- F/U WITH CT SURGERY/INTERVENTIONAL CARDIOLOGY
- Adjust lasix 80 mg po qd
- Should have RHC to assess shunt function which could help
decide whether patient needs to have her shunt fixed
# A-fib: Pt was found to have a period of unsustained
symptomatic A-fib, lasting ~30 mins. This could be a result of
changes in RA volume and dynamics. Given patient's already
compromised CO, atrial kick is necessary to maintain adequate
MAP. Amiodarone was started for rhythm control. She was
continued on metoprolol for rate control.
CHRONIC DIAGNOSES:
DM: Pt has documented hx of diabetes, controlled by Pioglitizone
prior to admission. She was covered with ISS during this
hospitalization. She was restarted on pioglitizone prior to
discharge.
# HTN - Her home Verapamil was held and she was started on
Metoprolol and Lisinopril with SBP goal in the 90s given the
lack of mortality benefit of CCB (especially verapamil)
# GERD - Patient has a documented history of GERD, and takes
omeprazole at home. Omeprazole was stopped in setting of plavix
while ranitidine was started at 150 mg po qhs.
# HLD: She was started on atorvastatin 80 mg po qdaily (PROVE
trial) but it was decreased to 40 mg po qdaily given she was on
multiple medications (amiodarone) which would uptitrate her
statin dose putting her at risk for rhabdomyolysis.
TRANSITIONAL ISSUES:
- Pt maintained a full code during this admission
- Pt has follow up with Dr.[**Doctor Last Name 3733**] in one week and CT
surgery in 2 weeks
Medications on Admission:
- Vit D 50,000U every other sunday
- Verapamil 240mg qday
- Omeprazole 20mg qday
- Clonazepam 0.5mg po qhs
- Pioglitizone 30mg qday
- Pregalbin 25mg qday
- Ultram 50mg prn back pain
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. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
5. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. pregabalin 25 mg Capsule Sig: One (1) Capsule PO once a day.
8. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO every
other Sunday or as directed.
15. Benefiber Sugar Free (dextrin) Oral
16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical ASDIR.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
PRIMARY:
1. Acute Myocardial Infarction
2. Ventricular-Septal Rupture
SECONDARY:
1. Hypertension
2. Diabetes
3. Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure participating in your care during your
admission to [**Hospital1 69**]. You were
transferred to our hospital for treatment of a heart attack. The
blockage in your arteries was opened and a stent was placed in
one of your coronary arteries to help keep it open. We also
treated you with several medications to reduce the risk of both
another heart attack and of your heart becoming weak from having
had a heart attack.
Your heart also suffered a complication from your heart attack
in which one of the walls between the different [**Doctor Last Name 1754**] of your
heart ruptured, allowing blood to flow in a direction it
normally would not flow. This is a serious complication and
requires repair. You were evaluated by our interventional
cardiologists as well as our cardiac surgeons who felt that it
would be best to postpone correcting this problem until you have
had a bit more time to recover from your heart attack.
We have changed some of your medications and started you on
several new medications. Please take all of your medications
exactly as prescribed.
In terms of new medications, we have started you on the
following medications:
-Aspirin, 325mg daily to prevent another heart attack
-Plavix, 75mg daily to keep the stent open. Do not stop taking
your aspirin and plavix together unless Dr.[**Doctor Last Name 3733**] tells you
it is OK.
-Lisinopril, 5mg daily to lower your blood pressure
-Atorvastatin, 40 mg daily to lower your cholesterol
-Amiodarone, 200mg once daily to keep your heart in a regular
rhythm.
-Furosemide (Lasix), 80mg daily to prevent fluid overload
-Metoprolol 25mg twice daily to lower your heart rate and help
your heart recover from the heart attack.
-Ranitidine, 150mg, at bedtime to prevent stomach upset
You should STOP taking the following medications:
-Omeprazole (instead you should take the Ranitidine listed
above)
-Verapamil (this is no longer necessary because of the other
medications we have started you on)
.
Weigh yourself every day, Call Dr.[**Doctor Last Name 3733**] if you notice your
weight increase more than 3 pounds in 1 day or 5 pounds in 3
days.
Followup Instructions:
Department: Cardiology
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Friday [**2139-9-18**] at 2:40 PM
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Department: CARDIAC SURGERY
When: MONDAY [**2139-9-21**] at 2:15 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
|
[
"428.31",
"424.0",
"410.41",
"493.90",
"276.1",
"585.9",
"722.6",
"426.0",
"250.00",
"584.9",
"414.01",
"403.90",
"272.4",
"429.71",
"414.2",
"426.13",
"427.31",
"428.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"00.40",
"00.45",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
15572, 15686
|
10682, 13466
|
285, 315
|
15850, 15850
|
3882, 10659
|
18191, 18811
|
2439, 2604
|
13863, 15549
|
15707, 15829
|
13657, 13840
|
16033, 18168
|
2619, 3563
|
2047, 2052
|
3579, 3863
|
13487, 13631
|
227, 247
|
343, 1957
|
15865, 16009
|
2083, 2221
|
1979, 2027
|
2237, 2423
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,073
| 138,234
|
37751
|
Discharge summary
|
report
|
Admission Date: [**2109-10-19**] Discharge Date: [**2109-10-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Progressive dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a [**Age over 90 **] y/o male with Hx of emphysema, COPD, CAD, who was
recently hospitalized for PNA, and discharged to rehab last
week. Over the course of last couple days he developed
progressive worsening of shortness of breath. He was taken to
OSH where he was found to be out of proportionally hypoxic with
regard to his CxR. Subsequent CT revieled bilateral pulmonary
PEs. He was started on Heparin gtt and transferred to [**Hospital1 **].
Here in ED, initial VS: 98.1 95 112/62 30 100% on NRB, Hep gtt
was cont and pt admitted to ICU.
Past Medical History:
- COPD on 2 L home O2
- Emphysema
- CAD, S/P MI 8 years ago
Social History:
lived with son until recent hospitalization and at rebab since
then. He used to ambulate independenly at baseline tobacco:
former smoker, quit 20 years ago.
Family History:
N/C
Physical Exam:
VITAL SIGNS: T=98.3 BP= 127/66 P= 83 R= 18 SaO2 98% on 3LNC
GENERAL: Pleasant, in mild respiratory distress
HEENT: sclerae anicteric, PERRLA/EOMI. MMM. OP clear.
NECK: Supple, No LAD, No thyromegaly. JVP at 7cm
CARDIAC: Heart sounds distant. Regular rhythm, normal rate.
Normal S1, S2. No m/r/g.
LUNGS: diffuse upper airway sounds, good air entry bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
Pertinent Results:
[**2109-10-20**] 12:54AM BLOOD WBC-13.1* RBC-4.09* Hgb-12.4* Hct-38.8*
MCV-95 MCH-30.4 MCHC-32.1 RDW-14.3 Plt Ct-318
[**2109-10-20**] 12:54AM BLOOD Neuts-88.2* Lymphs-7.9* Monos-2.4 Eos-1.1
Baso-0.4
[**2109-10-20**] 12:54AM BLOOD PT-12.2 PTT-99.5* INR(PT)-1.0
[**2109-10-20**] 12:54AM BLOOD Glucose-122* UreaN-15 Creat-0.9 Na-145
K-5.4* Cl-104 HCO3-36* AnGap-10
[**2109-10-20**] 02:40PM BLOOD Type-[**Last Name (un) **] O2 Flow-3 pO2-22* pCO2-78*
pH-7.32* calTCO2-42* Base XS-8 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2109-10-20**] 12:54AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.3
.
PE [**2109-10-19**]:
ACUTE PULMONARY EMBOLISM WITH A MODERATE-TO-LARGE EMBOLUS
BURDEN AS
ABOVE. THERE IS EQUIVOCAL EVIDENCE FOR ELEVATED RIGHT
HEART PRESSURE
AND RIGHT HEART STRAIN. CORRELATION WITH ECHOCARDIOGRAPHY
IS
INDICATED
Brief Hospital Course:
[**Age over 90 **] yo male with COPD on home O2 and recent hospitalization for
pneumonia, presenting with bilateral PE.
1. Pulmonary Embolism: Upon arrival to [**Hospital1 18**], patient was
switced from heparin drip to weight-based lovenox for
anticoagulation. Monitored daily INR while titrating coumadin
dose to INR of [**2-5**]. Throughout hospital course, remained
hemodynamically stable with no signs of right ventricular strain
on EKG or exam. Echo was deferred as results would not impact
management - patient was not a candidate for thrombolysis given
multiple comorbidities. Although patient was initially on 100%
nonrebreather on admission, this was quickly weaned to 4LO2 NC
which is near patient's baseline. Hospital staff stressed
importance of pulmonary toilet with incentive spirometry and
elevation of head of bead. On discharge, INR was 2.7
This was a primary thromboembolic event, most likely provoked in
setting of recent hospitalization and immobilization at acute
rehab. No indication to suspect clotting disorder or other
secondary causes like malignancy. Although patient has remote
hisotry of prostate cancer, recent PSA was within normal limits.
Therefore patient will require anticoagulation for 6 months.
2. Altered Mental Status: waxing and [**Doctor Last Name 688**] mental status in
MICU likely secondary to delerium with possible underlying
dementia. Delerium multifactorial including change of
environment (ICU psychosis) and hypoxia secondary to COPD/
massive PEs. Infectious etiology contributing to delerium not
thought to be likely (see below). Patient had several episodes
of agitation requiring halidol. Hospital staff were encouraged
to maintain a consistent/ normal schedule for patient to
minimize delerium. Oxygen saturation was kept above 90%.
Throughout stay, mental status improved and at the time of
discharge he was breathing comfortably on 3 L NC.
3. CAD: Stable, no signs of ischemia. Patient was previously
taken off all his other cardiac medication secondary to
"intolerance"/ i.e. confusion. Continued on aspirin throughout
hospital course.
4. leukocytosis: Initial elevation in WBC to 13.1 with left
shift was likely secondary to stress reaction from recent PE.
Patient had no focal signs of infection and remained afebrile.
While CXR did show a hazy infiltrate in right lower lobe this
was felt to represent resolving consolidation from recent
pneumonia rather than active infection. It would be prudent to
follow up the current exam with another CXR in [**4-8**] weeks to
ensure complete resolution.
5. COPD: stable, continued on nebs and home O2.
6. Code: Full code.
Medications on Admission:
- hep gtt
- ASA 325
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every four (4) hours as needed for
wheezing.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) miligrams
Subcutaneous Q12H (every 12 hours) for 1 days: Last day
[**2109-10-23**].
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Puff Inhalation twice a day.
9. Labs
Please check INR on [**2109-10-25**] and adjust coumadin accordingly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis:
bilateral pulmonary thromboembolism
Secondary Diagnosis:
COPD
CAD
Discharge Condition:
Hemodynamically stable; breathing comfortably on 3 L NC
(baseline 2 L).
Discharge Instructions:
You initially presented with increasing shortness of breath
after a prior hospitalization for pneumonia. A CT scan at an
outside hospital showed two large clots in the main pulmonary
blood vessels. You were transferred to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] Medical
Center for further medical care.
We started you on a blood thinning medication called coumadin
that will prevent extension of the blood clots and worsening of
your respiratory status. The blood levels of this drug will
need to be measured carefully to ensure that they are
appropriate for your condition (target INR [**2-5**]). While the
medication coumadin is reaching appropriate levels, you will
need to continue the lovenox shots (another blood thinning
medication that is given in the subcutaneous tissue). You will
need to be on blood thinning medications for 6 months.
Please continue to take your previous medications as prescribed:
In addition please take coumadin--- daily. The rehabilitation
facility will tell you how to adjust the doses of this
medicatipn to maintain an INR of [**2-5**].
Followup Instructions:
please follow up with your primary care proivider. You will need
to have your blood drawn to check your INR within the next 3
days. You will also need follow up with your PCP as soon as you
get discharged from ReHab.
|
[
"276.2",
"799.02",
"294.8",
"276.7",
"415.19",
"293.0",
"288.60",
"492.8",
"412",
"276.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6142, 6226
|
2535, 3791
|
285, 292
|
6356, 6430
|
1667, 2512
|
7587, 7807
|
1145, 1150
|
5255, 6119
|
6247, 6247
|
5211, 5232
|
6454, 7564
|
1165, 1648
|
225, 247
|
320, 871
|
6324, 6335
|
6266, 6303
|
3806, 5185
|
893, 955
|
971, 1129
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,036
| 178,240
|
26369
|
Discharge summary
|
report
|
Admission Date: [**2107-5-18**] Discharge Date: [**2107-5-24**]
Date of Birth: [**2034-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Spiriva / Niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
unstable angina with tight left main disease
Major Surgical or Invasive Procedure:
[**2107-5-18**]:
emergent coronary artery bypass grafts x
3(LIMA-LAD,SVG-OM,SVG-RCA)
History of Present Illness:
This 71 year old white male with known coronary artery disease
developed chest pain, shortness of breath and hemoptysis over
the previous 2 days. A stress test was abnormal.Cardiac
catheterization revealed 99% left main coronary artery stenosis.
He was transferred for urgent revascularization.
Past Medical History:
hypertension
hyperlipidemia
myocardial infarction [**2088**]
emphysema
h/o dysphagia with Schatzki ring
right upper lobe wedge resection (necrotic granuloma) [**2105**]
s/p appendectomy
Social History:
Race: caucasian
Lives with: wife
Occupation: retired military
Tobacco: quit [**2088**]
Family History:
noncontributory
Physical Exam:
Admission:
Pulse: 65 Resp: 16 O2 sat:
B/P Right: Left: 142/78
Height: Weight:
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 x
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2107-5-24**] 07:15AM BLOOD WBC-10.4 RBC-3.44* Hgb-11.0* Hct-32.7*
MCV-95 MCH-31.9 MCHC-33.7 RDW-13.5 Plt Ct-326
[**2107-5-23**] 06:30AM BLOOD WBC-17.7* RBC-3.99* Hgb-12.9* Hct-37.3*
MCV-93 MCH-32.2* MCHC-34.5 RDW-13.9 Plt Ct-303
[**2107-5-22**] 06:25AM BLOOD WBC-16.6* RBC-4.00* Hgb-12.8* Hct-37.9*
MCV-95 MCH-31.9 MCHC-33.7 RDW-13.5 Plt Ct-256#
[**2107-5-20**] 06:15AM BLOOD WBC-13.5* RBC-3.90* Hgb-12.6* Hct-37.5*
MCV-96 MCH-32.2* MCHC-33.5 RDW-14.1 Plt Ct-170
[**2107-5-18**] 02:06PM BLOOD WBC-8.7 RBC-5.06 Hgb-16.1 Hct-48.1 MCV-95
MCH-31.8 MCHC-33.4 RDW-14.0 Plt Ct-278
[**2107-5-23**] 06:30AM BLOOD Glucose-148* UreaN-19 Creat-0.8 Na-136
K-4.3 Cl-102 HCO3-24 AnGap-14
[**2107-5-20**] 06:15AM BLOOD Glucose-116* UreaN-19 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-28 AnGap-11
[**2107-5-18**] 02:06PM BLOOD Glucose-113* UreaN-15 Creat-0.7 Na-137
K-4.7 Cl-105 HCO3-25 AnGap-12
[**2107-5-18**] 02:06PM BLOOD ALT-21 AST-24 LD(LDH)-145 CK(CPK)-52
AlkPhos-60 TotBili-0.8
[**2107-5-18**] 09:57PM BLOOD Type-ART pO2-74* pCO2-36 pH-7.36
calTCO2-21 Base XS--4
Brief Hospital Course:
This is a 73 year old male who presented after a markedly
positive stress test. Cardiac cath demonstrated severe 99%
distal left main stenosis with a subtotally occluded LAD filling
via collaterals from a dominant right system which had a 60-70%
mid lesion. The patient was transferred emergently from [**Hospital 40796**] to the [**Hospital1 **] Hospital for
emergent coronary artery bypass grafting. Upon arrival the
patient was hemodynamically stable and chest painfree on
intravenous nitroglycerin only.
He was taken to the Operating Room on [**5-18**] and underwent
emergent coronary bypass grafting x3. See operative note for
full details. He tolerated the procedure well,weaning from
bypass on Neo Synephrine and Propofol infusions.
Post-operatively he was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward his preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes were left in for a persistent air leak with chest x-ray
showing a right basilar pneumothorax. The air leak resolved and
the right chest tube was removed with a persisitent small
basilar pneumothorax. This was stable at dischage and the
patient was assymptomatic. Pacing wires were discontinued
without complication.
The patient was evaluated by the Physical Therapy service for
assistance with strength and mobility. He had a leukocytosis to
17,700 with no obvious source or fever after POD 1. Blood
culture were sent on two days, urine culture was nagative and
his CXR was clear. The WBC fell to 10,000 on [**5-24**] and he was
discharged home.By the time of discharge on POD 6 the patient
was ambulating freely, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged
home with visiting nurse services in good condition with
appropriate follow up instructions.
Medications on Admission:
simvastatin 80 daily, atenolol 50 daily, valsartan 320 daily,
finasteride 5 daily, asa 325 daily, asmanex 220mcg [**Hospital1 **], foradil
12mcg [**Hospital1 **], fish oil capsules 1000mg [**Hospital1 **], calcium 600mg daily,
multivitamin daily, proventil prn
Allergies: spiriva, niacin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. 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*
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*1 * Refills:*0*
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and Hospice
Discharge Diagnosis:
Coronary Artery Disease with tight left main disease
s/p coronary artery bypass grafts
chronic obstructive pulmonary disease
Schatski Ring w/ dysphagia
hyperlipidemia
hypertension
s/p wedge resection Right upper lobe for granulomatous disease
s/p appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Perocoet
Incisions: sternum/left leg-clean, dry and intact
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1+ 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 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**
Followup Instructions:
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2107-6-21**] at 1:30pm ([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) **] in [**1-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2107-5-24**]
|
[
"786.3",
"512.1",
"411.1",
"780.62",
"401.9",
"E878.2",
"250.00",
"496",
"412",
"530.3",
"787.20",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6426, 6497
|
2814, 4943
|
327, 414
|
6805, 7065
|
1741, 2791
|
7823, 8226
|
1071, 1088
|
5283, 6403
|
6518, 6780
|
4969, 5260
|
7089, 7800
|
1103, 1722
|
243, 289
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442, 740
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762, 950
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966, 1055
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17,728
| 109,804
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26870
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Discharge summary
|
report
|
Admission Date: [**2139-3-8**] Discharge Date: [**2139-3-20**]
Date of Birth: [**2056-10-31**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Shellfish / adhesive tape
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Inferior epigastric artery embolization
Drug eluting stent placement
History of Present Illness:
Ms. [**Known lastname **] is an 82 year-old female with HTN, DM, CAD s/p VF
arrest with anterior STEMI and LAD stenting in [**4-5**], pacemaker
placement, h/o TIA, who presents from [**Hospital3 **] for
presumed NSTEMI. She has been having intermittent heavy left
sided chest pain radiating to arm, neck and back for a couple
days. She additionally c/o diarrhea for 1 week prior to
presentation in addition to nausea. No fevers or chills. She
notes stopping clopidigrel a week ago. At [**Hospital1 **], she was found
to have a trop of 1.15. EKG was ventricularly paced without new
signs of ischemia. Patient was given ASA 325 mg and stared on
heparin and nitroprusside gtts with improvement in pain from
[**9-9**] to [**3-12**]. She also received zofran 4mg for nausea. She was
subsequently transferred to [**Hospital1 18**].
.
In the ED, initial vitals were: T 97.6, P 81, BP 186/113, RR 18,
O2sat 99% on 3L O2. Patient is stable with no further complaints
of chest pain. JVD elevated but lungs clear without complaints
of dyspnea on 3L O2. She did complain of nausea and stomach
upset at times. Exam notable for red, hot, and mildly edematous
(nonpitting) RLE without pain; nontender. RLE U/S negative for
DVT. EKG was ventricularly paced with ?LBBB but no ST changes.
Trop here 0.57, CK not sent; Cr 1.2. Anion gap 17. The patient
was continued on Heparin gtt and nitro gtt (titrated down in ED)
and started metoprolol 25 mg po bid. Patient also given zofran
8mg IV. On transfer to floor, vitals were: T 97.8, P 65, BP
140/88, RR 22, O2sat 99% on 3L.
.
On arrival to the floor her initial VS were: , patient currently
feels well, denies any CP, SOB, nausea, vomiting or diarrhea.
Her back pain has improved since getting off the stretcher in
the ER.
.
REVIEW OF SYSTEMS
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 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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
Hypertension
CAD s/p MI and s/p LAD stenting
CHF EF (last know EF 25 % [**2134**])
Mitral regurgitation
Tricuspid regurgition
VF arrest s/p pacemaker placement
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: S/p ppm
3. OTHER PAST MEDICAL HISTORY:
DM
TIA
Breast cancer s/p R mastectomy
DVTs with a questionable hypercoagulable state in the past (pt
report of occurrence with pregnancy and s/p hysterectomy)
Chronic low back pain s/p epidural injections in past
Osteoarthritis
H/o pneumonia
Depression
LE neuropathy
B/l knee surgery
Social History:
lives at home alone. Used to work as a waitress. Daughter lives
locally.
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Brother with CAD. Father with CVA in 40s. Mother with CVA.
Physical Exam:
On admission:
VS: T=98.3 BP=119/83 HR=78 RR=20 O2 sat=98% on RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple with JVP about 3cm above the clavicle
CARDIAC: RR, normal S1, S2 II/VI systolic murmur at RUSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. mildly TTP in LLQ, no rebound or guarding
EXTREMITIES:1+ bilateral LE edema, chronic venous stasis changes
SKIN: No ulcers, scars
NEURO: AOx3, CNII-XII intact, non-focal motor and sensory exam
(has symmetrically decreased strength in distal lower ext;
decreased proprioception b/l, report pain in both lower ext to
touch [**3-4**] neuropathy)
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
.
On discharge:
VS: Tm 98.3, 136/64, 66, 16, 95-9% RA; FS 190
GENERAL: awake, alert, AOx2, dysarthria
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple with elevated JVP, no LAD
CARDIAC: RR, normal S1, S2; [**3-8**] holosystolic murmur at apex
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Poor inspiratory effort
with decreased breath sounds at bases
ABDOMEN: Soft, mildly tender in RLQ and LLQ, no suprapubic
tenderness. No rebound or guarding
EXTREMITIES: no pedal edema, faint distal pulses
SKIN: No ulcers, scars; chronic venous stasis changes of LE b/l
NEURO: CNII-XII intact, L ankle dorsiflexion spasticity with
withdrawal, downgoing toes on R side, 4/5 strength hip flexors
bilaterally, [**4-4**] plantarflexion L ankle, [**6-4**] R ankle; [**6-4**] in all
UE motor groups; no focal sensory deficits
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
Admission [**Month/Day (1) **]:
---------------
[**2139-3-8**] 05:40PM BLOOD WBC-6.3 RBC-3.80* Hgb-12.1 Hct-35.6*
MCV-94 MCH-31.9 MCHC-34.1 RDW-14.6 Plt Ct-206
[**2139-3-8**] 05:40PM BLOOD Neuts-59.9 Lymphs-32.0 Monos-5.3 Eos-2.0
Baso-0.8
[**2139-3-8**] 05:40PM BLOOD PT-17.6* PTT-57.1* INR(PT)-1.6*
[**2139-3-8**] 05:40PM BLOOD Glucose-158* UreaN-25* Creat-1.2* Na-141
K-3.9 Cl-108 HCO3-16* AnGap-21*
[**2139-3-8**] 05:40PM BLOOD CK-MB-15* MB Indx-7.6* cTropnT-0.57*
[**2139-3-9**] 02:00AM BLOOD CK-MB-24* MB Indx-8.5* cTropnT-0.94*
[**2139-3-9**] 09:30AM BLOOD CK-MB-18* MB Indx-8.3* cTropnT-0.94*
[**2139-3-10**] 06:40AM BLOOD CK-MB-8 cTropnT-0.57*
[**2139-3-14**] 03:06AM BLOOD CK-MB-3 cTropnT-1.09*
[**2139-3-8**] 05:40PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2
[**2139-3-16**] 07:25AM BLOOD VitB12-686 Folate-9.1
[**2139-3-9**] 06:10PM BLOOD %HbA1c-5.9 eAG-123
[**2139-3-9**] 09:30AM BLOOD Triglyc-92 HDL-34 CHOL/HD-3.4 LDLcalc-64
LDLmeas-73
Discharge [**Year/Month/Day **]:
---------------
[**2139-3-19**] 07:45AM BLOOD WBC-8.0 RBC-3.25* Hgb-10.4* Hct-30.4*
MCV-93 MCH-32.0 MCHC-34.2 RDW-14.3 Plt Ct-282
[**2139-3-16**] 07:25AM BLOOD Neuts-75.2* Lymphs-16.5* Monos-6.1
Eos-1.7 Baso-0.6
[**2139-3-19**] 07:45AM BLOOD Glucose-159* UreaN-43* Creat-1.1 Na-146*
K-3.4 Cl-110* HCO3-25 AnGap-14
[**2139-3-15**] 06:55AM BLOOD ALT-24 AST-24 AlkPhos-45 TotBili-0.8
Imaging / Procedures:
Cardiac cath: [**2139-3-9**]
1. Selective coronary angiography of this right dominant system
demonstrated 3-vessel coronary artery disease. The LMCA was free
of angiographically significant disease. There was in stent
restenosis of the proximal LAD to 70%. The remainder of the LAD
was free of angiographically significant disease. A ramus
demonstrated serial 90% stenoses. The Lcx gave rise to a small
OM that was totally occluded and filled late via left to left
collaterals. There was a mid vessel 60% stenosis. There was a
thrombotic occlusion of the distal RCA which was an ectatic
vessel throughout. Left to right collaterals supplied the distal
RCA.
2. Resting hemodynamics revealed significantly elevated right
and left heart filling pressures (RA mean 17mmHg, PCW mean
19mmHg). There was severe pulmonay artery hypertension
(PASP=80mmHg PADP=33mmHg PA mean=48mmHg). The cardiac output and
index were low at 3.8L/min and 1.98L/min/m2. The SVR was
elevated at 2147 dynes/sec/cm-5 and PVR severely elevatd at 611
dynes/sec/cm-5.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with culprit vessel for
NSETMI likely RCA thrombosis. Lesion not well suited for PCI so
surgical evaluation recommended.
2. Elevated left and right heart filling pressures consistent
with LV diastolic and systolic dysfunction given low cardiac
output.
3. Severe pulmonary artery hypertension with increased pulmonary
vascular resistence.
.
TTE [**2139-3-10**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is severe regional left ventricular
systolic dysfunction with mid- and distal septal, anterior, and
basal inferior akinesis. There is moderate hypokinesis of the
remaining segments, most c/w multivessel CAD (LVEF = 25%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
estimated cardiac index is depressed (<2.0L/min/m2). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) 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: Severe regional and global left ventricular systolic
dysfunction, c/w multivessel CAD. Mild right ventricular
systolic dysfunction. Moderate to severe mitral and tricuspid
regurgitation. Severe pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2134-6-10**], LV
systolic function has substantially deteriorated, primarily due
to inferior wall akinesis. Mitral and tricuspid regurgitation
have increased in severity and pulmonary pressures are higher.
.
Carotid U/S:
Findings are consistent with less than 40% stenosis bilaterally.
Somewhat reduced velocities were seen in the vertebral arteries
bilaterally.
.
FDG Cardiac viability study:
1. Viable myocardium in the anterolateral wall and anterior
portion of the apex with left ventricular dilation.
2. Mildly decreased FDG avidity in the remainder of the
myocardium. This could represent non viable myocardium due to an
interval infarct. A more recent perfusion study may be helpful
to evaluate global myocardial perfusion.
3. LUL 15 mm nodule, could represent focal atelectasis.
Recommend short interval dedicated chest CT for follow-up.
.
Cardiac cath [**3-13**]:
1. Three vessel coronary artery disease.
2. Successful PCI of distal RCA and proximal LAD.
3. PCI of Ramus could be done if necessary but would be very
long small stent
4. Stenting of distal RCA could be done if recurrent ischemia
5. Medical management of LM lesion.
.
Cardiac cath [**3-13**]:
1. Retroperitoneal bleeding from a small [**Last Name (un) **] of inferior
epigastric artery.
2. Successful coil embolization of the inferior epigastric
artery to control the course of retroperitoneal bleeding.
.
CT abd [**3-13**]:
1. Large right retroperitoneal hematoma from right groin,
extending to right rectus muscle into the right retroperitoneum,
up to the tip of the liver. Small amount of hemorrhage seen in
the cul-de-sac. Expansion of the right pelvic retroperitoneal
space with displacement of the urinary bladder. No hematoma
below the inguinal ligament.
2. Bilateral small pleural effusions and bibasilar atelectasis.
3. Innumerous renal hypodensities and small cysts.
.
CXR [**3-14**]:
This is a slightly rotated film. Given technique, there is no
significant interval change compared to prior. There is a
pacemaker with two leads projecting over the heart in expected
locations. There is moderate cardiomegaly. There is increased
retrocardiac opacity that could be due to volume
loss/infiltrate/effusion. The right lung is clear.
.
CT head [**3-15**]:
No acute intracranial pathologic process. Specifically no
evidence of hemorrhage or recent infarction.
.
CXR [**3-16**]: Improved aeration of the left lung.
.
CXR [**3-18**]: In comparison with the study of [**3-16**], there has been
placement of a Dobhoff tube that curls within the upper stomach.
Little change in the appearance of the heart and lungs and the
pacemaker device.
.
Brief Hospital Course:
82-year-old female with HTN, DM, CAD s/p VF arrest with anterior
STEMI and LAD stenting in [**4-5**], pacemaker placement, h/o TIA,
who presents from [**Hospital3 **] with NSTEMI, now s/p PCI with
2 DES to prox LAD ISR, and POBA/export thrombectomy of RCA,
procedure complicated by retroperitoneal bleed s/p coiling of
inferior epigastric artery, and delirium.
===========================================================
ACTIVE ISSUES:
--------------
.
# NSTEMI with stenting, complicated by retroperitoneal bleed: pt
presented with typical chest pain, cardiac enzymes peaked (trop
0.94). She was started on heparin drip, full dose ASA. She
underwent cardiac cath which showed 3-vessel disease. After a
long discussion between CT surgery, patient, and her family they
decided not to pursue CABG given high risk of procedure and pt's
wishes. She underwent a FDG PET cardiac viability study which
showed viable myocardium in the anterolateral wall and anterior
portion of the apex, and decreased FDG activity in the rest of
the myocardium. Pt underwent repeat catheterization with PCI of
distal RCA and proximal LAD, and POBA/export thrombectomy of
RCA. Post-cath course was complicated by RP bleed which was seen
on CT, pt was taken back to cath lab and had successful coil
embolization of the inferior epigastric artery to
control the course of retroperitoneal bleeding. She was
transferred to the CCU for overnight observation.
.
Brief CCU course:
Patient underwent a planned cardiac catheterization on [**2139-3-13**]
in which two drug-eluting stents were placed to her proximal LAD
in-stent stenosis. An export thrombectomy was performed on her
RCA. After the procedure the patient complained of back pain,
was found to have a 5 point hematocrit drop and evidence of a
large right-sided retroperitoneal bleed on CT. She was
immediately taken back to the cath lab, and the bleeding artery
(right inferior epigastric) was succesfully embolized with
coils. The patient was transferred to the CCU for monitoring.
Her post-cath check was normal. Serial hematocrits were
monitored and remained stable. She did not require any blood
products. Her vital signs remained stable and within normal
limits. She was transferred back to her primary team for further
management.
.
After return to the floor, pt did not have any chest, back, or
abdominal pain. She did not have shortness of breath or any
events on telemetry. We continued her ASA 325mg daily, plavix
75mg daily, toprol XL 25mg daily. Her amlodipine 5mg was changed
to lisinopril 5mg for myocardial protection. She will follow up
with Dr. [**Last Name (STitle) **] after discharge from rehab.
.
# Delirium: pt developed altered mental status and hypoactivity
after transfer from CCU. Though delirium was likely related to
ICU stay and hospitlization in a patient with some underlying
dementia, we pursued work-up of other etiologies. Infectious
work-up was unrevealing with negative urine and blood cultures,
and CXR without pneumonia. Her Foley was pulled out to minimize
delirium. CT head was negative. Pt underwent speech/swallow
evaluation which found dysphagia (likely due to inattention
rather than mechanical causes). She was made NPO and meds
crushed in apple sauce. Pt slowly improved daily with increased
alertness and orientation, though continued to be below baseline
per family. Neurology was consulted and believes that
encephalopathy is likely hospital-related delirium vs post-cath
microemboli vs medication-related (oxycodone and gabapentin were
held after pt developed altered mental status). They proposed
that deficits will likely improve with time. An NG tube was
placed and tube feeds were initiated, pt should have repeat
swallow evaluation at rehab and NG tube can be taken out once
she does not show aspiration. On discharge, pt's speech was
clearer, she was AOx2-3 (knew month and year, not day of week).
She was slightly lethargic but easily arousable and interactive.
.
# Chronic systolic heart failure (last EF 25 % in [**2134**], now LV
systolic function has substantially deteriorated, primarily due
to inferior wall akinesis. Mitral and tricuspid regurgitation
have increased in severity and pulmonary pressures are higher).
Pt was initially diuresed with IV lasix and after cath/PCI, she
remained overall euvolemic on exam. Her renal function was 1.1
at time of discharge. We continued metoprolol and started an
ACE-i on discharge. She should continue lasix 20mg PO daily
after discharge to maintain her volume status.
.
INACTIVE ISSUES:
----------------
# Hypertension - BP elevated to 180s/80s on admission, she was
started on nitro gtt with improvement to SBP 130s/80s. She was
quickly weaned off the nitro drip and had well controlled BP's
on toprol XL 25mg daily and amlodipine 5mg daily. Prior to
discharge, amlodipine was changed to ACI-i as above.
.
# Diabetes: per patient, she is diet controlled at home. We
placed her on diabetic diet and insulin sliding scale during
hospitalization with control of blood sugars.
.
# Spinal Stenosis: pt has chronic pain from spinal stenosis, she
was recently started on Ultram for pain at home which caused her
GI upset. We initially gave her oxycodone with good control of
pain, but discontinued this after she developed delirium, as
above. She can continue on low dose oxycodone when her mental
status improves.
.
TRANSITION OF CARE:
-------------------
# Pulmonary nodule - PDG viability study showed LUL 15 mm
nodule, which could represent focal atelectasis. Recommend short
interval dedicated chest CT for follow-up. A copy of this
discharge summary will be faxed to pt's PCP and cardiologist,
Dr. [**Last Name (STitle) 10543**], who can scheduled a follow-up for this.
.
# NG tube - pt was discharged with NG tube and tube feeds due to
dysphagia in setting of delirium. She should have a repeat
swallow evaluation in [**3-5**] days and once aspiration is not noted,
NG tube can be removed.
.
# [**Name (NI) **] - pt should have Chem 7 checked in [**3-5**] days at rehab to
trend Cr, Na since she was recently started on tube feeds and is
restarting gentle diuresis with PO lasix, as above.
.
# Pain control - as above, has spinal stenosis pain. Took Ultram
prior to admission with GI upset. Had good pain control
initially with oxycodone, which was held after altered mental
status developed. Gabapentin also held due to AMS. Discharged
with Lidocaine patch on back and tylenol prn. Can restart
oxycodone and gabapentin when mental status improves.
Medications on Admission:
Aspirin 325mg daily
Gabapentin 600mg daily
Metoprolol XL ?50mg daily
Tramadol 50mg [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
Please have your Chemistry 7 panel checked within 1-2 days of
discharge. [**Name8 (MD) 6**] MD at your rehab facility can follow up on the
results.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale.
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please
place on back for spinal stenosis pain.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, headache.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
13. heparin Sig: 5000 (5000) units Subcutaneous three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
NSTEMI
Retroperitoneal bleed
Delirium
Congestive heart failure
Secondary:
Hypertension
Diabetes type 2
Spinal stenosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] with chest pain and we found that you
had a heart attack. We started you on medications for your heart
attack and did a cardiac catheterization, which showed 3-vessel
disease of your coronary arteries (the vessels feeding your
heart). The surgeons discussed possibility of bypass surgery
with you, but given the high risk of the procedure, you and your
family decided not to pursue surgical treatment. We did an MRI
of your heart and decided to put stents into some of your
vessels to help the blood flow to your heart. You had successful
stenting of your coronary arteries, but developed a small bleed
in your abdomen which we repaired. You were observed overnight
in the cardiac care unit and transferred to the floor the next
day. After the procedure, you developed some confusion and
disorientation which is likely caused by delirium from being in
the hospital. Our neurology team evaluated you and believes that
you will regain much of your function with time. You were having
difficulty swallowing and an evaluation of your swallowing
showed that you were aspirating food and drink into your lungs.
We placed a nasogastric tube for feeding, which can be removed
once another swallow evaluation at your rehab facility shows
that you can swallow well.
You will be going to a rehab facility to regain your strength
and should follow up with Dr. [**Last Name (STitle) 10543**] after your discharge (see
below).
We have made the following changes to your medications:
- START aspirin 325mg daily
- START plavix 75mg daily (it is very important to take this
medication daily without missing any doses, it helps keep your
stents open)
- START atorvastatin 80mg daily
- START lisinopril 10mg daily and toprol XL 50mg daily for blood
pressure and heart failure
- TAKE lasix 20mg daily for your heart failure
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.--Cardiologist
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt: We are working on a follow up appt for you. The office
will call you at home with an appt. If you dont hear from them
by tomorrow, please call them directly to book follow up for
your cardiology needs.
Completed by:[**2139-3-20**]
|
[
"458.29",
"250.60",
"E879.0",
"599.71",
"729.92",
"357.2",
"518.89",
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"724.00",
"401.9",
"998.11",
"996.72",
"584.9",
"V45.01",
"428.43",
"V10.3",
"416.8",
"293.0",
"410.71",
"276.2",
"294.8",
"E878.4",
"414.01",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"37.23",
"36.07",
"88.56",
"39.79",
"96.6",
"00.66",
"00.46",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
20333, 20430
|
12416, 12837
|
372, 467
|
20603, 20603
|
5583, 8000
|
22777, 23298
|
3585, 3645
|
19054, 20310
|
20451, 20582
|
18930, 19031
|
8017, 12393
|
20783, 22298
|
3660, 3660
|
2875, 3101
|
4586, 5564
|
22327, 22754
|
322, 334
|
12852, 16923
|
495, 2767
|
16940, 18904
|
3674, 4572
|
20618, 20759
|
3132, 3417
|
2789, 2855
|
3433, 3569
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,097
| 104,939
|
27912
|
Discharge summary
|
report
|
Admission Date: [**2107-7-28**] Discharge Date: [**2107-8-3**]
Date of Birth: [**2085-9-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
"collapse"
Major Surgical or Invasive Procedure:
lumbar puncture
intubation, extubation
History of Present Illness:
21 y/o AAM with PMHx of asthma who was at work and had a
witnessed collapse at work at 11:40am today. Employees heard
"gasp" and then patient collapsed to floor. Per family,
employees described some sort of movement while patient was
unresponsive on the floor. Not able to give a time frame for
unconsciousness.
.
EMS was called, described pt as "agitated and fighting."
Conversed but screaming, not able to obtain history, AAOx0. Had
L supraorbital laceration from fall on L head on counter. VS in
field HR 90, RR26.
.
At [**Location (un) **] OSH, VS T99.1, HR126, BP140/70, RR27, 98%RA. Head
and c-spine CT were negative for any bleed or mass. Intubated
at [**Location (un) **], received Succ/Vecuronium prior to intubation. Got
Ativan 1mg x6; loaded with Dilantin 1g IV. Received Vanco 1g
and CTX 2g x1. U/A neg, utox/stox (-), blood cx's x2 sent. Had
ABG of 7.40[32[ 275.
.
ROS could not be obtained. Per family, pt was feeling well last
night and this morning and was not complaining of any fevers,
photophobia, neck stiffness, fatigue or any other systemic
symptoms.
Past Medical History:
asthma
Social History:
Employed at [**Company 2486**] in [**Location (un) **].
Family History:
No known fam hx of seizure or sudden cardiac death.
Physical Exam:
VS: T98.1 BP103/57 HR77 RR17 o2:100% on AC 550x14 PEEP5 50%
Fi02
GEN: Intubated, sedated, moves all ext spontaneously. Does not
respond to questions
HEENT: L supraorbital area with subcutaneous swelling. No conj
injection. R pupil 4 -> 2mm.
NECK: c-collar in place.
CV: Regular, nml s1,s2. No murmurs
RESP: CTAB anteriorly. No c/w/r.
ABD: Soft, nondistended. No HSM.
EXT: No edema bilat. Pulses 2+, symmetric
NEURO: Sedated, does not respond to questions. Moves all ext
spontaneously.
SKIN: No rashes seen.
Pertinent Results:
Imaging from OSH:
Read as (-) Head CT and (-) C-spine. Reviewed films with
radiology here, with ? hypodensity in L temporal area, but poor
quality films.
.
CXR [**7-28**]: Endotracheal tube as described above. Extremely
limited study due to motion. Somewhat prominent cardiac
silhouette and small bowel gas.
.
EKG: Sinus tach, 110. Nml axis, nml intervals. PR 162, QRS 82.
TWI V1-V2, nml TW otherwise normal. No Q waves. No ST
elevations or depressions. No previous to compare.
.
[**2107-7-29**] CT head: FINDINGS: Consistent with the recent MRI,
within the left parietal lobe is an area of low attenuation
consistent with edema. The known mass in this region is not
clearly appreciated on this CT scan. However, there is a single
focus of high attenuation on series 2, image 25, which could
represent a small focus of calcification versus hemorrhage.
There is no evidence of subdural or subarachnoid, or epidural
hemorrhage. There is no hydrocephalus, shift of normally midline
structures, or alteration in the [**Doctor Last Name 352**]-white matter
differentiation. There are no other areas of mass effect. The
osseous structures are normal. There is mucosal thickening
within the ethmoid air cells as well as sphenoid sinus.
IMPRESSION: Consistent with the recent MRI which showed the
lesion in the left parietal lobe, there is evidence of edema in
this region. There is a punctate focus of high attenuation which
could represent calcification or less likely hemorrhage. No
evidence of subarachnoid, subdural, or epidural hemorrhage.
.
[**2107-7-29**] MRI/MRA Brain: TECHNIQUE: Multiplanar T1 - and
T2-weighted pre- and post-contrast imaging of the brain was
reviewed. In addition, MR angiography of the circle of [**Location (un) 431**]
with 3D time-of-flight imaging and 3D reconstructions was
reviewed.
MR brain with contrast: Within the [**Doctor Last Name 352**] matter of the left
parietal lobe is a small thick rim enhancing 7 mm round lesion
with moderate amount of associated vasogenic edema. Signal is
slightly hyperdense to [**Doctor Last Name 352**] matter on T2 imaging with a
hypodense surrounding rim. There is no susceptibility to
indicate hemorrhage. Diffusion-weighted imaging demonstrates
mild high signal consistent with slow diffusion. There is no
evidence for dural extension. No other lesions are identified.
Otherwise, the brain is unremarkable with no shift of midline
structures, or abnormal T1 or T2 signal. The ventricles, sulci,
and cisterns appear normal. There is a small amount of mucosal
thickening in the sphenoid sinuses. The paranasal sinuses are
otherwise unremarkable.
MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **]: Appropriate flow signal
is present within the internal carotids and common circle of
[**Location (un) 431**] and its major tributaries. Note is made of a right
dominant vertebral artery posterior circulation without evidence
for hemodynamically significant stenosis or aneurysm.
IMPRESSION:
1. Thick rim enhancing 7 mm right parietal lesion with
associated edema that represents abscess versus neoplasm.
Correlation with outside CT to determine presence of
calcification is advised, and if access to outside CT is not
available, reimaging is advised for further characterization.
2. Normal MR angiography of the circle of [**Location (un) 431**]. These findings
were discussed with Dr. [**First Name (STitle) **] at 5 p.m. on [**2107-7-29**].
.
[**2107-7-29**] CXR: IMPRESSION: Motion artifacts limit the evaluation
of this study. The ET tube tip is 3 cm above the carina. The NG
tube tip is in the stomach, but the side hole is at the level of
the gastroesophageal junction. The heart size is normal. A left
lower consolidation is most probably due to atelectasis and is
mild. The pulmonary vasculature engorgement is mild,
representing mild congestion which could be due to volume
overload.
.
[**2107-7-29**] ABNORMALITY #1: This recording appears to have taken
place in about three phases with the first phase the patient was
sedated with Propofol and background rhythms are slowed with
overlying faster beta activity seen. The Propofol was then
turned off and the patient arouses easily and appears agitated.
Background rhythms at this time vacillated
between about an 11 Hz posterior rhythm and were obscured by
faster beta
rhythms and muscle artifact. The Propofol was reinstated and the
background rhythms, once again, became of a lower voltage with
slowing
and faster beta overlying the slowing seen. No epileptiform
activity
was observed throughout any of this recording.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable EEG.
SLEEP: No definitive sleep/wake cycles were observed.
CARDIAC MONITOR: Showed a regular rate and rhythm with a rate of
approximately 80 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of
suppressed
background rhythms and secondary medication effects. With
weaning of
medication, a more normal alpha background-type rhythm does
appear;
however, not for long as this is obscured by mostly muscle
artifact as
well as medication side effect. No focal or epileptiform
features were
seen on this EEG. No electrographic seizures were observed.
.
[**2107-7-30**] CXR: CHEST, ONE VIEW: Comparison with [**2107-7-29**],
again shows the NG tube, which would need to be advanced
approximately 7 cm to have all the side ports within the
stomach. There is decreased pulmonary vascular congestion. There
is a new consolidation within the right lower lobe consistent
with pneumonia. There is no pneumothorax. The cardiac contour is
stable. No new pleural effusions.
.
[**2107-8-1**] CXR: There has been removal of endotracheal tube and
nasogastric tube. Previously reported bilateral lower lobe areas
of consolidation have improved, with residual consolidation
predominantly in the right lower lobe. There are probable small
bilateral pleural effusions.
.
[**2107-7-28**] 9:50 pm CSF;SPINAL FLUID Source: LP.
CRY AG ADDED 2118 [**2107-7-29**].
GRAM STAIN (Final [**2107-7-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2107-8-1**]): NO GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
CRYPTOCOCCAL ANTIGEN (Final [**2107-7-30**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
Performed by latex agglutination.
Reference Range: Negative.
Results should be evaluated in light of culture results
and clinical
presentation.
.
[**2107-7-29**] 8:00 pm SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2107-8-1**]**
GRAM STAIN (Final [**2107-7-30**]):
[**12-7**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2107-8-1**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). RARE GROWTH.
.
[**2107-8-3**] 1:52 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2107-8-3**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Pending):
.
T LYMPHOCYTE SUBSET WBC Lymph Abs [**Last Name (un) **] CD3% Abs CD3 CD4% Abs CD4
CD8% Abs CD8 CD4/CD8
[**2107-7-29**] 04:08AM 7.1 14.3* 1015 68 690 52 533 12 123* 4.4*
.
Iron 26, Iron Binding Capacity, Total 234, Ferritin 49,
Transferrin 180
.
CYSTICERCOSIS ANTIBODY (BLOOD and CSF) Results Pending
Brief Hospital Course:
21 y/o AAM with PMHx of asthma who was at work and had a
witnessed collapse at work.
.
1. Collapse/seizure/right parietal brain lesion.
This is a 21 y/o with no PMHx besides asthma had a witnessed
collapse, no antecedent illness. No blood or mass seen on Head
CT at OSH. Appeared to have had tonic-clonic movements with
what appears to be post-ictal confusion and agitation that make
seizure more likely. Patient was given an Dilantin load at the
OSH prior to transfer. An LP on the night of admission was
negative for any bacterial meningitis, although it did show red
cells that did not clear. He was started on IV Acyclovir at
treatment doses (700mg q8) until his HSV PCR returned negative.
His LP cx's and blood cx's remained NGTD throughout his
admission. An MRI revealed a thick rim enhancing 7 mm right
parietal lesion with associated edema that neurosurgery felt was
consistant with a single neurocysticercosis lesion and did not
feel any surgical intervention was required at this time. ID
was also consulted who did not feel that any treatment was
required at this time. Neurology recommended continuing the
Dilantin/Keppra for seizure ppx given the ongoing presence of
the lesion. ID thought dilantin could possibly causing
persistent fevers and dilantin was weaned and Keppra was
titrated upo 1000mg [**Hospital1 **] but unlikley given pt defervesced while
on Dilantin 100mg TID. There also was a question of left eye
deviation and consulted ophthalmology who noted no abnormalities
with either eyes or movements. Pt developed post LP headaches
which resolved after receiving IV caffeine and hydration. The
patient will follow-up with neurology in [**Month (only) 216**] and with
neurosurgery and ID after obtaining repeat MRI in 3months. Pt
will also establish primary care physician at [**Name9 (PRE) **] Internal
Medicine. Pt's cysticercosis serology (blood and CSF) are
pending at the time of discharge and these can be followed by
neurology/ID or neurosurg. Pt's HIV returned negative at the
time of discharge.
.
2. Resp failure/Pneumonia
Patient was intubated at the OSH given his agitation and
post-ictal confusion. He was transferred here and weaned off
the vent, until he was extubated successfully on [**7-31**]. Pt
became febrile while intubated and was treated for empiric
aspiration PNA (ETT sputum cx with sparse GNR growth) while in
the unit with CTX/vanc then levo/flagyl/vanc then zosyn/vanc
then levo/flagyl which were then discontinued per ID as
persistent fevers were thought to be drug related, rather than
from active lung infection. After 5 days of antibiotics,
stopped all abx per ID recs and pt's temperature was monitored.
Pt remained afebrile for 24hours after stopping all antibiotics.
.
3. L facial laceration
Patient with head trauma with his collapse. He was placed in a
c-collar and transferred here intubated. He had a neck MRI here
that did not show any fracture or subluxation, and once he was
extubated and off sedation and neck pain-free, his c-spine was
cleared and his c-collar was removed.
.
4. Hypocalcemia. Unclear etiology. Was repleted in the unit x i
and since repletion, calcium level stayed normal.
.
5. Anemia. Iron studies sent during this admission c/w mild
iron deficiency. Unclear etiology; defer further
treatment/workup to PCP. [**Name10 (NameIs) 116**] need repeat studies in the future.
.
4. Coagulopathy. INR improved to 1.2 after receiving Vit K SQ
and PO. Unclear etiology. Deferred further w/u to outpatient
PCP.
.
5. FEN - ADAT to regular
6. PPx - Hep SQ. Pneumoboots.
Medications on Admission:
none
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO once a day for 3 days: take one pill at 8PM today [**2107-8-3**]
then one tablet daily for the next 2 days.
Disp:*3 Capsule(s)* Refills:*0*
2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Seizure
Brain lesion, ? Neurocystocercosis
Post lumbar puncture headache
Discharge Condition:
Stable
Discharge Instructions:
Return to emergency department if you develop worsening
headache, nausea, vomiting, dizziness, seizures, loss of
consciousness, or any other worrisome symptoms. Take medications
as instructed and keep your follow-up appointments. Take both
Dilantin for two days and Keppra daily until you see your
neurologist.
Followup Instructions:
You have an appointment at [**Location 11797**] at
230 [**Hospital1 **] streetn, tomorrow ([**2107-8-4**]) with the financial
officer at 10:30 am. [**First Name5 (NamePattern1) 67996**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2107-8-4**] 10:30
.
You need to have an MRI of brain on [**10-14**] at 2:30pm.
Please go to the [**Hospital Ward Name 23**] buildling on the [**Location (un) **].
.
You have an appointment with [**First Name11 (Name Pattern1) 2801**] [**Last Name (NamePattern4) 14773**], [**MD Number(3) 4974**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2107-8-10**] 4:45
.
You have an appointment with Dr. [**First Name4 (NamePattern1) 4333**] [**Last Name (NamePattern1) 4334**] (infectious
disease) on [**2107-10-26**] at 10 AM. Phone: ([**Telephone/Fax (1) 4170**]. MRI of
brain.
.
Provider: [**Name Initial (NameIs) 43**]/[**Doctor Last Name **] (Neurology) Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2107-10-6**] 2:30
.
Please call Dr.[**Name (NI) 9034**] office at [**Telephone/Fax (1) 2731**] to make a
follow-up appointment after you have your MRI in [**Month (only) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"349.0",
"780.6",
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|
[
[
[]
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icd9pcs
|
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,444
| 108,884
|
54483
|
Discharge summary
|
report
|
Admission Date: [**2136-6-4**] Discharge Date: [**2136-6-15**]
Date of Birth: [**2079-2-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Morphine / Codeine / Lipitor / erythromycin /
Clindamycin / Chlorhexidine / Iodine-Iodine Containing /
adhesive tape / Darvocet-N 100
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitations and syncope
Major Surgical or Invasive Procedure:
[**2136-6-4**] Aortic Valve Replacement (19mm St. [**Male First Name (un) 923**] mechanical),
Mitral Valve Repair (30mm annuloplasty ring), Excision of
[**Company 1543**] Reveal Device from left anterior chest
History of Present Illness:
This is a 54 year old female with significant medical history of
mitral valve prolapse and moderate mitral regurgitation. This
was initially diagnosed 20 years ago when it was picked up on an
echocardiogram which was done in preparation for gynecologic
surgery. Since that time she has been followed with serial
echocardiograms with her most recent showing moderate to severe
mitral regurgitation with increasing LV dimensions. Cardiac cath
in [**Month (only) 547**] showed clean coronaries.
Past Medical History:
-Mitral valve (bileaflet) prolapse and Moderate Mitral
regurgitation
-Longstanding history of palpitations, status post recent
electrophysiology study with subsequent diagnosis of AVNRT
- Ventricular tachycardia
-Pericarditis (Small pericardial effusion) [**2133-8-18**]
-Hyperlipidemia (Elevated Total cholesterol and HDL)
-[**2115**] Endometriosis s/p Total abdominal hysterectomy
-[**2125**] Vaginal Cancer s/p radiation
-Frequent bowel obstruction d/t adhesions from XRT and abdominal
surgeries.
-Recurrent Stomach ulcers
-Gastroesophageal reflux disease and gastric ulcers
-Frequent bowel obstructions
-Atypical tuberculosis in the lung
-Dyslipidemia
-MUGS-abnormal low white blood cell count and low protein.
Followed by Dr. [**Last Name (STitle) 410**] (Heme/Onc)
-Complex migraines
-Syncopal episodes
-[**11/2134**] Lyme disease s/p 6 week treatment with Doxycycline
-Glaucoma
-Seasonal allergies
-Bronchitis
Past Surgical History:
-Tonsillectomy as a child
-Appendectomy as a child
-Right elbow surgery after a fall s/p three surgeries
-s/p TAH
-s/p 7 gynecological surgeries
-s/p Bowel resection
-Reveal implant in left upper chest
Social History:
Lives with: Mother and sister
Occupation: Disability
Tobacco: Never
ETOH: Denies ETOH or illicit drug use
Family History:
Non-contributory
Physical Exam:
Pulse: 92 Resp: 18 O2 sat: 100%
B/P 146/77
Height: 5'7" Weight: 115 lbs
General: WDWN in NAD
Skin: Warm, Dry, intact. No lesions or rashes. Well healed
abdominal incisions. Left upper chest Reveal Monitor noted
subcutaneously.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, II/VI holosystolic murmur, Nl S1-Split S2 vs S3
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] No 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: None Left: None
Pertinent Results:
[**2136-6-4**] TEE: Pre CPB: No spontaneous echo contrast or thrombus
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 is moderately dilated. Overall left ventricular systolic
function is normal (LVEF>55%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Moderate (2+) aortic regurgitation is seen. There is
moderate bileaflet mitral valve prolapse. Severe (4+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the
results. Post CPB: The patient is in sinus rhythm with a cardiac
output of 4.9L/min on a phenylephrine infusion. The
biventricular systolic function is preserved. There is a mitral
annuloplasty ring seen. There is trivial MR, the mean/peak
gradient across the mitral valve are 4/8mmHg. There is a well
seated mechanical valve in the aortic position. Both leaflets
are seen to move freely, washing jets are noted. The mean/peak
gradients across the aortic valve are 16/30mmHg. The visible
contours of the thoracic aorta are intact.
[**2136-6-4**] 11:15AM BLOOD WBC-5.3# RBC-2.86*# Hgb-8.8*# Hct-25.7*#
MCV-90 MCH-30.7 MCHC-34.2 RDW-13.5 Plt Ct-130*
[**2136-6-7**] 09:58PM BLOOD WBC-7.0 RBC-3.09* Hgb-9.5* Hct-27.1*
MCV-88 MCH-30.7 MCHC-35.1* RDW-14.0 Plt Ct-113*
[**2136-6-14**] 02:02AM BLOOD WBC-5.5 RBC-3.09* Hgb-9.0* Hct-27.5*
MCV-89 MCH-29.0 MCHC-32.5 RDW-14.0 Plt Ct-396
[**2136-6-4**] 11:15AM BLOOD PT-15.8* PTT-30.5 INR(PT)-1.4*
[**2136-6-7**] 01:14PM BLOOD PT-61.0* INR(PT)-6.7*
[**2136-6-8**] 06:04PM BLOOD PT-14.1* PTT-29.8 INR(PT)-1.2*
[**2136-6-13**] 04:15AM BLOOD PT-19.2* PTT-69.0* INR(PT)-1.7*
[**2136-6-14**] 02:02AM BLOOD PT-20.2* PTT-87.2* INR(PT)-1.8*
[**2136-6-14**] 08:43AM BLOOD PT-20.3* PTT-64.5* INR(PT)-1.9*
[**2136-6-4**] 12:55PM BLOOD UreaN-10 Creat-0.6 Na-145 K-3.6 Cl-117*
HCO3-23 AnGap-9
[**2136-6-14**] 02:02AM BLOOD Glucose-115* UreaN-11 Creat-0.7 Na-142
K-4.8 Cl-104 HCO3-32 AnGap-11
[**2136-6-7**] 09:58PM BLOOD ALT-25 AST-36 LD(LDH)-333* AlkPhos-50
Amylase-144* TotBili-0.4
[**2136-6-14**] 02:02AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.7*
[**2136-6-15**] 03:03AM BLOOD PT-23.4* INR(PT)-2.2*
Brief Hospital Course:
The patient was brought to the operating room on [**2136-6-4**] where
he underwent an Aortic Valve Replacement (mechanical), Mitral
Valve repair and excision of Reveal device from left chest.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Post-op day one
he was weaned from sedation, extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. She briefly
went into Atrial Fibrillation and converted to sinus rhythm.
Coumadin was started with a Heparin bridge. She had quick
increase in INR on [**6-7**] to 6.7 which was treated with FFP and
Vitamin K. INR trended down and Coumadin was titrated for goal
INR for mechanical valve. Titration of her Coumadin for a goal
INR took much longer than expected and she wasn't discharged
until post-op day 11. The patient was discharged to home in
[**State 5887**] in good condition with appropriate follow up
instructions. Follow up appointments scheduled in [**State 5887**].
Target INR 2.5-3.0 for mechanical AVR. First blood draw [**2136-6-16**].
Coumadin to be managed through Dr.[**Name (NI) 5572**] office over
weekend, then Dr. [**Last Name (STitle) 28224**] will take over on Monday, [**2136-6-18**].
Medications on Admission:
BUTALBITAL-ACETAMINOPHEN-CAFF [ESGIC] - (Prescribed by Other
Provider) - 50 mg-325 mg-40 mg Capsule - one Capsule(s) by mouth
twice a day to three times a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution -
injection of 1000 ug once a month
LATANOPROST [XALATAN] - 0.005 % Drops - one drop conjunctiva
daily
MOM[**Name (NI) **] [NASONEX] - (Prescribed by Other Provider) - 50 mcg
Spray, Non-Aerosol - one spray(s) nasally daily - No
Substitution
MONTELUKAST [SINGULAIR] - 10 mg Tablet - one Tablet(s) by mouth
daily
ONDANSETRON HCL - (Prescribed by Other Provider) - 4 mg Tablet
- one Tablet(s) by mouth three times a day breakfast, before
dinner and at bed
PANTOPRAZOLE - (Dose adjustment - no new Rx) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth at breakfast, one
tablet before dinner and one before bed
SUCRALFATE - 1 gram Tablet - one Tablet(s) by mouth four times a
day
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA CONCENTRATED] - 2,400
mg/10 mL Suspension - 3 tbs by mouth nightly
MULTIVITAMIN [CHEWABLE-VITE] - Tablet, Chewable - one
Tablet(s) by mouth daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
Disp:*2 bottles* Refills:*1*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): may
resume pre-op schedule of dosing.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*1*
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dr.
[**Last Name (STitle) 28224**] to manage for goal INR 2.5-3.0, dose may change daily.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Labs: PT/INR
Coumadin for mechanical Aortic Valve
Goal INR 2.5-3.0
First draw [**2136-6-16**] (results to [**Telephone/Fax (1) 170**] over weekend)
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28224**]/coumadin
clinic Results to phone [**Telephone/Fax (1) 111495**]
12. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for rash: DO NOT USE ON CHEST.
Disp:*qs * Refills:*0*
13. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
Q4H (every 4 hours) as needed for itching.
Disp:*QS * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Health Systems
Discharge Diagnosis:
Aortic Insufficiency s/p Aortic Valve Replacement
Mitral Regurgitation s/p Mitral valve repair
Post-op A Fib
PMH:
-Mitral valve (bileaflet) prolapse and Moderate Mitral
regurgitation
-Longstanding history of palpitations, status post recent
electrophysiology study with subsequent diagnosis of AVNRT
- Ventricular tachycardia
-Pericarditis (Small pericardial effusion) [**2133-8-18**]
-Hyperlipidemia (Elevated Total cholesterol and HDL)
-[**2115**] Endometriosis s/p Total abdominal hysterectomy
-[**2125**] Vaginal Cancer s/p radiation
-Frequent bowel obstruction d/t adhesions from XRT and abdominal
surgeries.
-Recurrent Stomach ulcers
-Gastroesophageal reflux disease and gastric ulcers
-Frequent bowel obstructions
-Atypical tuberculosis in the lung
-Dyslipidemia
-MUGS-abnormal low white blood cell count and low protein.
Followed by Dr. [**Last Name (STitle) 410**] (Heme/Onc)
-Complex migraines
-Syncopal episodes
-[**11/2134**] Lyme disease s/p 6 week treatment with Doxycycline
-Glaucoma
-Seasonal allergies
-Bronchitis
Past Surgical History:
-Tonsillectomy as a child
-Appendectomy as a child
-Right elbow surgery after a fall s/p three surgeries
-s/p TAH
-s/p 7 gynecological surgeries
-s/p Bowel resection
-Reveal implant in left upper chest
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2136-6-28**], 1:30
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28224**] [**Telephone/Fax (1) 111495**] [**6-26**] @ 12:30
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22311**] [**Telephone/Fax (1) 111496**] [**6-18**], 9:25am
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for mechanical Aortic Valve
Goal INR 2.5-3.0
First draw [**2136-6-16**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28224**]/coumadin
clinic
Results to phone [**Telephone/Fax (1) 111495**]
**Please call INR results to Dr.[**Name (NI) 5572**] office over weekend
[**Date range (1) 7218**]***
Completed by:[**2136-6-15**]
|
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28,105
| 122,502
|
4913
|
Discharge summary
|
report
|
Admission Date: [**2133-4-24**] Discharge Date: [**2133-5-6**]
Date of Birth: [**2057-7-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Intubation/Extubation
History of Present Illness:
Mrs. [**Known lastname **] is a 75 year old female with a history of
hypertension, hyperlipidemia, diabetes and diastolic congestive
heart failure who presented to [**Location (un) 745**] [**Hospital 20468**] Hospital on
[**2133-4-23**] with worsening shortness of breath. According the her
family the patient had increasing lower extremity edema for one
week and one day of heavy breathing at rest. Her dyspnea was
not relieved by her albuterol inhaler. On the afternoon of
admission she experienced dull substernal chest pain without
radiation, initially [**2-16**] but increasing to [**7-19**], that lasted
for 4-6 hours, for which she called EMS.
.
She presented to the [**Location (un) 745**]-[**Location (un) 3678**] ED, where her initial
vitals signs were notable for a blood pressure of 220/80 in the
setting of respiratory distress. She was treated with Combivent
nebulziers, Solumedrol 125 mg IV x1, Lasix 40 mg IV, aspirin,
nitropaste and sublingual nitroglyerin with improvement in her
symptoms. She was initially on a nitro gtt. Her EKG showed NSR
at 62 with no obvious evidence of ischemia. Her troponins came
back elevated and she was started on a heparin and nitro drips
and transferred to the ICU. She was transferred to [**Hospital1 18**] for
cardiac catheterization.
.
On review of systems she currently denies fevers, chills,
lightheadedness, dizziness, chest pain, shortness of breath,
nausea, vomiting, abdominal pain, dysuria, hematuria, diarrhea,
constipation. She has chronic leg swelling which is much
improved from her hospitalization here in [**Month (only) **]. She has two
pillow orthopnea which has not worsened. She denies paroxysmal
nocturnal dyspnea. All other review of systems negative in
detail.
Past Medical History:
Diastolic Heart Failure
h/o bradycardia
Hyperlipidemia
Hypothyroidism
Hypertension
Type II Diabetes
GERD
s/p CVA in [**2128**]
Osteoarthritis
Stage 3 Chronic Kidney Disease
s/p cholecystectomy
Social History:
She is mostly Spanish-speaking and originally from [**Male First Name (un) 1056**].
She has several children. She quit smoking 15 years ago with a
20 pack year smoking history. Denies alcohol or illicit drug
use.
Family History:
The family history is significant for coronary artery disease in
both her mother and father who died from acute myocardial
infarctions. Her mother died at age 76 and her father died at
the age of 59. The patient has three male siblings, two of whom
have died from complications of acute myocardial infarction. One
of them apparently had significant liver disease of unknown
etiology. The patient has female siblings and one of them has
diabetes.
Physical Exam:
VS - T: 97.4 BP: 137/52 HR: 69 RR: 18 O2: 99% on RA
Gen: Edlerly female, no acute distress lying in bed
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 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, trace crackles at
bases, no wheezes or rhonchi.
Abd: Soft, obese, 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: DP, PT and femoral pulses palpable bilaterally
Pertinent Results:
IMAGING:
ECG ([**4-24**]): Sinus arrhythmia at a rate of 64, Borderline first
degree A-V block with PR 204, Vertical axis, Long QTc interval
at 489, Late R wave progression, Possible anterior infarct - age
undetermined, ST-T changes may be due to myocardial
ischemia/myocardial infarction/ central nervous system
event/metabolic derangemant
.
ECG ([**4-26**]): Irregular sinus bradycardia at a rate of 57, First
degree A-V block with PR 290, Vertical axis, Possible anterior
infarct - age undetermined, ST-T changes may be due to
myocardial ischemia/ myocardial infarction/central nervous
system event metabolic derangement
.
TTE ([**4-27**]):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 55-60%). The
apex is not well seen. The remaining LV segments all appear to
contract normally. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2132-10-9**], no
change.
.
Cardiac Catheterization ([**4-27**]): COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated an LMCA with mild plaquing to 30% at the origin and
the bifurcation; the LMCA was heavily calcified and demonstrated
40-mmHg pressure damping when engaged with JL4 and JL3.5
catheters. The LAD was heavily calcified and diffusely diseased
throughout with abrupt tapering to 50% after D1 at a large S1;
there is diffuse disease to 70% in the mid-LAD and diffuse
disease in the distal LAD; the large D1 had proximal 50% tubular
disease; by QCA the "anuerysmal" mid-LAD was 2.6 mm diameter,
with MLD 1.08 and proximal reference 2-mm after S1. The LCX was
heavily calcified with luminal irregularities and 40% origin
disease; there was a large OM3 and LPL/OM4. There was a small
ramus. The RCA had diffuse disease with up to 50% disease
proximally and 50% narrowing in the proximal RPDA.
2. Abdominal aortography showed a small, tapering distal
abdominal aorta with diffuse atherosclerosis and calcification.
There was moderate 40-50% right renal artery stenosis and mild
plaquing in the left renal artery.
3. Limited resting hemodynamics revealed severe systemic
arterial hypertension, severe LV diastolic dysfunction and
moderate-severe pulmonary arterial hypertension.
4. ECG monitoring showed intermittent bradycardia with blocked
PACs and occasional junctional rhythm with apparent retrograde P
waves.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
3. Mild-moderate right and left renal artery stenosis.
4. Moderate-severe pulmonary arterial hypertension and severe
systemic arterial hypertension.
.
CXR Portable ([**4-28**]): FINDINGS: On today's radiograph, the
cardiac silhouette is markedly enlarged. There is retrocardiac
atelectasis. Interstitial markings, a dilated azygos vein and
small pleural effusions as well as the bronchial cuffing all
indicate the presence of moderate pulmonary edema. There is no
focal parenchymal opacity suggestive of pneumonia.
.
CXR Portable ([**4-28**]): SINGLE AP semi-upright radiograph at 10:00
a.m. bedside: There has been interval placement of an ET tube
terminating 3.7 cm above the carina. No other short-term
interval changes with unchanged moderate pulmonary edema, and
bilateral pleural effusion.
.
CXR Portable ([**4-29**]): There are small bilateral pleural
effusions. Evaluation of the pulmonary parenchyma is limited due
to soft tissue scatter. Persistant moderate pulmonry edema is
noted. There is a dense retrocardiac opacity, possibly reflects
atelectasis. Stable moderate cardiomegaly is noted. ET tube is
in standard location. NG tube is extending into the stomach and
out of field of view.
IMPRESSION: Moderate pulmonary edema and persistant bilateral
pleural effusions.
.
CXR Portable ([**4-29**]): FINDINGS: In comparison with the earlier
study of this date, the endotracheal tube tip lies at the mid
clavicular level approximately 5 cm above the carina. There is
still cardiomegaly with pulmonary vascular congestion and
bilateral pleural effusions. Nasogastric tube extends to the
stomach.
.
CXR Portable ([**5-1**]): FINDINGS: Mild vascular engorgement has
increased mainly in the left lung with worsening blunting of the
left costophrenic angle secondary to a component of effusion.
Stable left retrocardiac atelectasis is small. The small right
pleural effusion is stable. Mild cardiomegaly is stable.
IMPRESSION:
1) Mild vascular engorgement indicative of pulmonary edema.
2) Worsening small left pleural effusion.
.
ECG ([**5-1**]): Sinus rhythm with premature ventricular
contractions. Left atrial abnormality. Prolonged P-R interval.
Poor R wave progression and anterolateral ST-T wave changes
which are non-specific but consistent with myocardial ischemia.
Compared to the previous tracing of [**2133-4-30**] the premature
ventricular contractions are new.
.
Left LENIs ([**5-2**]): IMPRESSION:
No evidence of DVT in the left lower extremity.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 75 year old female with a history of
hypertension, hyperlipidemia, diabets and diastolic congestive
heart failure admitted to OSH w/dyspnea, found to have NSTEMI,
now s/p cardiac cath w/CAD not amenable to intervention.
1)Hypoxic/Hypercarbic Respiratory Failure: Likely flash
pulmonary edema from hypertension and volume overload. On [**4-28**]
in the AM, the patient was walking to the bathroom and felt
dizzy and diaphoretic. She also complained of [**9-18**] chest pain
and SOB, and was found to have bp 234/63. She was given her
morning blood pressure medications, was given SL NTG x1, and
then started on a nitro gtt with little change in the blood
pressure. She was noted to have RR 36, diffuse wheezes on exam
(likely cardiac in nature), and desatted to 89% on 2L so was put
on a NRB. She continued to feel fatigued and SOB. EKG showed
pseudonormalization of the T waves and slight increase in the ST
segment elevation in V2. Given her persistent hypertension, she
was given Labetalol 20 mg IV x1, but then had brady down to the
30s and subsequent junctional rhythm. She was given Atropine 0.5
mg IV x1, and a code blue was called however the patient never
lost her pulse. ABG on NRB showed 7.30/62/61/32. She was
intubated [**4-27**] and sent to the CCU. Received Lasix gtt (up to
20) and Diuril IV in the CCU with LOS 4.6 L negative. Extubated
[**4-30**]. She was initially continued on IV lasix for diuresis on
the floor and then changed to lasix 80mg po daily on discharge.
2)CAD/NSTEMI: During the patient's only catheterization in our
system the coronary arteries were not visualized to protect the
kidneys. She now presents with acute onset chest pain in the
setting of worsening shortness of breath and hypertension. CEs
were elevated at the OSH: CK: 193->207->221; CK-MB: 17 -> 21;
Troponin I: 1.97 -> 4.17 -> 4.93. Her TTE showed EF 55% but
showed abnormal motion in the mid septum segment, apical septum
segment, and mid anterior septum segment. Her EKG now showed new
deep TWI in V4-V6. CEs: CK 183->193->160; CKMB 23->19->13;
TropT: 0.59->0.66->0.42. Cardiac catheterization on [**4-27**] showed
two vessel CAD with diffuse disease to 70% in the mid LAD and
diffuse disease in the distal LAD, RCA with diffuse disease up
to 50% proximally and 50% narrowing in the proximal RPDA. No
interventions were done, Plavix was discontinued. She was
continued on ASA 325 mg daily, Imdur 60mg daily and changed to
Simvastatin 40 mg daily. She was not started on an ACE-I given
her history of hyperkalemia to ACE-I. She was discharged on
metoprolol 12.5BID as below.
3)Rhythm: The patient has a history of bradycardia while on beta
blockers, and was not on any beta blockers on admission. She had
episodes of bradycardia on telemetry with up to [**3-14**] second
pauses. She also has first degree AV block on telemetry with a
PR interval of 320. She developed junctional bradycardia after
receiving Labetalol IV in the setting of hypertension and flash
pulmonary edema. Continued to have frequent <2 second pauses
secondary to Wenckebach AV block during her admission. She was
followed by EP service during her admission and was started on
Metoprolol 12.5 [**Hospital1 **] which she tolerated without problem. She
was discharged on metoprolol 12.5 [**Hospital1 **].
4) Acute on Chronic Diastolic Heart Failure: The patient
presented to the OSH with SOB in the setting of SBP 220 and
NSTEMI, and CXR showed pulmonary vascular congestion. BNP 542.
She received several doses of Lasix 40 mg IV and was briefly on
a nitro gtt. On TTE at [**Hospital1 18**], she had EF 55-60%, mild symmetric
LVH. Cardiac catheterization showed severe LV diastolic
dysfunction and moderate-severe pulmonary arterial hypertension.
Received Lasix gtt and Diuril in CCU for LOS 4.6 L negative.
Her antihypertensive regimen was titrated up during her
admission. She was discahrged on Imdur, Hydralazine,
metoprolol, minoxidil, amlodipine, hydrochlorothiazide and
lasix.
5)Hypertension: Patient has a history of uncontrolled
hypertension. Cardiac catheterization showed moderate 40-50%
right renal artery stenosis and mild plaquing in the left renal
artery. She was discahrged on Imdur, Hydralazine, metoprolol,
minoxidil, amlodipine, hydrochlorothiazide and lasix. Her
clonidine patch and oral clonidine were discontinued during her
admission.
6)Hyperlipidemia: Lipid panel showed Chol 121, TG 41, HDL 73,
LDL 40. She was continued on Simvastatin 40 mg daily
7) Type II Diabetes: Blood sugars were elevated on presentation
to the emergency room. She was briefly on an insulin drop at the
OSH as she was given IV meds with D5W. HgA1c 8.7%. She was then
treated with Insulin 70/30, 35 qAM and 20 qPM.
8) Acute on Chronic Renal Failure: Her Cr was increased to 1.7
at the OSH, from a baseline of 0.9. Renal ultrasound at OSH
showed R kidney 8.6 cm with cortical thinning, L kidney 9.9 cm
with minimal cortical thinning, no hydronephrosis. It did show
>1 cm disparity in renal artery size, suggesting at least
unilateral renal artery stenosis (but dopplers were not
available at the OSH). FeNa 1.76%, FeUrea 20%, urine eos
negative. UA normal and culture with no growth. Received
Mucomyst and IVF prior to catheterization. Patient diuresed in
CCU with Lasix gtt and Diuril, and Cr increased back up to 2.4.
Her creatinine was improved to 1.5 by the time of discharge.
9)Hypothyroidism: TSH 6.0 in [**Month (only) **], TSH 12.0 on this
admission but Free T4 normal at 1.1, likely due to sick
euthyroid. She was continued on home dose of Levothyroxine 125
mcg daily.
10) Anemia: Baseline hematocrit between 30 and 35, was 33.4 on
admission. In [**3-17**], Ferritin 26, iron 40, TIBC 391 consistent
with iron deficiency. She did not have any evidence of acute
bleeding during her admission and she was continued on FeSO4 324
mg daily.
11) Asthma: She was continued on albuterol inhaler
Medications on Admission:
OUTPATIENT MEDICATIONS:
-Insulin 70/30 35 QAM and 20 QPM
-Clonidine patch 0.3 mg/24 hour patch Qweek
-Levothyroxine 125 mcg daily
-Lasix 60 mg [**Hospital1 **]
-Minoxidil 5 mg [**Hospital1 **]
-Hydralazine 100 mg tid
-Imdur 60 mg daily
-Simvastatin 40 mg daily
-FeSO4 325 mg daily
-Clonidine 0.2 mg TID
-Omeprazole 20 mg daily
-Aspirin 325 mg daily
-Albuterol 90 mcg, 2 puff qid
-Calcitriol 0.25 mcg capsule PO qMWF (on hold, as patient
developed CP, HTN, N/abd pain 4 hours afterwards)
.
MEDICATIONS ON TRANSFER:
Protonix 40 mg daily
Clonidine 0.2 mg TID
Aspirin 325 mg daily
Insulin 70/30 35 QAM and 20 QPM
Lispro SS
Clonidine patch 5 mg weekly
Levothyroxine 125 mcg daily
Minoxidil 5 mg [**Hospital1 **]
Hydralazine 100 mg TID
Simvastatin 40 mg daily
Iron sulfate 324 mg daily
Heparin drip
Nitro drip
Lasix 40 mg IV prn
Albuterol nebs prn
Mucomyst 1200 mg, 1-2 doses
Docusate 100 mg [**Hospital1 **] prn
.
ALLERGIES: Intolerant of beta blockers, ACE-I (hyperkalemia),
and HCTZ (urinary frequency)
Discharge Medications:
1. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Thirty Five (35) Units Subcutaneous qAM.
2. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) Units Subcutaneous qPM.
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. HydrALAzine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation four times a day as needed.
11. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
12. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. 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*
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Please check Chem 7 panel twice weekly. First check on Friday
[**2133-5-8**]. Please send results to patients PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] at
[**Telephone/Fax (1) 1792**].
16. Hydrochlorothiazide 25 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:
CAD/NSTEMI
Bradycardia/Wenckebach AV block
Hypoxic/Hypercarbic Respiratory Failure
Acute on Chronic Diastolic Heart Failure
Hypertension
Acute on Chronic Renal Failure
.
SECONDARY:
Hyperlipidemia
Diabetes mellitus Type 2
Hypothyroidism
Anemia
Asthma
GERD
Discharge Condition:
Stable
Weight 140 pounds
Discharge Instructions:
You were admitted with shortness of breath and chest pain, and
had EKG changes and elevated cardiac enzymes indicating a heart
attack. You had a cardiac catheterization which showed diffuse
disease in your coronary arteries, but no interventions were
required. Your blood pressure went very high causing fluid to
acutely build up in your lungs, and you were transferred to the
cardiac ICU to be intubated. You were given diuretic
medications, and you were able to be extubated. Several of your
medications were changed as below.
.
If you develop chest pain, shortness of breath, lightheadedness
or dizziness, palpitations, weakness or numbness, difficulty
speaking or swallowing, or any other symptoms that concern you,
call your physician or return to the ED.
.
Please check your weight every day, in the morning after
urinating. Your weight on discharge was 140 pounds. Please
call your doctor if your weight increases by more than 3 pounds.
.
Medications:
1)Your Clonidine patch and Clonidine pills were discontinued.
Please do not take these any longer.
2)Your Lasix was changed to 80mg once daily.
3)Your Minoxidil was increased to 10 mg twice daily.
4)You were started on Amlodipine 10 mg every evening.
5)You were started on Metoprolol XL 25mg daily.
6) You were started on hydrochlorothiazide 25mg daily.
Followup Instructions:
You have a follow up appointment with Dr.[**Name (NI) 3733**] in
Cardiology
([**Telephone/Fax (1) 62**]) on [**2133-5-22**] at 3:20 in the [**Hospital Ward Name 23**] Center, [**Location (un) 3971**].
.
You have a follow up appointment with Dr. [**Last Name (STitle) 1366**] in Nephrology
([**Telephone/Fax (1) 435**]) on [**2133-8-27**] at 4:00 in the [**Hospital Ward Name **] CENTER, [**Location (un) **].
Please call Dr. [**Last Name (STitle) 1789**] at [**Telephone/Fax (1) 1792**] and schedule an
appointment to follow up within one to two weeks of discharge.
|
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icd9cm
|
[
[
[]
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[
"88.45",
"89.64",
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icd9pcs
|
[
[
[]
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|
9522, 15440
|
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|
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|
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15490, 15955
|
235, 268
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382, 2125
|
15980, 16467
|
2147, 2341
|
2357, 2571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,099
| 172,074
|
46635
|
Discharge summary
|
report
|
Admission Date: [**2119-2-10**] Discharge Date: [**2119-2-14**]
Service:
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
with multiple medical problems. She was brought to the
Emergency Department by paramedics after vomiting coffee
ground emesis. According to her visiting nurse, she has also
had a question of melena over the past week. The patient was
hypotensive at EMT arrival with a systolic blood pressure of
80.
Arrival in Emergency Department revealed a temperature of
100.4; heart rate of 92; blood pressure 102/85; respiratory
rate of 30; saturation 96% on room air.
Nasogastric tube was placed and drained coffee grounds but
lavage cleared with 750 cc. No recent ANSAID use.
The patient is demented but complained of abdominal pain.
This pain is longstanding per past records.
PAST MEDICAL HISTORY: Coronary artery disease; status post
myocardial infarction in [**12-4**]. Chronic obstructive
pulmonary disease on home oxygen, 1.5 liters. Hypertension.
Peptic ulcer disease. Diverticulitis. Status post
cholecystectomy. Status post total abdominal hysterectomy
bilateral salpingo-oophorectomy.
Breast cancer, diagnosed in [**2112**], infiltrative ductal type;
ER positive; status post lumpectomy; status post XRT,
currently on Tamoxifen.
Congestive heart failure. Dementia. Chronic renal failure.
Creatinine of 1.5 to 2.0. Rectal prolapse.
MEDICATIONS ON ADMISSION:
Lipitor 10 mg q. day.
Mavic 2 mg q. day.
Multi-vitamin one daily.
Protonic 40 mg q. day.
Tamoxifen 10 mg twice a day.
Colace 100 mg twice a day.
Lopressor 25 mg twice a day.
SOCIAL HISTORY: Born in [**Country 2784**], immigrated to the United
States during the World War II. Widowed times ten years. No
children. 70 pack year smoking history. No alcohol use.
Lives alone in an apartment. Has VNA. Health care proxy is
[**Name (NI) **] [**Name (NI) 12982**], [**Telephone/Fax (1) 99018**], [**Telephone/Fax (1) 99019**]. Case manager is
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 99020**], [**Telephone/Fax (1) 99021**] and [**Telephone/Fax (1) 53844**]. Primary
medical doctors are Dr. [**First Name (STitle) 1158**] Tray and [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**].
PHYSICAL EXAMINATION: On admission vital signs revealed a
temperature of 100.2; blood pressure 99/60; pulse of 90;
respiratory rate of 36; 96% on 100% non rebreather. In
general: No acute distress, resting in bed. HEAD, EYES,
EARS, NOSE AND THROAT: Mucous membranes dry. Extraocular
movements intact. Pupils are equal, round, and reactive to
light and accommodation. Neck: No jugular venous
distention, bruits or lymphadenopathy. Chest was clear
bilaterally. Mild expiratory wheezes. Cardiovascular:
Distant heart sounds. Abdomen: Positive bowel sounds, no
rebound, guarding, non distended. Extremities showed no
clubbing, cyanosis or edema. Neurologic: Alert, not
oriented to place or time, otherwise nonfocal neurological
examination. Skin: No jaundice or visible external lesions.
LABORATORY DATA: On admission, white count was 18;
hematocrit of 30.9; platelets of 471. Sodium of 143;
potassium of 5.5; chloride 102; C02 of 25; BUN 113;
creatinine 2.8; glucose of 122. Urinalysis showed a few
bacteria, otherwise negative. Blood cultures times two were
drawn.
Electrocardiogram showed normal sinus rhythm at 90; Q's in 2,
3 and F and V1, no ST or T wave changes, unchanged from
previous.
ASSESSMENT AND PLAN: [**Age over 90 **] year old female, multiple medical
problems; long history of gastrointestinal bleed with
documented gastritis and duodenal angioectasia and
diverticulosis. Now with hematemesis and coffee grounds.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit over night on [**2119-2-10**]. The patient was made n.p.o.
and was given intravenous blocker. Code status was
documented as DNR/DNI. Her blood pressure medications were
held overnight. The patient was transfused two units of
packed red blood cells. Hematocrit increased to 36.8.
The patient had a pelvic x-ray which showed no fracture of
the left hip.
Abdominal and pelvic CT showed no evidence of diverticulitis
or other acute inflammatory process in the abdomen, sigmoid
diverticulosis, [**Date Range **] atherosclerosis and a left upper
pelvic cyst.
Esophagogastroduodenoscopy was not performed with a stable
hematocrit and the patient's guaiac subsequently became
negative.
She was transferred to the floor on [**2119-2-11**] in stable
condition. She was kept on chronic obstructive pulmonary
disease treatments with nebulizers and maintained saturation
greater than 95% on two liters. She remained afebrile
throughout her hospital stay. Metoprolol was reinstituted
after she was hemodynamically stable. Overall, the patient's
hematocrit remained stable throughout her stay in the
hospital.
On [**2-13**], hematocrit was 37.4 without further transfusions.
The patient remained guaiac negative. Mentally, she
continued at her baseline.
DISCHARGE CONDITION: Stable.
DISPOSITION: The patient was discharged back to an extended
facility.
DISCHARGE MEDICATIONS:
As above except Mavic was held and continues to be held with
some mild renal insufficiency.
CODE STATUS: The patient continues to be DNR/DNI.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], M.D. [**MD Number(1) 144**]
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2119-2-14**] 12:33
T: [**2119-2-14**] 13:03
JOB#: [**Job Number 99022**]
|
[
"276.3",
"276.7",
"458.9",
"197.7",
"496",
"280.0",
"578.9",
"428.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.33"
] |
icd9pcs
|
[
[
[]
]
] |
5059, 5140
|
5163, 5585
|
1431, 1606
|
3730, 5037
|
2281, 3712
|
111, 832
|
855, 1405
|
1623, 2258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,177
| 163,264
|
11853+56293
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-4-8**] Discharge Date: [**2182-4-15**]
Date of Birth: [**2116-3-26**] Sex: M
Service: MICU/Internal Medicine
CHIEF COMPLAINT: Mental status change
HISTORY OF PRESENT ILLNESS: A 66 year old male with a
history of intrathalamic lesions in [**2181-7-8**] which left him
inmaleverable with diffuse motor weakness. Post
cerebrovascular accident course was complicated by
hydrocephalus and placement of ventriculoperitoneal shunt was
necessary, it is complicated by infection. He has had
multiple aspiration pneumonias during his course as well and
is now status post gastrostomy tube placement.
Recent hospitalization at [**Hospital3 1443**] Hospital for
urosepsis with proteus, Clostridium difficile and pneumonia
resulted in his being treated with Levaquin. He was
readmitted to the [**Hospital6 256**] on
[**3-30**] with fever and mental status change. He was treated
empirically for aspiration pneumonia with Levofloxacin and
Flagyl as well as Vancomycin until his cerebrospinal fluid
gram stain was negative. During that time he also failed a
swallowing evaluation and was treated for dehydration and
sent out on an NPO diet on [**4-5**].
The patient comes back today with decreased mental status,
fever to 104 and evidence severe dehydration. The patient
has been hydrated in the Emergency Room and received
Vancomycin, Ceftriaxone 2 gm and stress dose steroid.
PHYSICAL EXAMINATION: Nonobtunded. Vital signs are 110/70,
temperature 105, respirations 32, saturations 98% on 100%
nonrebreather. Portacath in right frontal oropharynx-dry.
Lungs, clear to auscultation anteriorly. Heart, S1 and S2,
regular rate and rhythm. Abdomen, positive bowel sounds,
nontender, nondistended. Gastrostomy tube in place.
Extremities, no edema. Neurological, extraocular movements
intact, pupils equally round, and reactive to light, muffled
voice to painful stimuli. Babinski is downgoing bilaterally.
Deep tendon reflexes are 0/4 bilaterally in the lower
extremities and upper extremities.
LABORATORY DATA: White count 14.1, hematocrit 42.1,
platelets 377. PT 12.2, PTT 26.9, INR 1.0. Chem-7 as
follows, 152, 3.9, 110, 27, 52, 0.6. Glucose 132.
Urinalysis, yellow, clear, 1.025, negative nitrates, negative
leukocyte esterase, 0-2 red blood cells, 0-2 white blood
cells, a few bacteria, no yeast, no squamous epi's. CK 111,
MB 1, troponin less than 0.3. Cerebrospinal fluid, 2 white
blood cells, 0 red blood cells, 0 polys, 45 lymphs, 54 monos.
ALT 39, AST 22, total bilirubin 0.4, alkaline phosphatase
103, calcium 10.1, phosphate 2.1, magnesium 2.7.
Cerebrospinal fluid protein 80, cerebrospinal fluid glucose
133. Blood gas, 7.44/41/221.
HOSPITAL COURSE: 1. Dehydration - The patient was
approximately 3.3 liters water depleted on admission. He was
hydrated with D5/?????? normal saline and sodium levels were
checked. From his sodium of 152, his sodium decreased to the
138 range during the course of this stay. His hydration
status was of particular concern to his wife who felt that
dehydration was responsible for his infection. For this
reason, a nutrition consult was called to evaluate and
prescribe an optimal regimen for fluid management. This
regimen included ProMod with fiber at 80 cc/hr through the
percutaneous endoscopic gastrostomy tube, 200 cc free water
boluses t.i.d. and the stipulation that the free water
boluses should be increased to q.i.d. if the patient is
febrile. These were carried over to the nursing home to be
adopted there.
2. Infection - Possible sources included the lung, urine,
central nervous system, sacral decubitus. The sacral
decubitus appeared as good or better than they had in the
past, so this was thought not be a likely source of the
infection (per observation by the wife). The urinalysis did
not show any reactivity. The cerebrospinal fluid was tapped
from the ventriculoperitoneal shunt, however, the analysis
did not indicate any form of infection. The lungs were not
markedly abnormal, however, although the airway chest film
showed a mild amount of left lower lobe and small effusions
which were the only source that was available during the
[**Hospital 228**] hospital stay. While the patient had coagulase
negative Staphylococcus growing from his cerebrospinal fluid
cultures on [**4-1**], repeat cerebrospinal fluid cultures on
this admission did not show growth of this organism or any
positive gram stain. Whether or not the pulmonary symptoms
could account for a temperature of 105 was unclear, however,
the patient was promptly treated with Ceftriaxone (initially
meningitis doses), Vancomycin and Flagyl. He defervesced
well and his white count came into the normal range within
the day. At this point it was determined that Vancomycin
could be discontinued as the coagulase negative
Staphylococcus was not thought to be pathogen in this case
per Dr. [**Last Name (STitle) 1338**] of Neurosurgery. The patient continued on
Ceftriaxone and Flagyl and will be sent out on Cefixime and
Flagyl p.o.
Cardiovascular - The patient had an electrocardiogram showing
sinus tachycardia at 110, left axis deviation, no ST-T
segment changes with some deep vessel waves in V2 through V4.
It was difficult to determine whether these were significant
and CK MB and troponins were sent which were negative. The
patient also has a history of hypertension for which he has
been taking Lisinopril 40 q. day and was started on Labetalol
600 b.i.d. In-house, antihypertensives were initially held
due to the patient's relative hypotension and were only
restarted for the later part of his stay when he had been
called out of the MICU. In general, Lopressor t.i.d. was
given initially and Atenolol 50 b.i.d. and to the Atenolol 50
b.i.d. Captopril was added. The Captopril was titrated up as
tolerated and plan to convert to a longer acting ACE
inhibitor.
Pulmonary - Small left-sided effusion. Left lower lobe
collapse. A decubitus film was obtained to determine whether
the sputum could be tapped safely, however, the effusion was
too small to be tapped, even under ultrasound guidance.
Because the patient defervesced nicely it was determined that
an abscess was unlikely and the patient could be safely
treated with outpatient p.o. antibiotics.
Gastrointestinal - The patient had a percutaneous endoscopic
gastrostomy tube which was in place and showed no erythema or
induration. He was to have the percutaneous endoscopic
gastrostomy tube according to recommendation from nutrition
which included ProMod at 80 cc/hr.
Neurological - The patient is status post thalamic
cerebrovascular accident. Repeat head computerized
tomography scan done in the Emergency Room for mental status
change was not significantly different from other outside
studies. The patient's mental status improved significantly
over two to three days as he was hydrated through the
gastrostomy tube. Towards the end of his stay the mental
status started to wane somewhat. The patient's wife was
concerned about this and Dr. [**First Name (STitle) **] of Neurology saw the
patient in-house and indicated no significant change to his
treatment was necessary.
Endocrine - Synthroid was continued. The patient finished a
recent steroid taper. CTH and were checked.
Prophylaxis - This was achieved with heparin subcutaneously
and Prilosec.
Lines and tubes - Gastrostomy tube and peripheral intravenous
lines.
DISCHARGE STATUS: To return to nursing home.
CONDITION ON DISCHARGE: Stable to nursing home.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (STitle) 18486**]
MEDQUIST36
D: [**2182-4-13**] 14:21
T: [**2182-4-13**] 15:58
JOB#: [**Job Number 37406**]
Name: [**Known lastname 6711**], [**Known firstname 6712**] Unit No: [**Numeric Identifier 6713**]
Admission Date: [**2182-4-8**] Discharge Date: [**2182-4-17**]
Date of Birth: [**2116-3-26**] Sex: M
Service:
ADDENDUM: The patient was slated for discharge on [**2182-4-15**]. However, his white count had increased to 15 on [**4-14**] and it was decided that the white count should be watched
even though the patient had remained afebrile. A urinalysis
and urine culture was sent and the urinalysis on [**4-17**]
showed 21-50 white blood cells with a few bacteria and no
epithelial cells. The urine culture should be followed up as
an outpatient to insure that the patient does not have a
urinary tract infection perhaps due to Enterococcus, as the
patient has been incontinent in-house. Despite the discovery
of this possible source of infection, the patient remained
afebrile and the white count decreased on [**4-16**] to the 11
range and he has not complained of any urinary symptoms.
The patient will be discharged on a course of oral cefixime
and Flagyl to complete a course of 10 days. Four more days
of these antibiotics will be required to complete this
course.
The patient was noted to have continued hypertension while
in-house and his antihypertensive medications were titrated
up accordingly. Captopril dose was increased to 75 tid and
Lopressor dose to 25 tid. As an outpatient, it is
recommended that the Lopressor be increased to 50 tid, as the
patient tolerated 50 tid of Lopressor x 1 dose on the day of
discharge. However, he could not be monitored throughout the
course of the day on three consecutive doses, so this regimen
was not instituted on the page one.
HYPERCALCEMIA: Also worked up further with a serum and urine
protein electrophoresis. The urine protein electrophoresis
was negative for Bence [**Doctor Last Name **] protein in the serum. Protein
electrophoresis needs to be followed up.
GASTROINTESTINAL: The patient's PEG tube fell out while he
was in-house over the weekend of [**4-14**] and was replaced
by interventional radiology without complication. At the
time of discharge, there was no drainage, erythema or
tenderness around these sites.
NEUROLOGICAL: In the interim, the patient's neurologic
status has waxed and waned during the rest of his hospital
stay. On the day of discharge, he seemed markedly improved
and was able to voice two to three words at one time. The
note from his neurology visit is attached with his page one
form.
MEDICATIONS ON DISCHARGE: Atorvastatin 40 mg qd,
lansoprazole 30 mg qd, multivitamin 1 capsule qd,
levothyroxine 50 mcg qd, heparin 5,000 U subcu [**Hospital1 **],
bromocriptine 2.5 mg tid, captopril 75 mg po tid,
metronidazole 500 mg tid x 4 days, cefixime 200 mg [**Hospital1 **] x 4
days, Lopressor 25 mg po tid (to be titrated to 50 tid as
tolerated in the nursing facility).
Detailed instructions for care and fluid management have been
recommended by the nutrition service. These are outlined in
detail in an attachment to the page one.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**]
Dictated By:[**Doctor Last Name 6714**]
MEDQUIST36
D: [**2182-4-17**] 11:36
T: [**2182-4-18**] 11:41
JOB#: [**Job Number 6715**]
|
[
"707.0",
"401.9",
"V55.1",
"276.5",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10400, 11215
|
2719, 7477
|
1443, 2701
|
172, 194
|
223, 1420
|
7502, 10373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,197
| 137,862
|
3670
|
Discharge summary
|
report
|
Admission Date: [**2159-5-18**] Discharge Date: [**2159-5-25**]
Date of Birth: [**2090-5-16**] Sex: F
Service: MEDICINE
Allergies:
promethazine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
ICU transfer for hypertensive urgency and Nausea/Vomiting
Major Surgical or Invasive Procedure:
ETT intubation for MRI.
History of Present Illness:
The patient is a 69 year old woman with a past medical history
of DM type 1, PVD, right hip fracture s/p intramedullary nail
[**1-12**] c/b malunion with revision [**2159-3-30**] admitted with sudden
onset nausea and emesis.
.
The patient reported sudden onset of nausea and emesis this am
upon awakening. She noted slight loose stools with no
hematochezia or melena. She denied abdominal pain. Denied chest
pain or dyspnea. She reports her current sensation is similar to
her prior episodes of gastroparesis. Denies fever or chills.
.
In the ED, initial VS: T 96.6, BP: 213/101, HR: 66, RR: 16, O2:
98% RA. She was given 2L NS. She also received 8mg IV zofran and
25mg phenergan. She received hydralazine with repeat BP of
184/98. She was also noted to be forcing emesis while in the ED
by nursing. Labs notable for WBC 6.4, Chem 7 notable for an AG
of 18, improved to 15 following IVF in ED.
.
On the floor, she reports nausea and emesis. Reports mild
epigastric pain. During the evaluation she has emesis x 3. No
hematemesis. Denies chest pain or shortness of breath. Denies
dysuria or urinary frequency.
.
Given persistent hypertensive urgency, with limited treatment
options on the floor (not tolerating po, IV labetalol or nitro
gtt not possible) she is being transferred to ICU for BP
treatment and close monitoring of symptoms.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. Remained per HPI.
Past Medical History:
- h/o DVT
- DMI on insulin pump
- Peripheral neuropathy
- h/o gastroparesis
- Chronic LBP/sciatica
- HTN
- Hyperlipidemia
- Hypothyroidism
- PVD/PAD
- Autonomic dysfunction, orthostatic hypotension
- History of seizure [**2158-1-19**] characterized by becoming less
responsive, oriented to name only, gaze deviation and left arm
shaking. FS 297 and was in the setting of receiving cipro, Neuro
felt [**1-3**] infection vs PRES.
- Barretts Esophagus on EGD [**2155**]
- Depression
.
PAST SURGICAL HISTORY:
[**2159-3-30**] - Malunion right intertrochanteric hip fracture with
protrusion of screw s/p revision arthroplasty
[**2159-1-7**] Comminuted right intertrochanteric hip fracture s/p right
hip fracture open reduction internal fixation (intramedullary
nail)
[**3-21**] RLE angiography
RLE SFA-AT BPG with NRSVG [**2157-9-6**]
Angioplasty of vein graft [**2158-10-4**]
[**2158-5-30**], L hip hemiarthroplasty
- Hiatal hernia
- s/p laminectomy
- s/p hysterectomy
Social History:
The patient lives with her husband. She is a former secretary.
Former tobacco use, quit in [**8-10**], previous 60 pack/yr history.
No history of EtOH or IVDU.
Family History:
Mother - coronary artery disease with MI in her 50s, died at age
84. Father - coronary artery disease with MI in her 60s, died at
age 82.
Physical Exam:
Admission Physical Exam:
VS: Tc: 99.5, BP: 200/91, HR: 100, RR: 22, O2: 95% RA.
GENERAL: no acute distress
HEENT: NC/AT, PERRLA, EOMI, mild conjunctival suffusion, dry MM,
OP clear.
NECK: Supple, no JVD.
HEART: [**Date Range 8450**], soft systolic murmur, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft, mild epigastric/RUQ TTP, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, R hip well-healed, no erythema or
TTP, decreased R PT/DP
SKIN: faint maculopapular rash over bilateral UE, eschar over
lateral heel - no erythema, no drainage
LYMPH: No cervical LAD
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact
Discharge Physical Exam:
VS: Tc: 98.0, Tm:98.1 BP: 131/58, HR: 87, RR: 18, O2: 100% RA.
GENERAL: NAD, conversational
HEENT: NC/AT, anicteric sclera, MMM, pharynx clear.
NECK: Supple, no JVD.
HEART: [**Date Range 8450**], soft systolic murmur, nl S1-S2.
LUNGS: CTAB, no w/r/r
ABDOMEN: Soft, NT/ND, normal BS, no organomegaly
EXTREMITIES: Minor soreness of b/l calves but no [**Date Range **]
tenderness, no unilateral edema or discoloration, decreased
distal pulses R>L
SKIN: 1.5-2cm ulcer on posterior R heel with overlying black
eschar no signs of infection
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact
Pertinent Results:
LABS:
CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2159-5-18**] 9.5 4.59 14.0 43.4 94 30.5 32.3 15.1 292
.
DIFF Neuts Lymphs Monos Eos Baso
[**2159-5-18**] 84.6* 10.7* 3.2 0.6 1.0
.
CHEM 7 Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2159-5-18**] 242*1 19 1.0 137 4.1 97 24 20
[**2159-5-18**] 242*1 18 1.1 135 4.82 96 21 * 23*
.
LFTS ALT AST AlkPhos
[**2159-5-18**]7*
.
Lipase
[**2159-5-18**] 17
.
CPK ISOENZYMES cTropnT
[**2159-5-18**] <0.011
CXR [**5-17**] - IMPRESSION: No effusion, edema or pneumonia.
.
R Femur [**5-17**] - There is again seen an intramedullary rod with
distal interlocking screw and proximal pin fixating an
intertrochanteric fracture of the right proximal femur. There is
good bridging callus at the site of the injury. There are no
signs for hardware-related complications. A [**Month/Year (2) 1106**] stent is
seen within the medial soft tissues, likely within the femoral
artery. No kinks within the
stent is seen. The stent within the popliteal artery below the
level of the knee joint, which is also intact and without kinks.
.
ECG: [**5-18**] - NSR, LAD, TWI [**Last Name (LF) 1105**], [**First Name3 (LF) **] dep V5-V6 w/ increase from
prior [**5-17**]
.
CXR ([**5-19**]):
Cardiomediastinal contours are within normal limits allowing for
accentuation by extreme lordotic projection and portable
technique. Lungs are grossly clear except for a questionable new
patchy opacity in the left
retrocardiac region. Standard PA and lateral chest radiographs
may be helpful to better evaluate this region and to exclude the
possibility of a developing pneumonia at this site.
.
CT Head ([**5-19**]): No acute intracranial process.
.
CXR ([**5-19**]):
Compared with [**2159-5-19**], an ET tube has been placed. The tip lies
in satisfactory position approximately 4.1 cm above the carina.
Minimal bibasilar atelectasis of both lung bases again noted,
without significant interval change. No [**Month/Day/Year **] consolidation.
Incidental note is made of marked degenerative changes about the
right glenohumeral joint, incompletely evaluated.
.
MRA Neck ([**5-19**]):
Bilateral carotid stenosis, left greater than right, partially
evaluated due to motion artifacts, please consider obtaining the
carotid Doppler ultrasound if clinically warranted.
.
MRI Head ([**5-19**]):
Lacunar ischemic change is demonstrated on the left pons,
apparently new since the prior examination. Stable lacunar
ischemic changes identified at the posterior limb of the left
internal capsule and lentiform nucleus. No diffusion
abnormalities are detected to suggest acute or subacute ischemic
changes.
.
Carotid US ([**5-21**]): Right ICA <40% stenosis. Left ICA 60-69%
stenosis.
.
CXR ([**5-21**]):
1. Interval removal of the endotracheal tube.
2. Stable mild pulmonary edema.
.
CXR ([**5-22**]): 1. New left PICC, at the level of the mid SVC. No
pneumothorax. 2. Stable mild cardiomegaly.
DISCHARGE LABS:
[**2159-5-25**] 06:00AM BLOOD WBC-6.0 RBC-3.30* Hgb-10.2* Hct-30.8*
MCV-94 MCH-30.8 MCHC-33.0 RDW-14.5 Plt Ct-216
[**2159-5-25**] 06:00AM BLOOD Plt Ct-216
[**2159-5-25**] 06:00AM BLOOD
[**2159-5-25**] 06:00AM BLOOD Glucose-292* UreaN-27* Creat-1.2* Na-134
K-4.4 Cl-96 HCO3-30 AnGap-12
[**2159-5-25**] 06:00AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8
[**2159-5-23**] 9:54 am URINE Source: Catheter.
**FINAL REPORT [**2159-5-24**]**
URINE CULTURE (Final [**2159-5-24**]): NO GROWTH
Brief Hospital Course:
69 year old woman with DM type 1, PVD with significant RLE
ischemia, R hip revision [**3-12**] admitted with N/V and abdominal
pain and transferred to the MICU for hypertensive emergency.
# Hypertensive Urgency/Emergency - The patient had increased
BP's of 210's/100's in the setting of N/V, improved with
hydralazine in ED. She has recently been off of home BP meds
with well controlled BP's. She was on a labetalol gtt for
titration to BP's, and was transitioned to Chlorthalidone which
was uptitrated as she was weaned off Labetalol gtt. She was
previously on Lisinopril and clonidine patch as an outpatient,
and the clonidine patch was re-started in-house and d/c'd prior
to dispo. Her BP's came under better control and her dose of
chlorthalidone was halved prior to discharge to prevent
hypotension with good outpatient follow-up scheduled.
# Aphasic Episodes - AMS able to follow commands but not able to
speak, SBP 198. Fingerstick nl. Labetalol 10mg IV given, gtt
started. CT head obtained, no acute process.
- Had another episode of aphasia at 2pm with normal neuro exam,
able to follow commands, but did not remember event
subsequently. Lasted ~20 mins and slowly recovered. MRI head
and continuous EEG ordered
The patient had Suspect this is due to high BPs as pt has had no
repeat episodes with BPs in the 160 range. [**Month/Year (2) 878**] called
yesterday stating no seizure activity on EEG, can d/c EEG.
[**Month/Year (2) 878**] signing off. No further episodes occurred prior to
d/c.
.
# N/V - Pt presented with N/V and mild abdominal pain similar to
her prior flares of gastroparesis. She was dehydrated on
initial admission which improved with IVF. She was continued on
her home gastroparesis medications with subsequent improvement
of her n/v and abdominal symptoms. She was hydrated with IVF
and diet was advanced without incident. Of note, she had no
clear EKG changes from prior with exception of increase ST
depressions in the setting of hypertension with negative CE's.
She had stool studies and cultures sent which were negative.
.
# PVD - pt has severe ischemic rest pain of her right foot and
nonhealing pressure ulcer of her right heel. Arteriography
showed peripheral arterial disease and she was scheduled to have
a fem-distal anterior tibial bypass by Dr. [**Last Name (STitle) 1111**] in the
near future, and Dr. [**Last Name (STitle) 1111**] was emailed. Her ulcer had no
evidence of infection. She is scheduled to f/u with D.r
[**Doctor Last Name **] to reschedule the surgery.
.
# DM Type 1 - Patient was initially in DKA which resolved on
admission to the MICU and she was covered with ISS and Glargine.
The patient was subsequently continued on SSI and continued her
home glargine rather than her home insulin pump initially, per
patient request. She was restarted on her home insulin pump
prior to callout from the MICU, per patient preference, and
[**Last Name (un) **] was consulted. Recommendations were implemented and a
follow-up appointment was set up on day of discharge.
.
# CODE: Full
Medications on Admission:
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day
CYCLOSPORINE [RESTASIS]
GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth qam
GLUCAGON (HUMAN RECOMBINANT) - 1 mg Kit - inject as directed for
low blood sugar
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 5 units at
bedtime
INSULIN LISPRO [HUMALOG] - 100 unit/mL Cartridge - on insulin
pump basal rate
LEVOTHYROXINE [LEVOXYL] - 88 mcg Tablet - 1 Tablet daily
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for anxiety
METOCLOPRAMIDE - 10 mg Tablet - 1 (One) Tablet(s) by mouth 30
minutes before meals
MORPHINE - 30 mg Tablet Extended Release - 2 Tablet(s) by mouth
QAM and 1 tab QPM
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
OXYCODONE - 10 mg Tablet - [**12-3**] to 1 Tablet(s) by mouth every [**5-8**]
hours as needed for pain
SIMVASTATIN [ZOCOR] - 40 mg Tablet - 1 Tablet(s) by mouth qpm
TRAVOPROST [TRAVATAN Z] - 0.004 % Drops - 1 drop ou daily
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D]
CARBOXYMETHYLCELLULOSE SODIUM [REFRESH] - 1 % Drops - as needed
CHOLECALCIFEROL (VITAMIN D3) - 400 unit Capsule - 1 Capsule(s)
by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet - 1 Tablet(s)
by mouth once a day
FOLIC ACID - Dosage uncertain
MULTIVITAMIN - (OTC) - Capsule - 1 Capsule(s) by mouth qam
OMEGA-3 FATTY ACIDS [FISH OIL]
SODIUM CHLORIDE - 1 gram Tablet - 1 Tablet(s) by mouth twice a
day
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. chlorthalidone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. insulin lispro 100 unit/mL Cartridge Sig: PUMP Subcutaneous
continuous: Continue your current regimen with your insulin
pump.
8. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO QAM (once a day (in the morning)).
9. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO QPM (once a day (in the evening)).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. insulin glargine 100 unit/mL Solution Sig: Seven (7) Units
Subcutaneous at bedtime.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for anxiety.
16. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
17. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
18. Omega 3 Fish Oil 684-1,200 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Gastroparesis
Hypertensive Emergency
Secondary:
Diabetes mellitus
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 5936**],
You were admitted to the hospital with nausea and vomiting. This
was related to your gastroparesis. You were treated for reglan
and bowel rest and your symptoms improved. You also had very
high blood pressures while you were in the hospital which
required a transfer to the intensive care unit. When you had
high blood pressures you had a couple of episodes when you had
difficulty speaking and confusion. You were evaluated by
[**Known lastname **] and had an EEG and MRI of your brain which showed no
stroke or seizure activity. The episodes are believed to be
related to your high blood pressure. You were started on
medications for your blood pressure and it improved.
As you were acutely sick in the hospital you were unable to have
your bypass surgery. Please follow up with Dr. [**Last Name (STitle) **] to
reschedule this procedure.
We have made the following changes to your medications:
- START taking chlorthalidone for your blood pressure
- START taking lisinopril for your blood pressure
- START taking baby Aspirin daily
- CHANGE your dose of glargine insulin to 7 units daily
- STOP taking Sodium Chloride Tablets
It was a pleasure taking care of you at the [**Hospital1 18**]. We wish you a
speedy recovery.
Followup Instructions:
Please follow up at the appointments below:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2159-5-30**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name **] SURGERY
When: MONDAY [**2159-6-11**] at 3:45 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Last Name (un) **] Diabetes Center Follow-up Appointment
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12101**]
[**2159-6-7**] at 4PM
Completed by:[**2159-5-27**]
|
[
"V45.85",
"536.3",
"250.63",
"244.9",
"250.13",
"707.25",
"440.23",
"293.0",
"V58.67",
"272.4",
"707.07",
"337.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14304, 14375
|
8038, 11088
|
330, 355
|
14495, 14495
|
4590, 7483
|
15966, 16831
|
3127, 3267
|
12588, 14281
|
14396, 14474
|
11114, 12565
|
14678, 15585
|
7500, 8015
|
2474, 2934
|
3308, 3948
|
15614, 15943
|
233, 292
|
383, 1947
|
14510, 14654
|
1969, 2451
|
2950, 3111
|
3973, 4571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,710
| 197,902
|
53251
|
Discharge summary
|
report
|
Admission Date: [**2178-7-6**] Discharge Date: [**2178-7-9**]
Service:
Of note, this is a summary of hospital course; however, the
patient expired.
HISTORY OF THE PRESENT ILLNESS: The patient is a 78-year-old
female status post three vessel CABG in [**2178-1-30**] with
postoperative course complicated by asystolic arrest times 15
seconds recovered by V pacing. She was admitted for elective
repair of ventral incisional hernia secondary to sternal
wound debridement/omental flap. The surgery was performed by
General Surgery on [**2178-7-6**].
The evening after surgery, the patient developed her typical
anginal symptoms consisting of substernal chest pain lasting
30 minutes, relieved by three sublingual nitrogen and was
found to have a troponin leak of 9.7.
On the following evening, [**2178-7-7**], she desaturated and
was reintubated for possible CHF exacerbation; at that time,
pulmonary artery pressure was 27/13 with a CVP of 6. She was
extubated the following morning. She was taken to the
Cardiac Catheterization Lab on [**2178-7-8**] and found to
have 60% midstenosis of the LIMA to the LAD graft, 90%
occlusion of the SVG to PDA and stump occlusion of the SVG to
OM graft. The native left main coronary and ramus were
stented and balloon dilatation was performed on the venous
graft to the RCA. During injection of the SVG to PDA bypass
graft, she became progressively bradycardiac, hypotensive,
and unresponsive. Subsequently, she developed an asystolic
arrest.
She was intubated, resuscitated with epinephrine, Atropine,
and dopamine. A temporary pacing wire was placed into the
right ventricle. She was started on IV Amiodarone for
nonsustained ventricular tachycardia, Levophed, and dopamine
and transferred to the CCU.
PAST MEDICAL HISTORY:
1. Non-Q wave MI in [**2171**].
2. COPD.
3. Peripheral vascular disease.
4. Peptic ulcer disease.
5. Hypertension.
6. Atrial fibrillation.
7. Question of brain aneurysm.
8. [**Doctor Last Name **] of Hearts in [**2178-5-30**] showed sinus arrhythmia.
9. Hyperlipidemia.
PAST SURGICAL HISTORY:
1. Aortobifemoral in [**2169**].
2. Right femoral-popliteal bypass in [**2174**].
3. Three vessel CABG (LIMA-LAD, SVG-OM, SVG-PDA), with
sternal wound debridement and omental flap.
4. Sustained ventricular tachycardia, status post ablation.
5. Cataracts.
6. Laminectomy.
SOCIAL HISTORY: Tobacco: Fifty pack years, quit one year
ago. The patient lives alone at home.
Alcohol: None.
OUTPATIENT MEDICATIONS:
1. Metoprolol 50 mg b.i.d.
2. Lasix 20 mg q.d.
3. Imdur 30 mg q.d.
4. Plavix 75 mg q.d.
5. Lipitor 10 mg q.d.
6. Captopril 25 mg t.i.d.
7. Meprobamate 400 mg t.i.d.
8. Prevacid.
PHYSICAL EXAMINATION ON ADMISSION TO CCU: Vital signs:
Temperature 98.4, blood pressure 103/73, heart rate 70,
respiratory rate 13. Ventilator settings, assist control:
Tidal volume 500, respiratory rate 14, PEEP 5, FI02 50%.
Swan readings: PI pressure 41/19, pulmonary capillary wedge
pressure 20, cardiac output 6.3, index 4.5 to SVR 797. In
general, the patient was intubated and sedated with an
occasional cough, lying flat. Her neck was supple. Jugular
venous pressure could not be assessed. Her lungs were clear
to auscultation bilaterally. Her heart revealed a regular
rate, a II/VI harsh systolic murmur at the left sternal
border which radiated to the apex was noted. There was no S3
or S4. Her abdomen was distended, tympanic to percussion
with normoactive bowel sounds. A recent midline surgical
scar oozing serosanguinous fluids was noted. There were no
signs or symptoms of infection over the wound. Right groin
site was without oozing or hematoma. No bruit was noted.
Very faint dorsalis pedis and posterior tibial pulses were
noted. The extremities were cold and mottled. Neurological
examination revealed that the patient does not withdrawal to
pain. Her left pupil was fixed and dilated. Her right pupil
was sluggish with 5 mm to 4 mm responsiveness. Her deep
tendon reflexes were brisk at 3+/4+ in both upper and lower
extremities symmetrically. She had a positive Babinski
bilaterally.
LABORATORY VALUES ON ADMISSION TO THE CCU: White count 7.3,
hemoglobin 9.3, hematocrit 27.8, platelets 127,000. Sodium
130, potassium 5.1, chloride 100, bicarbonate 14, BUN 28,
creatinine 1.2, glucose 168, anion gap 21. Her PT was 14,
PTT 62.7, INR 1.4. Calcium 7.6, phosphorus 6.9, magnesium
3.7. Initial arterial blood gas on admission was
7.22/37/354/16 on 100% oxygen. Subsequent arterial blood gas
7.27/38/103/18 on 50%.
Pertinent laboratory studies: EKG postcatheterization showed
a left bundle branch block morphology, normal sinus rhythm at
78 with normal axis and intervals. The chest x-ray showed
lungs which were hyperexpanded, no infiltrate or effusion and
tubes and line in place. Echocardiogram on [**2178-7-8**],
postprocedure, showed no effusion, inferior akinesis/septal
hypokinesis and EF of 30% with severe mitral regurgitation.
IMPRESSION: This is a 78-year-old woman status post CABG in
[**2178-1-30**] complicated by perioperative asystolic
arrest and sternal debridement/omental flap now with
perioperative myocardial infarction secondary to incisional
hernia repair, asystolic arrest in Cardiac Catheterization
Lab requiring multiple pressors and reintubation.
HOSPITAL COURSE: The patient was transferred from the
Catheterization Lab status post asystolic arrest to the CCU.
Cardiac enzymes were trended and a peak CPK of 3,900 was
noted as well as a CK MB of 291. The morning of [**2178-7-9**], the troponin reached a peak of greater than 50. Repeat
echocardiogram was performed on [**2178-7-9**] which showed a
worsening of ejection fraction to less than 15%. A CT scan
of the head was performed which showed no acute intracranial
hemorrhage with the possibility of a left vertebral artery
aneurysm.
The morning after transfer to the CCU, the patient developed
junctional tachycardia and was evaluated by
Electrophysiology. EP felt that there was no further workup
necessary at this time and to continue supportive ICU care.
She was continued on Integrelin for 18 hours. Heparin was
discontinued. Amiodarone was stopped per EP recommendations.
The patient became progressively hypotensive and required the
addition of additional vasopressive medications. Urine
output decreased significantly and by noon on the first day
of ICU hospitalization, the patient became anuric. Her pedal
pulses also were lost and were unable to be Dopplerable. The
pressors were switched to dobutamine. Her cardiac rhythm
became unstable and she required V pacing.
At 10:15 p.m. on [**2178-7-9**], the patient had an arterial
blood gas which showed 7.04/24/92/7 with a lactate level of
16.9. She was given one ampule of bicarbonate. At 11:00
p.m., [**2178-7-9**], she was transiently asystolic with
pacemaker not capturing. Chest compressions were begun and
perfusion rhythm returned. Discussion was held with the
family and per their wishes, no further resuscitation was to
occur. At 11:20 p.m., the patient again had asystolic arrest
and was not resuscitated per the family's wishes. The
patient expired at 11:21 p.m. The family and the attending
physician were notified at that time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2178-10-23**] 12:09
T: [**2178-10-25**] 05:47
JOB#: [**Job Number **]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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5335, 7523
|
2088, 2366
|
2506, 5317
|
1785, 2065
|
2383, 2482
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,317
| 161,195
|
13606
|
Discharge summary
|
report
|
Admission Date: [**2195-7-2**] Discharge Date: [**2195-7-15**]
Date of Birth: [**2174-11-11**] Sex: M
Service: [**Hospital1 212**]
REASON FOR ADMISSION: Management of seizure disorder,
persistent lactic acidosis.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 20-year-old
gentlemen with a past medical history significant for seizure
disorder diagnosed in [**2195-3-27**]. His history of present
illness dates back to [**2194-1-27**] where he developed visual
scatomas, which began in a periphery and travelled across his
entire visual field over a period of 15 minutes. These
episodes occurred with physical activity. In [**2195-3-27**], the
patient had an episode of these symptoms after drinking
alcohol, which were subsequently followed by tonic-clonic
seizure activities times two. He was intubated at an outside
hospital Intensive Care Unit for two days and treated with a
Dilantin load. Work-up at the outside hospital at that time
included a normal CT MRI and lumbar puncture. In [**Month (only) 547**], he
had recurrence of these visual symptoms during physical
activity, but no other seizure activity. He was seen by Dr.
[**Last Name (STitle) 41071**] in [**Month (only) 116**], in which a repeat MRI and MRA of the head
were performed which were all normal. In [**2195-6-29**], while
the patient was playing basketball, he developed visual
symptoms again, which lasted 18 hours, and was accompanied by
bilateral leg tingling and left-sided headache, which
prompted a visit to the [**Hospital3 7362**] Emergency Room where
he had a normal head CT and lumbar puncture.
He subsequently developed right-sided seizure activity. His
Dilantin level at that time was 15. He was given valproic
acid and continued on Dilantin. He also received Ceftriaxone
and acyclovir empirically for possible meningitis. His
initial arterial blood gas was PHF of 7.24, pCO2 of 40, PO
316. His bicarbonate was 30 with an anion gap of 13. Later
that night, the patient developed generalized tonic-clonic
seizure activity and was intubated for airway protection and
severe acidosis. He was continued on valproic acid and
started on a benzodiazepine drip. His PH at the time of
initiation was documented to be 6.65, pCO2 of 15, PO2 of 138
on room air. His bicarbonate was 7 on a Chem-7 and patient's
anion gap had increased to 29. He was given several ampules
of bicarbonate and started on a bicarbonate drip. The
patient's lactic acid was found to be 30. A work-up for
toxic alcohol poisoning such as methanol alcohol and ethylene
glycal were all negative. Electroencephalogram revealed
discharges in the left hemisphere. CKs rose to 1600 and
creatinine rose from 0.5 to 1.5, which was treated with
copious fluids. The patient's amylase and lipase were also
elevated to peaks of 217 and 1845 respectively which was
blamed on an idiosyncratic reaction to Depakote. The
patient's Depakote was discontinued and he was started on
Trileptal again while continued with the Dilantin.
The patient also developed a left lower lobe infiltrate with
sputum subsequently growing Staph aureus and hemophilus
influenza. He was initially on ampicillin and then switched
to vancomycin. He was transferred to [**Hospital6 649**] for further management and was initially
admitted to the Neurological Surgical Intensive Care Unit
overnight. In the unit, he was continued on Trileptal and
Dilantin and he continued to receive vancomycin and was
started on levofloxacin and Flagyl. He remained on a
ventilator on assist control with frequent changes in
respiratory rate per his arterial PH. He did not have any
evidence of recurrent seizure activity. He was then
transferred to the Medical Intensive Care Unit earlier this
morning.
PAST MEDICAL HISTORY:
1. Seizure disorder.
2. Migraines.
MEDICATIONS ON TRANSFER:
1. Fosphenytoin 200 mg q. 8 hours.
2. Trileptal 1200 mg q. 12 hours.
3. Protonix/Versed drip.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is an [**State 41072**]. He
drinks alcohol but the amount is unknown. He is not a
smoker.
FAMILY HISTORY: The Neurology Service has done a pedigree on
the patient and they suspect a mitochondrial disorder.
PHYSICAL EXAMINATION: His temperature was 102.3. Pulse 124.
Blood pressure 130/70. Respiratory rate 24, saturating 95%.
Patient is ventilating on assist control. Tidal volume of
650 with a rate of 24. PEEP of 7.5. FIO2 50%. General: He
was intubated and sedated. He is a young male in no acute
distress. Neck: There is no lymphadenopathy, no jugular
venous distention, no thyromegaly or masses. Lung
examination reveals coarse breath sounds diffusely. Cardiac
exam was regular rate and rhythm, slightly tachycardic.
There was no murmurs appreciated. There was a normal S1, S2.
Gastrointestinal: Soft, nontender, nondistended, no
hepatosplenomegaly, no masses. Patient had normal active
bowel sounds. Extremities were warm with excellent distal
pulses. Trace edema in the bilateral lower extremities.
Neurological: Patient's pupils equal, round and reactive to
light. He was hyperreflexic with equal toes.
LABORATORY DATA: White blood cell count 13.4, hematocrit
31.2, platelets 166,000. Sodium 135, potassium 4.4, chloride
101, bicarbonate 9, BUN 10, creatinine 0.6, glucose 97,
lactate 13.9, AST 154, ALT 59, alkaline phosphatase 78, total
bilirubin 0.4, albumin 2.9, amylase 247, lipase 121, calcium
8.6, phosphorus 2.5, magnesium 1.8. CK 992, MB fraction 69,
index 7. Dilantin level 14.4. ESR was 35. Arterial blood
gas: pH was 7.35, pCO2 of 25, PO2 of 101. Urinalysis
revealed large bloodm 30 mg/dl of proteinuria, [**3-31**] red blood
cells and 0-2 white blood cells. There was no bacteria.
Chest x-ray revealed bilateral infiltrates and air
bronchograms, left greater than right. An ETT tube is 5 cm
above the corona.
Electrocardiogram revealed patient to be in sinus tachycardia
with a rate in the 120s. There is normal axis. There are T
wave inversions inferiorly and in the precordial leads.
There was J point elevation in V2 through V3.
HOSPITAL COURSE:
1. Neurology: A Neurology consult was obtained. They
believed that the patient had a strong possibility of having
a mitochondrial disorder. Multiple laboratories were sent
including genetic studies which are pending at the time of
discharge. The patient was started on empiric treatment for
mitochondrial disorder including the use of pulse steroids
such as Solu-Medrol 1 gram q.d. times three, then prednisone,
Vitamin E and C, Creatine, coenzyme Q, and riboflavin. The
patient was continued on Dilantin and Trileptal with a no
recurrence of seizure activity during this hospitalization.
The patient's Dilantin doses were multiplier modified
according to serum levels and per Neurology recommendations.
After extubation, the patient continued to experience visual
disturbances predominantly in the right eye, mostly
exacerbated and attributed to exertion. He was instructed to
cease physical activity upon experiencing any visual symptoms
or changes. On discharge, the patient was started on a five
day steroid taper to off. He should follow-up closely with
Neurology upon discharge until a definitive diagnosis is made
and a treatment plan is formulated.
2. Hematology: On admission, a cranial MRI was obtained
which revealed evidence of new bilateral occipital infarcts.
These are new as compared to a previous MRI on [**2195-6-14**].
A hypercoagulable work-up was pending at the time of
discharge.
3. Gastrointestinal: Because the patient's LFTs, amylase,
and lipase were found to be elevated, the patient was NPO and
an abdominal CT was obtained. It revealed a large amount of
free fluid in the pelvis, a small amount of free fluid in the
large anterior peritoneal space, which was thought to be from
acute pancreatitis. There is also a small amount of free
fluid around the right lobe of the liver and gallbladder.
The next day, the patient's tube feeds were restarted and
since his enzymes had begun to fall two days afterwards, the
patient exhibited some abdominal tenderness on palpation and
a right upper quadrant ultrasound was performed. It revealed
multiple small hemangiomas and gallbladder polyps. There is
no evidence of cholecystitis, biliary obstruction or
pancreatitis. TPN was then initiated temporarily. Three
days afterwards, he was started on clears and denied any
abdominal pain and had no increase in LFTs from the rest of
his hospital course.
3. Pulmonary: On admission, a left large pleural effusion
was detected along with bilateral pulmonary consolidations,
predominantly in the left lower lobe. Because the left
pleural effusion was slowly enlarging, a thoracentesis was
performed with removal of two liters of transudative fluid.
The patient then completed a ten day course of Ceftriaxone
and clindamycin for aspiration pneumonia. The patient was
extubated on hospital day number five without difficulty.
4. Cardiovascular: The patient was transiently hypotensive
on admission and the patient's troponins and CKs were cycled.
Elevations in both cardiac enzymes prompted a Cardiology
Consult in which they did not believe that the patient's
enzyme elevation related to any significant cardiac disease.
A transthoracic echocardiogram revealed that his left atrium
was within normal size. His left ventricular wall thickness
was normal. His left ventricular cavity size was normal.
His overall left ventricular systolic function was normal
with an ejection fraction of greater than 55%. His right
ventricular chamber size and free wall motion were normal.
His aortic valve leaflets were mildly thickened. There was
mild 1+ mitral regurgitation.
5. Dermatologic: The patient had a small sacral decubitus
ulcer which was treated with a Duoderm dressing,
immobilization and ambulation. By the time of discharge, the
ulcer had almost completely healed.
CONDITION AT THE TIME OF DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE MEDICATIONS:
1. Fosphenytoin 200 mg po q.a.m., 250 mg po q.p.m.
2. Prednisone 30 mg po q.d. times two days, 20 mg po q.d.
times another two days, 10 mg po q.d. times two days, then
off.
3. Zinc 220 mg po q.d.
3. Multivitamin 1 po q.d.
5. Protonix 40 mg po q.d.
6. Vitamin C 100 mg po b.i.d.
7. Vitamin E [**2193**] international units q.d.
8. Oxcarbazepine 1200 mg po b.i.d.
9. Benzyl peroxide 10% topical applied to chest q.d. prn
folliculitis.
10. Riboflavin 115 po q.d.
11. Ubidecarenone 300 mg po q.d.
12. Creatine monohydrate 4.1 grams po q.d.
DISCHARGE INSTRUCTIONS: Please limit your activity to only
low grade physical activity only. IF you develop any visual
symptoms upon exertion, please see cease all physical
activity immediately. If you experience prolonged visual
disturbances, please go to the [**Hospital6 2018**] Emergency Department immediately.
DISCHARGE FOLLOW-UP; Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2195-7-17**] in his Primary Care Clinic. Also, please follow-up
with Neurology also within a week.
PROBLEM LIST:
1. Possible mitochondrial disorder leading to seizures and
severe lactic acidosis and visual disturbances.
2. Bilateral occipital infarcts.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], M.D. [**MD Number(1) 1208**]
Dictated By:[**Last Name (NamePattern1) 7690**]
MEDQUIST36
D: [**2195-8-1**] 22:57
T: [**2195-8-1**] 22:57
JOB#: [**Job Number 41073**]
|
[
"759.89",
"577.0",
"707.0",
"434.91",
"780.39",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"34.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4109, 4210
|
10036, 10582
|
6112, 10013
|
10607, 11117
|
4233, 6094
|
261, 3758
|
11131, 11549
|
3843, 3979
|
3780, 3818
|
3996, 4092
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,561
| 124,107
|
11151
|
Discharge summary
|
report
|
Admission Date: [**2178-10-9**] Discharge Date: [**2178-10-15**]
Date of Birth: [**2114-4-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Amoxicillin / Demerol / Latex / Nickel
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Decreased exercise tolerance
Major Surgical or Invasive Procedure:
[**2178-10-9**] Mitral valve replacement with a [**Street Address(2) 17009**]. [**Hospital 923**] Medical
mechanical valve and Tricuspid valve repair with a 26-mm
Contour annuloplasty ring.
History of Present Illness:
64 year old female with known rheumatic disease and mitral
stenosis and regurgitation which has been followed with serial
echocardiograms. She has noted a gradual decrease in exercise
tolerance, particularly over the
past year. She does continue to walk up to two miles on most
days at a moderate pace. However, she notes that with any uphill
walking, she does become short of breath. In addition, she also
notes this with climbing more than one flight of stairs or when
carrying her grandson. Recent echocardiogram on [**7-30**] showed mild
mitral stenosis and moderate mitral regurgitation with
thickened/deformed leaflets characteristic of rheumatic
deformity. She was recently evaluated for ballon valvuloplasty
however this was deferred given the amount of mitral
regurgitation that she had. Given the progression of her
symptoms and severity of her disease, she has been referred for
surgical management.
Past Medical History:
Mitral stenosis and regurgitation
Hypertension
Hyperlipidemia
Rheumatic heart disease around the age of 9
Multinodular goiter, presently euthyroid without medication
IBS/GERD/gastroparesis
Cervical radiculitis
Depression
Social History:
Lives with: Husband in [**Name2 (NI) 3307**]
Occupation: Retired
Cigarettes: Smoked no
ETOH: < 1 drink/week [X]
Illicit drug use None
Family History:
father CABG in his 70s and dying at age 80 with heart failure
mother having some type of mitral valve disease
Physical Exam:
Pulse: 93 regular Resp: 16 O2 sat: 99%
B/P Right: 149/93 Left: 138/91
Height: 4"11" Weight: 143
General: WDWN in NAD
Skin: Warm, Dry and intact. No lesions or rashes
HEENT: NCAT, PERRLA, EOMI, sclera anciteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] Non JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, II/VI quiet systolic murmur with faint diastolic
rumble.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
No hepatomegally noted
Extremities: Warm [X], well-perfused [X] No edema
Varicosities: None noted
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: None Left: ?Faintly transmitted murmur vs
bruit
Pertinent Results:
ECHO [**2178-10-9**]:
PRE-BYPASS: The left atrium is moderately dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. Mild spontaneous echo contrast is present in the left
atrial appendage. No thrombus is seen in the left atrial
appendage. The right atrium is dilated. 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
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 shows
characteristic rheumatic deformity. There is mild valvular
mitral stenosis (area 1.5-2.0cm2). Moderate (2+) mitral
regurgitation is seen. Moderate to (2+) tricuspid regurgitation
is seen. The tricuspid regurgitation jet is eccentric and may be
underestimated. There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results prior to incision.
POST-BYPASS: Preserved biventricular systolic function. The
prosthesis in the tricuspid position is stable and functioning
well. The mitral bioprosthesis is well seated and functioning
well and mean transmitral gradient is 3 mm of Hg. Intact
thoracic aorta.
.
Chest x-ray [**2178-10-13**]: Small bilateral/pleural effusions are
probably unchanged since [**10-11**]. Left lower lobe
atelectasis is mild, substantially improved. There is no
pulmonary vascular engorgement or pulmonary edema. Borderline
cardiomegaly is comparable to the preoperative appearance, but
the left atrium is no longer as dilated. No pneumothorax.
Left PICC line ends low in the SVC.
.
EKG
Normal sinus rhythm. J point elevation in leads II, III, aVF and
V5-V6.
Small non-diagnostic Q waves in leads II, III and aVF. There is
Wenckebach
block. Compared to the previous tracing of [**2178-10-9**] the
Wenckebach, Mobitz I heart block is new. Otherwise, no
diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 226 82 392/418 29 76 49
.
[**2178-10-9**] 02:00PM BLOOD WBC-16.4*# RBC-2.61*# Hgb-8.0*#
Hct-24.0*# MCV-92 MCH-30.5 MCHC-33.2 RDW-13.1 Plt Ct-197
[**2178-10-15**] 04:28AM BLOOD WBC-5.9 RBC-3.03* Hgb-9.2* Hct-27.6*
MCV-91 MCH-30.4 MCHC-33.5 RDW-13.4 Plt Ct-232
[**2178-10-9**] 02:00PM BLOOD PT-15.4* PTT-38.0* INR(PT)-1.3*
[**2178-10-15**] 04:28AM BLOOD PT-34.5* INR(PT)-3.4*
[**2178-10-9**] 03:15PM BLOOD Glucose-120* UreaN-11 Creat-0.5 Na-144
K-4.0 Cl-114* HCO3-24 AnGap-10
[**2178-10-15**] 04:28AM BLOOD Glucose-92 UreaN-11 Creat-0.5 Na-141
K-4.0 Cl-104 HCO3-28 AnGap-13
[**2178-10-15**] 04:28AM BLOOD Calcium-8.7 Phos-4.8* Mg-1.8
Brief Hospital Course:
Same day admission and was brought to the operating room where
she underwent a Mitral valve replacement with a [**Street Address(2) 17009**]. [**Hospital 923**]
Medical mechanical valve and Tricuspid valve repair with a 26-mm
Contour annuloplasty ring. See operative report for further
details. Post operatively she was admitted to the ICU intubated
and sedated on pressor support for hypotension. She awoke
neurologically intact, was weaned from the ventilator and
extubated. Pressors were weaned off. Chest tubes and pacing
wires were discontiued per protocol. She was started on coumadin
for mechanical mitral valve with heparin bridge. Betablockers
were initiated then stopped due to hypotension. She additionally
had short burst of atrial fibrillation and flutter that
converted without intervention. Her betablockers were slowly
restarted and she continued to progress and remained in normal
sinus rhythm. Physical therapy worked with her on strength and
mobility. She continued to progress and was ready for discharge
to home on post operative day six
Medications on Admission:
lisinopril 20mg daily
Toprol XL 100mg daily
Oeprazole 40mg daily
Transderm-Scop 1.5/72hr q72h prn
Simvastatin 10mg daily
tizanidine 4mg hs prn
Asa 81mg daily
digest assure
fibermucil
glucosamine
loratadine
MVI
Discharge Medications:
1. amitriptyline 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*1*
2. multivitamin 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:*1*
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*qs qs* Refills:*1*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
6. tizanidine 4 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*1*
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
9. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
Disp:*10 Tablet(s)* Refills:*0*
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain or fever .
12. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
13. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-21**] Sprays Nasal
QID (4 times a day) as needed for dry nares.
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
16. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication mechcanical MVR
Goal INR 3.0-3.5
First draw [**10-16**]
Results to Dr [**Last Name (STitle) **] phone [**Telephone/Fax (1) 4775**] fax [**Telephone/Fax (1) 4776**]
[**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25373**] coumadin RN
Discharge Disposition:
Home With Service
Facility:
visiting nurse and community health
Discharge Diagnosis:
Mitral stenosis and regurgitation s/p MVR
Tricuspid valve repair s/p TV repair
Post operative atrial fibrillation and flutter
Past medical history:
Hypertension
Hyperlipidemia
Rheumatic heart disease
Multinodular goiter
IBS/GERD/gastroparesis
Cervical radiculitis
Depression
s/p Shoulder surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace LE 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
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2178-11-18**] 1:00
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62**] on [**2178-11-9**]
10:40
Wound check: [**Telephone/Fax (1) 170**] on [**2178-10-22**] 10:00 - cardiac surgery
office
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4775**] in [**3-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechcanical MVR
Goal INR 3.0-3.5
First draw [**10-16**]
Results to Dr [**Last Name (STitle) **] phone [**Telephone/Fax (1) 4775**] fax [**Telephone/Fax (1) 4776**]
[**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25373**] coumadin RN
Completed by:[**2178-10-15**]
|
[
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"V58.61",
"426.13",
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icd9cm
|
[
[
[]
]
] |
[
"35.24",
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icd9pcs
|
[
[
[]
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] |
9146, 9212
|
5679, 6741
|
343, 537
|
9552, 9731
|
2838, 5656
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|
1888, 1999
|
7001, 9123
|
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|
6767, 6978
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9755, 10633
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2014, 2819
|
275, 305
|
565, 1477
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9381, 9531
|
1737, 1872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,424
| 126,822
|
35438
|
Discharge summary
|
report
|
Admission Date: [**2190-4-26**] Discharge Date: [**2190-5-2**]
Date of Birth: [**2128-8-13**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Right renal mass
Major Surgical or Invasive Procedure:
Right partial nephrectomy - [**2190-4-26**] - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
History of Present Illness:
The patient is a 61-year-old male with a history of pancreatitis
that was worked up and who underwent MRCP which revealed a 2-cm
right posterior exophytic renal mass. The patient underwent
renal mass protocol which revealed approximately a 2.3-cm right
posterior interpolar exophytic lesion. The patient had the
alternatives, risks, and benefits explained and elected to
proceed with a right partial nephrectomy.
Past Medical History:
HTN
Hyperlipidemia
Depression
Type 2 DM
Social History:
No tobacco, 2 glasses of wine/month, no drug use. Lives in
P-town, works as a cook.
Family History:
non-contributory
Pertinent Results:
[**2190-5-1**] 02:53AM BLOOD WBC-13.3* RBC-4.03* Hgb-12.0* Hct-33.0*
MCV-82 MCH-29.9 MCHC-36.5* RDW-13.6 Plt Ct-524*
[**2190-5-1**] 09:39AM BLOOD Glucose-191* UreaN-7 Creat-0.9 Na-137
K-3.8 Cl-101 HCO3-26 AnGap-14
Brief Hospital Course:
Pt was admitted to Dr.[**Doctor Last Name **] Urology service after undergoing
right partial nephrectomy on [**2190-4-26**]. Please see the dictated
operative note for details. His pain was initially controlled
with a PCA, and he was later transitioned to PO pain medication
before discharge. His NGT was removed on POD 1 and his chest
tube on POD 2 with f/u CXR showing no evidence of significant
pneumothorax. With passage of flatus, his diet was advanced.
On POD 4, he developed sudden onset of atrial fibrillation with
rapid ventricular rate that was not able to be controlled with
IV lopressor or diltiazem on the floor. He was transferred to
the [**Hospital Ward Name 332**] ICU and was placed on a diltiazem drip and loaded
with amiodarone IV. He converted to normal sinus rhythm on POD
5 and was discharged from the ICU to the floor with a standing
dose of metoprolol 50 mg PO bid at the request of cardiology.
The dose was switched to 25 mg PO bid upon discharge because his
heart rate on the medication ranged from the 50s to the low 60s
while in hospital. He was hemodynamically stable throughout his
hospitalization, and did not suffer from acute renal failure at
any point. On discharge, his pain was adequately controlled on
PO pain meds, he was ambulating without difficulty, and his rate
and rhythm were controlled on PO lopressor. He was given
explicit instructions to follow-up with his primary care
physician for further modification of his cardiac medications.
He will f/u wtih Dr. [**Last Name (STitle) **] for staple removal in clinic.
Medications on Admission:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day.
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Verapamil 240 mg PO bid
Discharge Medications:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day.
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 1 months.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take while taking dilaudid to prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Do not take if your heart rate is < 55.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right renal mass
Discharge Condition:
Stable
Discharge Instructions:
-Take your metoprolol as instructed. If your heart rate is <
60, only take half the dose (25 mg)
-You may shower but do not bathe, swim or immerse your incision.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up.
-Do not drive or drink alcohol while taking narcotics.
-Resume all of your home medications, except hold NSAID
(aspirin, advil, motrin, ibuprofin) until you see your urologist
in follow-up.
-Call your Urologist's office today to schedule a follow-up
appointment in 3 weeks AND if you have any questions.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER.
Call Dr. [**Last Name (STitle) **] to set up follow-up appointment and if you have
any urological questions.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] to set up follow-up appointment and if you have
any urological questions.
Completed by:[**2190-5-2**]
|
[
"788.20",
"250.00",
"311",
"997.1",
"E878.8",
"272.4",
"401.9",
"427.31",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.4"
] |
icd9pcs
|
[
[
[]
]
] |
4159, 4165
|
1350, 2917
|
330, 448
|
4226, 4235
|
1112, 1327
|
5205, 5344
|
1075, 1093
|
3264, 4136
|
4186, 4205
|
2943, 3241
|
4259, 5182
|
274, 292
|
476, 893
|
915, 957
|
973, 1059
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,498
| 132,226
|
41909
|
Discharge summary
|
report
|
Admission Date: [**2129-10-22**] Discharge Date: [**2129-11-9**]
Date of Birth: [**2061-8-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
ventricular fibrilation arrest
Major Surgical or Invasive Procedure:
[**2129-10-22**] - Rapid sequence intubation
[**2129-11-1**] - Post-pyloric Dobhoff tube placement ([**Last Name (un) **]-jejunal)
History of Present Illness:
70 year-old male with history of HTN found in VF arrest after
single car MVC. There was minimal damage to the vehicle and he
was found restrained. No overt injuries seen but multiple
abrasions. He was shocked four times in the field. ALS gave
him epi 1:[**Numeric Identifier 961**] x3, atropine 0.5mg x1, and amiodarone 300mg IVP
with return of circulation. Intraosseus line was placed in the
left pretibial region. He was estimated to be down for
approximately 10-15 minutes. [**Location (un) 86**] Med Flight placed an LMA,
gave fentanyl 350mcg, Midazolam 4mg, and amiodarone 1mg/min for
10 mins while en route to [**Hospital1 18**].
.
In the ED, he tried to pull out his LMA and moved both arms and
legs prior to sedation. Sedation and succ were started for
intubation. FAST ultrasound was negative. CT head and torso
were unremarkable for bleed. Two PIV's were placed and his IO
line was pulled. He was sent to the cath lab for EKG revealing
large anterolateral STEMI.
.
Family reports that he had a recent normal annual exam and had
not been complaining of anything except for hunger recently.
This morning, he was driving a tractor to help spread mulch for
his church. Family denies any recent antibiotics and notes his
only recent medical issue was evaluation for a torn meniscus.
Per family, up to date with malignancy screening.
.
Review of systems:
Family notes only positive for nocturia x1 per night.
Otherwise, they deny 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. They deny recent fevers, chills or rigors. they
deny 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 per the family.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- distant hernia repair
- ? torn meniscus
- no other surgeries or hospitalizations
Social History:
SOCIAL HISTORY: Lives in [**Location 1157**] with his wife. [**Name (NI) 1403**] as an
insurance salesman. No kids or pets at home. Plays volleyball
1-2x/week. Active in his church.
- Tobacco history: None
- ETOH: None
- Illicit drugs: None
Family History:
FAMILY HISTORY:
- Mother: D.38 breast cancer.
- Father: D.80 metastatic prostate cancer.
- Eldest son: D.__ MI in [**11-12**].
- Grandson: VT scheduled for cardiac MRI and potential
ablation.
Physical Exam:
ADMISSION EXAM:
GENERAL: Intubated and sedated. Sedated at times, agitated and
writing in bed at others.
HEENT: Sclera anicteric. Pupils equal and 2mm bilaterally.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with collar in place. Nontender anteriorly, blood
on anterior neck although no clear abrasion.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Distant heart sounds. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No crepitus on anterior chest wall. No evidence of flail
chest. Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi anteriorly.
ABDOMEN: +BS, soft, NT, ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Left pretibial I/O
site c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+
PT 2+
Pertinent Results:
[**2129-10-22**] 03:00PM BLOOD WBC-16.6* RBC-4.84 Hgb-15.3 Hct-43.8
MCV-91 MCH-31.6 MCHC-34.9 RDW-12.7 Plt Ct-235
.
[**2129-11-3**] 04:07AM BLOOD WBC-9.2 RBC-3.33* Hgb-10.1* Hct-30.2*
MCV-91 MCH-30.3 MCHC-33.3 RDW-12.8 Plt Ct-308
.
[**2129-10-22**] 06:55PM BLOOD Neuts-90.2* Lymphs-4.9* Monos-4.8 Eos-0.1
Baso-0
.
[**2129-10-22**] 03:00PM BLOOD PT-13.3 PTT-26.0 INR(PT)-1.1
.
[**2129-10-22**] 03:00PM BLOOD UreaN-23* Creat-1.4*
.
[**2129-10-25**] 05:05PM BLOOD Glucose-87 UreaN-34* Creat-2.0* Na-133
K-3.9 Cl-102 HCO3-22 AnGap-13
.
[**2129-11-3**] 03:00PM BLOOD Glucose-143* UreaN-46* Creat-1.5* Na-142
K-3.5 Cl-100 HCO3-36* AnGap-10
.
[**2129-10-22**] 06:55PM BLOOD ALT-658* AST-615* CK(CPK)-1001*
AlkPhos-82 TotBili-1.2
.
[**2129-10-24**] 08:14AM BLOOD ALT-527* AST-400* LD(LDH)-921*
CK(CPK)-2064* AlkPhos-64 TotBili-1.3
.
[**2129-10-25**] 02:29AM BLOOD ALT-374* AST-226* CK(CPK)-1870*
AlkPhos-66 TotBili-1.0
.
[**2129-11-1**] 04:07AM BLOOD ALT-53* AST-87* AlkPhos-427* Amylase-42
TotBili-0.7
.
[**2129-11-3**] 04:07AM BLOOD ALT-36 AST-53* AlkPhos-358* TotBili-0.7
.
[**2129-11-3**] 04:07AM BLOOD Lipase-62*
[**2129-11-2**] 05:00AM BLOOD Lipase-60
[**2129-11-1**] 04:07AM BLOOD Lipase-55
[**2129-10-31**] 04:00AM BLOOD Lipase-50
.
[**2129-10-22**] 03:00PM BLOOD cTropnT-0.03*
[**2129-10-22**] 06:55PM BLOOD CK-MB-80* MB Indx-8.0* cTropnT-0.73*
[**2129-10-23**] 08:00AM BLOOD CK-MB-GREATER TH cTropnT-2.79*
[**2129-10-23**] 02:20PM BLOOD CK-MB-GREATER TH cTropnT-4.30*
[**2129-10-23**] 07:53PM BLOOD CK-MB-GREATER TH cTropnT-3.94*
[**2129-10-24**] 01:53AM BLOOD CK-MB->500 cTropnT-3.51*
[**2129-10-25**] 02:29AM BLOOD CK-MB-117* MB Indx-6.3* cTropnT-2.25*
[**2129-10-26**] 04:03AM BLOOD CK-MB-24* MB Indx-2.4 cTropnT-2.60*
.
[**2129-11-2**] 05:00AM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.4 Mg-2.5
.
[**2129-10-31**] 04:00AM BLOOD Triglyc-139
.
[**2129-11-1**] 07:48PM BLOOD Vanco-16.7
.
[**2129-10-22**] 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2129-10-22**] 03:14PM BLOOD Glucose-248* Lactate-7.9* Na-139 K-3.4
Cl-103
.
[**2129-10-22**] 09:59PM BLOOD Lactate-4.3* K-3.8
[**2129-11-2**] 05:06AM BLOOD Lactate-0.7
.
MICRBIOLOGIC DATA:
[**2129-10-22**] MRSA screen - negative
[**2129-10-24**] Blood culture - negative
[**2129-10-24**] Blood culture - negative
[**2129-10-24**] Urine culture - negative
[**2129-10-25**] Sputum culture -
KLEBSIELLA PNEUMONIAE
| STAPH AUREUS COAG +
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM-------------<=0.25 S
OXACILLIN------------- 0.5 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
.
[**2129-10-28**] Urine culture - negative
[**2129-10-28**] Blood culture - negative
[**2129-10-28**] Blood culture - negative
[**2129-10-28**] Sputum culture - Gram negative rods, yeast (sparse),
Aspergillus fumigatus (sparse)
[**2129-10-28**] Right femoral catheter IV tip - negative
[**2129-10-30**] Blood culture - negative
[**2129-10-30**] Blood culture - negative
[**2129-11-3**] Blood culture - negative
[**2129-11-3**] Blood culture - negative
.
IMAGING:
[**2129-10-22**] CARDIAC CATHETERIZATION - Selective coronary
angiography of this right dominant system demonstrated one
vessel coronary artery disease. The LMCA has no
angiographically-apparent flow limiting stenosis. The LAD had a
mid 50% stenosis, a 100% oclussion of the first diagonal branch
without
collaterals or image of a distal vessel. There was a medium
ramus branch
was patent. The LCX had a distal tubular 50-60% stenosis. The
RCA had
proximal , mid and distal 30-50% lumen irregularities. 2.
Limited resting hemodynamics revealed mildly elevated left sided
filling pressures with an LVEDP of 24 mm Hg and normal systemic
arterial pressures with a central aortic pressure of 100/67
mmHg. There was no aortic valve gradient seen on careful
pullback from left ventricle to aorta. Left ventriculography
showed an LVEF 55% with anterolateral akinesis. Given small size
of the distribution of the diagonal branch, stump occlusion and
other issues related to blunt trauma precluding intensive
anticoagulation, conservative managment of the small diagonal
branch was used.
.
[**2129-10-22**] CT HEAD W/O CONTRAST - No evidence of acute
intracranial injury.
.
[**2129-10-22**] CT ABD & PELVIS WITH CO - Multiple right anterior rib
fractures at the costochondral junctions, with one fracture of
the costal cartilage. No pneumothorax. Bibasilar consolidations
could represent atelectasis and/or aspiration, less likely
contusion. Malpositioned enteric tube projecting laterally
distorting the greater curve. Consider repositioning. No solid
organ injury within the abdomen or pelvis.
.
[**2129-10-22**] CT C-SPINE W/O CONTRAST - No acute fracture or
malalignment. Multilevel degenerative disease with moderately
severe canal narrowing at multiple levels, as described above.
In the setting of significant canal narrowing, cord injury can
occur in the absence of fracture and further evaluation by MR
can be obtained if indicated (e.g. by new myelopathy). Biapical
dependent consolidations; aspiration pneumonitis is a
consideration (see report of concurrent CECT torso).
.
[**2129-10-23**] EEG - This is an abnormal continuous ICU video EEG
study because
of diffuse severe suppression of background consistent with
severe
encephalopathy. No electrographic seizures were present.
Compared to
the previous day, more mixed frequencies were present and for
longer
duration in this record indicating some decrease in the severity
of
encephalopathy.
.
[**2129-10-23**] ECHO - Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Limited study. Normal LV systolic
function.
.
[**2129-10-27**] PORTABLE ABDOMEN - A nasogastric tube is present,
terminating in the distal stomach. A non-obstructive bowel gas
pattern is visualized. Air-filled loops of large bowel are
present measuring up to 5.6 cm in diameter, and air-filled loops
of small bowel are present, measuring up to about 2 cm in
diameter. The lack of an upright view limits evaluation for
air-fluid levels or free intraperitoneal air. Focal
calcifications within the left lower pelvis probably reflect
phleboliths.
.
[**2129-10-31**] LIVER OR GALLBLADDER US - The gallbladder is distended
but without wall thickening, mural edema, or pericholecystic
fluid to suggest acute cholecystitis. Trace amount of
gallbladder sludge may be present.
.
[**2129-10-31**] CT CHEST, ABD & PELVIS W/O - Acute pancreatitis, new
since the [**2129-10-22**] examination. No free fluid or
pseudocyst formation detected. Small bilateral lower lobe
consolidations with adjacent severe atelectasis and small
pleural effusions, slightly progressed since [**2129-10-22**].
.
[**2129-11-3**] CHEST (PORTABLE AP) - One supine portable AP view of the
chest. Nasointestinal tube has been advanced with the tip out of
view on this image. A right internal jugular catheter ends in
the upper SVC. Right lower lobe collapse is unchanged. No left
pleural effusion. Right pleural effusion cannot be assessed.
Mild-to-moderate pulmonary interstitial edema is stable. Left
basilar atelectasis is stable.
Brief Hospital Course:
This is a 68 year-old Male with a past medical history of
well-controlled HTN who presented status-post motor vehicular
incident which was presumed to be initiated by transient
myocardial ischemia with ventricular fibrillation arrest who
underwent cooling protocol and was transferred to BIMC for
further care.
.
# FEVERS ?????? Mr. [**Known lastname **] presented with fevers and initially was
managed with IV Vancomycin and Zosyn empirically (which he
continued to spike through). CXR imaging showed Klebsiella and
MSSA pan-sensitive community-acquired pneumonia which was
initially managed with IV Cefazolin given the Klebsiella and
MSSA sensitivity profile. He also had CT imaging of the chest
which showed evidence of bilateral lower lobe consolidations.
However, mid-hospital course the patient continued to spike
fevers and was found to have trauma-induced pancreatitis, thus
we broadened his coverage to IV Vancomycin and Zosyn on [**10-31**]
with plans to complete a 10-day course for presumed infection;
he completed this course during his stay. His urine cultures and
blood cultures and right femoral line cultures throughout his
hospitalization were all without growth. Other sources of
infection that were considered: sinusitis vs. extremity clot
burden vs. line infections vs. occult abdominal infection or
acaculous cholecystitis. He showed no signs of these other
occult infection and eventually his pancreatitis was determined
to be the likely source of his leukocytosis and low grade cyclic
fevers. Specifically, his leukocytosis trended from 14 on
admission to 9.
.
# PANCREATITIS ?????? During his hospital stay, he continued to spike
fevers despite the treatment of his pneumonia with broad
spectrum antibiotic coverage; thus he underwent CT torso imaging
to evaluate for occult infection. This showed the incidental
finding of pancreatitis on [**10-31**] (CT torso); interestingly, his
lipase and amylase remained normal. He had no evidence of
liquefactive necrosis or a hemorrhagic component. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
from pancreatobiliary surgery reviewed the films and noted no
surgical issues. Etiologies for his pancreatitis included:
alcoholic vs. biliary or obstructive gallstone (unlikely given
no CBD dilatation, normal T-bili and no gallstones in GB on RUQ
imaging) vs. medication-effect (medication list reviewed without
inciting source other than Lasix which can cause type 1 injury)
vs. trauma (likely given MVA with airbag deployment and trauma)
vs. hypertriglyceridemia (reassuring triglycerides) vs.
hypercalcemia (calcium 8.3) vs. idiopathic. He was maintained
NPO status, a post-pyloric Dobhoff tube was placed and Peptamen
(low fat, high protein) tube feeds were initiated with a goal
rate of 55 cc/hr. He tolerated this feeding well. We trended his
amylase and lipase which remained flat and trended his
transaminitis, which resolved with conservative management. We
employed judicious diuresis given the concerns for third-spacing
with pancreatitis. We also carefully monitored his respiratory
status given concerns for ARDS. His pCO2 did demonstrate
evidence of hypercardia in the 56-60 range and we employed
strategies along with diuresis to prevent volume-induced lung
injury by dropping his tidal volumes and increasing his
respiratory rate, which he tolerated well. Serial abdominal
exams were reassuring and we controlled his pain with Fentanyl
while he was intubated, and transitioned him to a Fentanyl patch
for pain control with extubation. The chronic pain service
evaluated him to assist with this transition. The patient was
extubated on [**2129-11-4**] successfully. His abdominal pain was not
much of an issue following extubation and we started feeding him
slowly with clear liquids, slowly advancing to regular diet.
Once he tolerated PO intake, his nasojejunal feeding tube was
discontinued. He tolerated this well. His LFTs improved nicely.
.
# POOR RESPIRATORY STATUS, KLEBSIELLA AND MSSA PNEUMONIA - The
patient was intubated on [**2129-10-22**] with dependent consolidations
seen on CT chest with air bronchograms to complement. His sputum
culture gram stain shoeed 4+ GNR and 2+ GPCs, and cultures
showed pan-sensitive Klebsiella and MSSA which were initially
treated with IV Cefazolin and this was then broadened to
Vancomycin and Zosyn. His ventilation status remained stable
given right-sided rib fractures in the setting of pneumonia, but
this was initially causing a poor respiratory substrate for
extubation. We employed judicious diuresis given the concerns
for third-spacing with pancreatitis. We also carefully monitored
his respiratory status given concerns for ARDS. His pCO2 did
demonstrate evidence of hypercardia in the 56-60 range and we
employed strategies along with diuresis to prevent
volume-induced lung injury by dropping his tidal volumes and
increasing his respiratory rate, which he tolerated well.
Eventually his oxygenation improved and his PEEP was weaned from
10 to 5, his FiO2 was decreased and his RISBI supported
extubation. He was extubated on [**2129-11-5**] without issues and
tolerated weaning from nasal cannula to room air. He was
treated, as noted above, for a healthcare-acquired pneumonia vs.
aspiration pneumonia this admission.
.
# HYPERTENSION - He presents with a diagnosis of essential
hypertension on three agents at home. While intubatde, he
remained intermittently agitated when sedation was lightened and
her would become hypertensive to the 170-180 mmHg range; this
improved with resumption of his home anti-hypertensive regimen.
His Losartan was resumed at 100 mg PO daily and titrated to 150
mg PO daily, his Metoprolol was titrated to an effective dose
and his Amlodipine was continued at 10 mg PO daily. He did
initially require Nitroglycerin IV infusion which was weaned
early into his hospital course.
.
# NEUROPROTECTION S/P ARREST - Interval between arrest and
initiation of cooling was 7-hours. The patient was extremely
agitated upon arrival to the ED and CCU. He was initially moving
all four extremities in response to pain but he was not
following commands. A cooling protocol was initiated given his
poor mentation and for neuroprotection. He was rewarmed followng
the protocol. He remained intubated and we employed tactics to
wean him from the ventilator. He required Midazolam and Fentanyl
gtts for sedation while intubated and although his RISBI
improved, his agitation with less sedation was marked. We
discussed these concerns with the chronic pain service and
optimized his pain regimen given his rib fractures and
pancreatitis issues. The epilepsy service was also consulted and
his EEG was reassuring. Given ischemia was the underlying cause
of his degenerated ventricular rhythm, an ICD was not considered
this hospitalization; but this might be considered in the
future.
.
# ACUTE KIDNEY INJURY - The patient was admitted with a baseline
creatinine of 1.0 to 1.1. Initially, he presented with [**Last Name (un) **] and a
creatinine of 1.8-2.0. He responded to hydration and his
creatinine peaked at 1.6. We attributed his acute renal
insufficiency to his poor perfusion in the setting of low
forward flow from his cardiac ischemic event. His FeNA was 0.05%
on admission. He eventually stabilized his creatinine in the 1.3
to 1.5 range. We opted to employ judicious diuresis given his
third-spacing from the pancreatitis. He improved with diuresis
and creatinine stabilized. He did develop some component of
contraction metabolic alkalosis with compensatory respiratory
acidosis with diuresis. We avoided nephrotoxins and renally
dosed all of his medications.
.
# CORONARIES - The patient presented with a only a history of
HTN and a family history of early MI. It was presumed that he
had transient ischemia in his LAD which resulted in resulted in
ventricular fibrillation and resulting in his motorvehicular
accident. His EKG revealed a large anterolateral ST elevation
myocardial infarction with inferior ST-depression. His cardia
catheterization on arrival to [**Hospital1 18**] showed a completely occluded
first diagonal coronary artery without subsequent intervention
and evidence of 50% LAD stenosis. His 2D-Echo didn't show any
new wall motion abnormalities. We continued him on Aspirin 325
mg PO daily, resumed his Metoprolol and held his Clopidogrel
(Plavix) until further procedures were completed. We planned to
resume this medication. We continued his high dose Atorvastatin
at 80 mg PO daily. Serial EKG monitoring was reassuring. Again,
an ICD was not indicated on this admission given the transient
ischemia which likely led to his decompensated ventricular
rhythm; although this may be considered in the future.
.
# PUMP - He was noted to have significant volume overload with a
5 L positive fluid balance as of [**10-31**] in the setting of
resuscitation. A 2D-Echo performed on [**10-25**] showing mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). He had
evidence of mild crackles, 2+ pitting peripheral edema and
scleral edema ?????? significant third spacing noted in the setting
of pancreatitis from trauma? He responded to aggressive diuresis
with IV Lasix. Once he was stable, we added back his Losartan,
beta-blocker to optimize his regimen. His creatinine was closely
monitored in the setting of diuresis, and steadily improved.
Daily weights, in's and out's and electrolytes were closely
monitored in the setting of his aggressive diuresis. He received
erythromycin ophthalamic for scleral edema and ophthalamic
ointments for his scleral edema.
.
# RHYTHM - Remained in sinus rhythm, but found in ventricular
fibrillation with cardiac event requiring resuscitation. Serial
EKGs following this event were reassuring and he did have some
telemetry evidence of PVCs which improved with electrolyte
optimization.
.
# NUTRITION - He was initially started on tube feeds via NGT,
but once his pancreatitis was noted, he was switched to a
post-pyloric Dobhoff feeding tube for Peptamen tube feed
administration to promote nutrition. Nutrition was consulted to
optimize a low fat, high protein diet given his pancreatitis
issues. Following extubation, he was successfully transitioned
to PO intake and his Dobhoff feeding tube was removed.
.
TRANSITION OF CARE ISSUES:
1. Continue Tylenol as needed for abdominal pain.
2. Monitoring of electrolytes weekly, as needed, while at the
rehabilitation facility.
3. Liver function tests have normalized. Amlyase and lipase have
remained normal even during pancreatitis episodes.
4. Patient needs follow-up appointment with Behavoral
Nneurology, Dr. [**Last Name (STitle) **] [**Name (STitle) **], if there are concerns with his
memory or cognitive function when he is ready to leave
rehabilitation.
5. Telemetry monitoring given coronary artery disease, while at
rehabilitation facility.
6. Noted scleral edema and conjunctival injection which was
treated with erythromycin ointment for 7-days and is improving.
Visual acuity is not affected.
Medications on Admission:
1. Amlodipine 10 mg PO daily
2. Atenolol 50 mg PO daily
3. Losartan-HCTZ 100-25 mg PO daily
4. Ecotrin
5. Omega-3 fatty acid tablet PO daily
6. Multivitamin 1 tablet PO daily
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily): Hold
HR < 55, SBP < 100.
2. Multiple Vitamins Daily Tablet Sig: One (1) Tablet PO
once a day.
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
HOLD SBP < 100.
5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**]
Puffs Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day:
Hold SBP < 100.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnoses:
1. Ventricular fibrillation arrest
2. Acute, traumatic pancreatitis
3. Acute coronary syndrome
4. Hospital-acquired pneumonia
5. Right-sided rib fractures
.
Secondary Diagnoses:
1. Hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
motorvehicular accident and ventricular arrhythmia leading to
cardiac arrest. You were driving and collapsed and hit a tree.
The EMT's found that you were in a dangerous heart rhythm called
ventricular fibrillation. The EMT's shocked you out of this
rhythm and brought you to [**Hospital1 18**]. A heart attack was causing the
heart rhythm but the clot in your arteries went away and you did
not need to have any procedure done in the cardiac
catheterization lab. Your heart is strong despite the trauma.
You underwent a cooling protocol to help you recover from the
accident and you were on a ventilator for 12-days and required
intubation for some time. You were treated for a pneumonia with
antibiotics. You pancreas was injured in the accident but this
has recovered well. You also have some broken right-sided ribs.
You will go to a rehabilitation facility to increase your
strength.
.
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:
START: Metoprolol 150 mg XL by mouth daily
START: Aspirin 81 mg by mouth daily
START: Acetaminophen 1000 mg PO three times daily as needed for
pain
START: Albuterol-Ipratropium 1-2 puffs every 4 hours as needed
for wheezing or shortness of breath
START: Docusate sodium 100 mg by mouth twice daily to prevent
constipation
START: Gabapentin 300 mg by mouth three times daily
START: Plavix 75 mg by mouth daily
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Atenolol
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2129-12-7**] at 1:20 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
.
** Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Behavioral Neurology ([**Telephone/Fax (1) 1690**])
would like to follow up with you regarding your recent inpt
stay. Please call once you have left rehabilitation if you have
concerns about your thinking or memory. **
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
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"401.9",
"482.41",
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"410.01",
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"577.0",
"427.5",
"427.41",
"V70.7",
"807.09",
"276.2",
"518.4",
"482.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"37.22",
"88.53",
"96.6",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
24378, 24450
|
12079, 23138
|
336, 468
|
24707, 24754
|
4227, 12056
|
27583, 28333
|
3048, 3229
|
23363, 24355
|
24471, 24647
|
23164, 23340
|
24924, 27560
|
3244, 4208
|
24668, 24686
|
2563, 2639
|
1868, 2455
|
266, 298
|
496, 1849
|
24769, 24868
|
2670, 2754
|
2477, 2543
|
2786, 3016
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
824
| 177,990
|
23412
|
Discharge summary
|
report
|
Admission Date: [**2121-2-20**] Discharge Date: [**2121-3-13**]
Date of Birth: [**2050-1-9**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 18252**] is a 71-year-old male
patient with known 3-vessel disease diagnosed in [**2120-2-4**] by cardiac catheterization. At that time, he was
referred to Dr. [**First Name (STitle) **] [**Name (STitle) **] for evaluation for CABG.
Surgery was deferred secondary to a climbing creatinine with
a maximum of 5.0 and need for temporary dialysis. Mr. [**Known lastname 18252**]
has since been seen in our office with hopes for a decreased
creatinine and optimized hemodynamics prior to coronary
artery bypass grafting and mitral valve replacement/repair.
He presented to an outside hospital with anemia. He was
transfused with 1 unit of packed red blood cells with flash
pulmonary edema and intubation. He was thus transferred to
the [**Hospital1 69**] for ongoing
management. His creatinine was below baseline on admission
at 1.6, and we were asked to consider surgery at that time.
Mr. [**Known lastname 18252**] reports dyspnea on exertion, orthopnea, shortness
of breath, and weakness.
PAST MEDICAL HISTORY: Type 1 diabetes (diagnosed at the age
of 24), chronic renal insufficiency (baseline creatinine of
1.9), glaucoma (legally blind), coronary artery disease
(myocardial infarction in [**2119**]), congestive heart failure,
peripheral vascular disease, anemia, hypertension, benign
prostatic hypertrophy, hard of hearing, and degenerative
joint disease.
ALLERGIES: Question allergy to ACE INHIBITOR'S.
MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. once daily,
multivitamin, Lipitor 80 mg p.o. once daily, Protonix 40 mg
p.o. once daily, Lopressor 50 mg p.o. three times per day,
Imdur 40 mg p.o. three times per day, amlodipine 5 mg once
daily, trazodone 50 mg p.o. once daily, hydralazine 50 mg
p.o. three times per day, Timolol 0.5 percent 1 drop at
bedtime, Bimatoprost 0.03 percent 1 drop both eyes at
bedtime, and insulin.
PHYSICAL EXAMINATION ON PRESENTATION: Height of 5 feet 0
inches, weight of 69.9 kilograms. Vital signs revealed
temperature was 96.0, the heart rate was 63 (in sinus
rhythm), the blood pressure was 94/31, the respiratory rate
was 16, and 100 percent intubated. In general, flat in bed.
Intubated, sedated, and in no acute distress.
Neurologically, responded to painful stimuli. He moved all
extremities. Respiratory examination revealed fine rales at
bilateral bases. Cardiovascular examination revealed a
regular rate and rhythm. S1 and S2. A positive 2/6 systolic
ejection murmur. Gastrointestinal examination revealed soft,
round, nontender, and nondistended. Positive bowel sounds.
The extremities were warm and dry. Positive red scaly shins
without any open areas.
LABORATORY DATA ON PRESENTATION: White blood cell count was
8.9, the hematocrit was 30.9, and platelets were 230. PT was
13.9, PTT was 28.8, and INR was 1.2. Sodium was 142,
potassium was 3.8, chloride was 109, bicarbonate was 25, BUN
was 38, creatinine was 1.6, and glucose was 245. Urinalysis
was negative. Typed and crossed - O positive.
RADIOLOGIC STUDIES: A chest x-ray revealed congestive heart
failure with bilateral effusions.
SUMMARY OF HOSPITAL COURSE: As stated in the History of
Present Illness, Mr. [**Known lastname 18252**] was admitted on [**2121-2-20**]
from an outside facility with flash pulmonary edema, status
post red blood cell transfusion.
On [**2-21**] - on hospital day two - he was successfully
weaned and extubated. He continued in the Intensive Care
Unit that day. His cardiac surgery workup was continued.
The patient suspected of having a right lower lobe pneumonia,
for which he was on azithromycin with sputum culture pending.
His anemia was worked up showing low iron stores and low TIBC
which supported anemia of chronic disease diagnosis, and was
transfused as needed for that with a Hematology consult
deferred. He remained in the Intensive Care Unit for
hemodynamic management.
On hospital day four, he was transferred to the inpatient
floor for continued management. A preoperative
echocardiogram documented no mitral regurgitation; whereas a
past echocardiogram in [**2120-12-4**] had shown 2 plus
mitral regurgitation and transesophageal echocardiogram was
performed in the Operating Room to thoroughly evaluate this.
Mr. [**Known lastname 18252**] [**Last Name (Titles) 20354**] to the Operating Room on [**2121-2-26**] with Dr. [**First Name (STitle) **] [**Name (STitle) **] and underwent coronary artery
bypass grafting times three with a LIMA to the LAD, a
saphenous vein graft to the OM, and a saphenous vein graft to
the RCA. He also had a mitral valve repair with a 28-mm
ring. Please see the Operative Report for further details.
He was unable to wean on his operative evening, and on
postoperative day one was successfully weaned and extubated.
His IV drip medications were also discontinued as tolerated,
and he was started on Natrecor as well as Lasix for diuresis.
On postoperative day three, his milrinone was restarted. As
well, he was transfused with 1 unit of packed red blood cells
for a hematocrit of 27. On postoperative day three, he
remained hemodynamically stable on milrinone and Natrecor;
increased to maintain his blood pressure for renal perfusion.
The Lasix drip was also continued to maintain urine output.
On postoperative day four, the same medications were
continued. As well, he was transfused with 1 more unit of
packed red blood cells. On postoperative day four, a Renal
consultation was also obtained for a rise in creatinine of up
to 2.3 with recommendations for diuretics as needed, but no
aggressive diuresis. On postoperative day four, he also had
sustained bursts of rapid atrial fibrillation which was
treated with intravenous amiodarone.
On postoperative day six, he was started on Coumadin for
anticoagulation secondary to the atrial fibrillation with a
subsequent jump in his INR to 2.2 the following day. His
creatinine also dropped down to 2.0 with ongoing evaluation
by the Renal staff.
Over the next several days his intravenous drip medications
were discontinued. As well, his Coumadin was held for an
elevated INR, and his creatinine remained stable at 2.0. He
was transferred to the inpatient floor on postoperative day
10 for ongoing recovery and rehabilitation. He was also
restarted on his Coumadin on postoperative day 11 at only 1
mg with close monitoring of his INR. A pericardial friction
rub was noted on postoperative day 12; for which he was
started on ibuprofen 800 mg p.o. q.8h.
On postoperative day 13, a recheck of his creatinine showed a
creatinine of 1.6; which was significantly improved. He was
reevaluated by Physical Therapy, and it was decided that he
needed some additional physical therapy prior to being safe
for discharge home, with dropping of his oxygen saturation to
74 on room air with ambulation.
On postoperative days 14 and 15, he continued on his oral
Coumadin and was seen by Physical Therapy with some
improvement in ambulation, but still requiring oxygen with
ambulation with a decrease oxygen saturation on room air to
84 percent. On postoperative day 15, it was decided that he
would be better served to be discharged home than to
rehabilitation with agreement by the patient and his wife.
[**Name (NI) **] was thus discharged home with followup by visiting nurses.
CONDITION ON DISCHARGE: Stable. Vital signs revealed
temperature was 98.0, the pulse was 68 (in sinus rhythm), the
blood pressure was 112/50, the respiratory rate was 18,
weight was 76.7 kilograms (with a preoperative weight of
72.7), and his oxygen saturation was 97 percent on room air.
PT was 14.8 with an INR of 1.4. On physical examination,
neurologically he was alert and oriented; nonfocal.
Pulmonary examination revealed the lungs were clear
bilaterally. Cardiac examination revealed a regular rate and
rhythm. The sternal incision without drainage or erythema.
The sternum was stable. The abdomen was soft, nontender, and
nondistended with positive bowel sounds. The extremities
were warm with 2 plus edema. Right and left leg incisions
were clean and dry.
DISCHARGE STATUS: To home with visiting nurses to follow.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass grafting.
3. Mitral regurgitation.
4. Status post mitral valve repair.
5. Type 1 diabetes.
6. Chronic renal insufficiency.
7. Peripheral vascular disease.
8. Anemia.
9. Hypertension.
10. Benign prostatic hypertrophy.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg p.o. once daily.
2. Lipitor 40 mg p.o. once daily.
3. Colace 100 mg p.o. twice daily.
4. Percocet 5/325 one to two tablets by mouth q.6h. as needed
(for pain).
5. Trazodone 50 mg p.o. at bedtime.
6. Methazolamide 50 mg p.o. twice daily.
7. Coumadin 2 mg tonight ([**2121-3-13**]); to be dosed daily
per INR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**].
8. Norvasc 5 mg p.o. once daily.
9. Lasix 20 mg p.o. twice daily.
10. Potassium chloride 20 mEq p.o. twice daily.
11. Brimonidine tartrate 0.15 percent drops 1 drop
ophthalmic twice daily.
12. Timolol 0.5 percent drops 1 drop bilateral eyes at
bedtime.
13. Bimatoprost 0.03 percent drops 1 drop both eyes
daily.
DISCHARGE FOLLOWUP:
1. Call to schedule an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **]
within four weeks.
2. Call to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**]
within two to four weeks.
3. Call to schedule an appointment with Dr. [**Last Name (STitle) 284**] within
four weeks.
4. Visiting nurses daily to draw INR and call results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] (telephone number [**Telephone/Fax (1) 36012**]).
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2121-3-13**] 16:27:49
T: [**2121-3-13**] 17:37:17
Job#: [**Job Number 60055**]
|
[
"486",
"414.01",
"424.0",
"458.29",
"365.9",
"496",
"583.81",
"401.9",
"250.41",
"584.5",
"285.29",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"35.33",
"00.13",
"99.04",
"36.15",
"39.61",
"89.60",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8302, 8592
|
8618, 9369
|
1630, 3255
|
3284, 7446
|
9389, 10163
|
164, 1180
|
1203, 1603
|
7471, 8281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,785
| 178,615
|
14750
|
Discharge summary
|
report
|
Admission Date: [**2179-8-9**] Discharge Date: [**2179-8-17**]
Date of Birth: [**2113-1-23**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Weakness.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43400**] is a pleasant
66-year-old male with a history of NIDDM and PVD who
complains of recent weakness with any exertion and back pain
radiating to his neck. An echo performed at an outside
hospital revealed aortic stenosis with a 56 mm peak gradient.
He is subsequently transferred to [**Hospital1 190**] for cardiac catheterization which showed
severe left main and LAD disease. The catheterization also
confirmed aortic stenosis. Mr. [**Known lastname 43400**] was subsequently
evaluated for cardiac surgery.
PAST MEDICAL HISTORY: NIDDM, PVD, left leg vascular bypass,
hypertension, hyperlipidemia, anemia.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 325 mg q d, Diovan 80 mg q d.
REVIEW OF SYSTEMS: Mr. [**Known lastname 43400**] has had several episodes of
confusion. He has had no headache or vision changes. No
shortness of breath, cough or wheezes. He has had no melena,
urinary retention, no arthralgias or myalgias. He has had
fatigue with activity.
PHYSICAL EXAMINATION: Vital signs, blood pressure 130/70,
heart rate 70, normal sinus rhythm. Head is normocephalic,
atraumatic. Neck is supple with no bruits. His lungs are
clear to auscultation bilaterally. Heart is regular rate and
rhythm with normal S1 and S2. He does have a 3/6 systolic
ejection murmur. His abdomen was soft, nontender, non
distended with normoactive bowel sounds. His extremities are
without clubbing, cyanosis or edema.
HOSPITAL COURSE: Mr. [**Known lastname 43400**] was taken to the operating room
on [**2179-8-11**] for CABG times two and AVR. CABG graft included
LIMA to LAD, SVG to OM. Aortic valve replacement with a #23
CE pericardial valve. The operation was performed without
complication and Mr. [**Known lastname 43400**] was subsequently transferred to
the Surgical Intensive Care Unit. On postoperative day #1
Mr. [**Known lastname 43400**] was followed for a falling hematocrit. It
eventually reached 18 and he was transfused two units of
packed red blood cells. Otherwise he did well and his
hematocrit stabilized. Mr. [**Known lastname 43400**] was extubated and weaned
off drips and adequately fluid resuscitated. By
postoperative day #4 Mr. [**Known lastname 43400**] was felt to be
hemodynamically stable for transfer to the floor. Mr.
[**Known lastname 43400**] had an uneventful stay on the floor. He recovered
well with good ambulation and oral intake. His pain was
controlled with oral medications. By postoperative day #6
Mr. [**Known lastname 43400**] was felt to be stable for discharge home. He
will receive visiting nurse to follow his recovery. Physical
exam at discharge, vital signs with temperature 98.2, pulse
75, blood pressure 106/60, respirations 18, O2 saturation 92%
on room air. Heart was regular rate and rhythm. Lungs were
clear to auscultation bilaterally. His incision was clean,
dry and intact. Abdomen was nontender, non distended with
normoactive bowel sounds. Extremities were remarkable for 1+
edema.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Docusate 100
mg [**Hospital1 **] while taking Percocet, KCL 20 mEq q d times 10 days,
Lasix 40 mg q d times 10 days, Metoprolol 25 mg po bid,
Percocet 1-2 tablets q 4-6 hours prn for pain, Lorazepam 0.5
mg q 4-6 hours prn for anxiety.
FOLLOW-UP: Mr. [**Known lastname 43400**] should follow-up with Dr. [**Last Name (STitle) 70**]
in 6 weeks. He should follow-up with his primary care
physician [**Last Name (NamePattern4) **] [**4-12**] weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Mr. [**Known lastname 43400**] is to be discharged home with
visiting nurse assistance.
DISCHARGE DIAGNOSIS:
1. Status post CABG and AVR.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor First Name 24423**]
MEDQUIST36
D: [**2179-8-20**] 10:43
T: [**2179-8-20**] 10:57
JOB#: [**Job Number 43401**]
|
[
"424.1",
"443.9",
"411.1",
"414.01",
"401.9",
"250.00",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"37.23",
"39.61",
"88.55",
"36.11",
"36.15",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
3253, 3725
|
3888, 4217
|
1697, 3229
|
1248, 1679
|
963, 1225
|
172, 183
|
212, 752
|
775, 943
|
3750, 3867
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,339
| 144,796
|
2223
|
Discharge summary
|
report
|
Admission Date: [**2181-11-25**] Discharge Date: [**2181-12-1**]
Date of Birth: Sex:
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient was an 83 year-old
woman resident at [**Hospital3 537**] was transferred to the [**Hospital1 1444**] Emergency Room for a large
amount of blood noticed in her diaper as well as clots in the
vaginal area. Vital signs at the nursing home are reportedly
abnormal with a systolic blood pressure in the 100s, pulse 62
and room air oxygen saturation of 87%. The nursing home
staff called the primary care physician and she was sent to
the Emergency Department for further evaluation.
The patient is nonverbal at baseline secondary to multiple
cerebrovascular accidents and she is also Portuguese
speaking. The family was involved in initial evaluation in
the Emergency Room and requested full workup. The nursing
home patient is totally dependent for activities of daily
living. The nursing home staff denied any other apparent
symptoms besides the vaginal bleeding. She appeared
comfortable in the Emergency Room, but was nonverbal and
noncommunicative.
PAST MEDICAL HISTORY:
1. Chronic atrial fibrillation.
2. Multiple cerebrovascular accidents leaving her nonverbal
at baseline and totally dependent with activities of daily
living.
3. Neurogenic bladder.
4. History of esophageal cancer status post resection in
[**2178**].
5. Status post D2.
6. Diabetes type 2.
MEDICATIONS ON ADMISSION: Coumadin 1.5 q.h.s., Bisacodyl
suppository prn, Metoprolol 25 b.i.d., Ranitidine 150 mg po
b.i.d., vitamin C, Reglan 10 t.i.d., Roxicet prn, Tylenol
prn, Jevity tube feeds 78 cc an hour. Novolin 43 units
b.i.d., Simethicone 30 per G tube q 6 hours and regular
insulin sliding scale.
PHYSICAL EXAMINATION: Temperature 96.7. Pulse 71. Blood
pressure 110/64. Respirations 24. Sating 98% on room air.
HEENT pupils 3 mm bilaterally. Cataracts, spontaneous eye
movements. No scleral icterus. Neck supple without
lymphadenopathy. Heart irregularly irregular with a 3 out of
6 systolic ejection murmur at the left upper sternal border.
Chest clear to auscultation, but poor effort and decreased
breath sounds. Abdomen protuberant, dull to percussion,
bowel sounds are present. Stools were negative in the
Emergency Department. Extremities with trace edema. On
lower extremities left hand was contractured. Neurological
unable to communicate with the patient to follow commands.
There is no noticable facial droop. Deep tendon reflexes
were 2+ throughout. Toes were downgoing. Gyn there was no
active bleeding visualized at the vagina on internal
examination in the Emergency Department, however, there was
pooled blood in the vaginal vault.
LABORATORIES ON ADMISSION: White blood cell count 10.4,
hematocrit 35, platelets 303, INR 1.9. Chem 7 normal except
for glucose of 273. Electrocardiogram showed atrial
fibrillation with a left axis deviation. No change from
prior. Pelvic ultrasound showed a uterus 4.8 by 4.3 by 3 cm
with thickened endometrial strip of 8 mm. There is a
hyperechoic fossae in the uterus consistent with blood.
Bladder ultrasound revealed a round mass in the bladder,
question clot versus mass versus stone.
HOSPITAL COURSE: The patient was admitted to the Medical
Service for further workup of her vaginal bleeding.
Initially her hematocrit remained stable, however, she
continued to have hematuria and vaginal bleeding, continuous
bladder irrigation was begun on [**11-26**] secondary to clots.
She had a cystogram that day, which showed no vesicouterine
fistula. She also underwent cystoscopy on [**11-28**], which
showed a bladder mass, however, a biopsy was not done. Gyn
was also involved and had planned an endometrial biopsy. On
hospital day number two the patient developed increasing
abdominal distention and her tube feeds were held. KUB
showed constipation, but no evidence of obstruction.
On [**11-28**] at approximately 12:00 p.m. the patient went into
rapid atrial fibrillation in the 140s and her respiratory
rate increased into the 50s with a slight drop in her O2
saturation. No peripheral access was available and a left
femoral vein triple lumen catheter was placed. The planned
bladder and endometrial biopsy were postponed. At 3:00 that
day the patient's status remained tenuous. She did not
respond to fluid boluses and her heart rate. Arterial blood
gas was 7.36, 25 and 73 with a lactate of 7.6. Her INR had
also increased to 3.3. A CT scan was able, however, the
patient did not tolerate the gastrogram. The patient was
transferred to the MICU team later that afternoon.
Once in the MICU the patient was intubated for tachycardia,
hypotension and tachypnea and her abnormal arterial blood
gas. Workup in the Intensive Care Unit included a CT scan of
the abdomen, which was consistent with ischemic bowel disease
in the small bowel and right colon.
The MICU team had extensive discussions with the family about
the patient's prognosis given her multiple problems including
esophageal cancer, possible bladder cancer, ischemic bowel
disease and history of stroke as well as her rising INR
despite vitamin K. The patient required pressor support
while in the Intensive Care Unit. By [**11-29**] her INR had
increased to 5.8 and hematuria and vaginal bleeding
continued. Her blood cultures subsequently were positive for
gram positive coxae and gram negative rods. She was started
on Gentamycin, Flagyl and Ampicillin.
On [**11-30**] after prolonged discussions with the family and the
MICU team the family opted to withdraw care given grim
prognosis. The patient was extubated at 1750 on [**11-30**] and
pressor support and antibiotics were discontinued. The
patient expired peacefully on [**12-1**] at 9:30 a.m. and the
family was notified.
FINAL DIAGNOSES:
1. Ischemic bowel.
2. Sepsis.
3. Rapid atrial fibrillation.
4. Esophageal cancer.
5. Hematuria.
6. Abnormal uterine bleeding.
7. Coagulopathy.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (NamePattern1) 11820**]
MEDQUIST36
D: [**2183-1-30**] 10:22
T: [**2183-1-30**] 10:43
JOB#: [**Job Number 11821**]
|
[
"250.00",
"188.8",
"599.7",
"427.31",
"458.2",
"564.00",
"276.2",
"557.0",
"596.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"38.91",
"57.32"
] |
icd9pcs
|
[
[
[]
]
] |
1469, 1754
|
3237, 5801
|
5818, 6244
|
1777, 2735
|
156, 1123
|
2750, 3219
|
1145, 1442
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,996
| 141,405
|
34587
|
Discharge summary
|
report
|
Admission Date: [**2107-9-1**] Discharge Date: [**2107-9-7**]
Date of Birth: [**2041-5-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Chest pain and dyspnea secondary to pericardial Effusion
Major Surgical or Invasive Procedure:
Pericardiocentesis and thoracocentesis
History of Present Illness:
Patient is a 66 yo male, with a history of coronary artery
disease, who presented to [**Location (un) **] with chest pain and dyspnea.
Two weeks ago, patient developed severe right sided pain. He
presented to an OSH and was told that he had fluid in his lungs.
He was given 20 mg of Vicodin for the pain and 200 mg Celebrex
daily. Patient continued to have increasing chest pain over the
past two weeks.
The morning of admission, he awoke with 10/10 mid-sternal
chest pain and dyspnea. Patient went to [**Hospital3 **] where
he was tachycardic to 130 on arrival and had a positive pulsus
on exam. He had a CT scan which was negative for dissection but
showed a pericardial effusion and small left pleural effusion.
An ECHO was then performed, which showed a moderate to large
pericardial effusion, with sigs of tamponade and RV collapse.
Patient was given 4 L of NS, and his SBP remained in the 90s.
Patient was transferred to [**Hospital1 18**] for pericardiocentesis, where
he was found to have sinus tachycardia to 133, BP 118/76, 100%
on 2L and afebrile. Patient became hypotensive to SBP 80s, which
responded to IVFs. Patient had pericardiocentesis, which showed
an initial pericardial pressure of 24 mm Hg. 260 cc of
straw-colored fluid was drained and a drain was placed. Patient
was then admitted to CCU for further workup and evaluation.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies headaches, dysphagia, diarrhea, constipation. All of
the other review of systems were negative.
Past Medical History:
CAD: LM 50-60%, and t.o RCA from cath [**3-19**], [**Hospital6 **]
IDDM
HTN
Carotid stenosis: 70% stenosis on right, 50-69% stenosis on left
Hyperlipidemia
S/P Parotid gland surgery for sialolithiasis
S/P Multiple foot surgeries
Social History:
Patient lives with his wife in [**Name (NI) **], MA. Patient has a 50
pack-year smoking history. Patient drinks EtOH occasionally.
He works as a security officer.
Family History:
[**Name (NI) **] father died secondary to complications from diabetes.
[**Name (NI) **] brother had a recent angioplasty.
Physical Exam:
PHYSICAL EXAM ON ARRIVAL:
VS: T 97.0, BP 129/76, HR 96 , RR 21 , O2 97% on RA
Gen: Middle aged man in NAD. Well-nourished and pleasant. Poor
historian
HEENT: PERRL, EOMI, oropharynx clear, moist, and without
exudates. Neck: Supple, no LAD, no appreciable JVD
CV: RR, normal S1, S2. ?Friction rub. No S4, no S3.
Chest: Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi.
Abd: +BS, soft, NTND, No HSM or tenderness.
Ext: No cyanosis or edema. 2+ DP pulses.
Skin: No rashes, stasis dermatitis
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS:
[**2107-9-1**] 06:33PM GLUCOSE-310* UREA N-30* CREAT-1.2 SODIUM-134
POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-17* ANION GAP-18
[**2107-9-1**] 06:33PM estGFR-Using this
[**2107-9-1**] 06:33PM CALCIUM-7.3* PHOSPHATE-3.7 MAGNESIUM-1.5*
[**2107-9-1**] 06:33PM WBC-13.5* RBC-3.88* HGB-11.7* HCT-36.3*
MCV-94 MCH-30.2 MCHC-32.3 RDW-12.8
[**2107-9-1**] 06:33PM NEUTS-90.1* LYMPHS-6.8* MONOS-2.6 EOS-0.4
BASOS-0.1
[**2107-9-1**] 06:33PM PLT COUNT-365
[**2107-9-1**] 06:33PM PT-19.5* PTT-35.1* INR(PT)-1.8*
.
Pericardial fluid:
TotProt: 5.3
Glucose: 258
LD(LDH): 1310
Amylase: 12
Albumin: 3.1
WBC: [**Numeric Identifier 79389**]
RBC: 450
Polys: 87
Bands: 3
Lymphs: 0
Monos: 10
Micro: Fluid Culture in Bottles (Preliminary): NO GROWTH
GRAM STAIN (Final [**2107-9-1**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2107-9-3**]):
NO GROWTH.
A swab is not the optimal specimen collection to evaluate
body
fluids.
.
Pleural fluid:
[**2107-9-3**] 01:08PM PLEURAL WBC-[**Numeric Identifier **]* RBC-278* Polys-84* Lymphs-2*
Monos-13* Meso-1*
[**2107-9-3**] 01:08PM PLEURAL TotProt-3.6 Glucose-134 LD(LDH)-455
Amylase-11 Albumin-2.1
GRAM STAIN (Final [**2107-9-3**]):
4+ (>10 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 (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
.
OTHER PERTINENT LABS DURING ADMISSION:
[**2107-9-2**] 03:46AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 dsDNA-POSITIVE
[**2107-9-4**] 05:34AM BLOOD ESR-92*
[**2107-9-4**] 05:34AM BLOOD PSA-1.0
[**2107-9-2**] 03:46AM BLOOD TSH-3.3
[**2107-9-4**] 05:34AM BLOOD calTIBC-255* Ferritn-GREATER TH TRF-196*
[**2107-9-5**] 07:10AM BLOOD Hapto-505*
[**2107-9-4**] 02:24PM BLOOD LYME BY WESTERN BLOT-PND
[**2107-9-4**] 07:36PM BLOOD HIV Ab-NEGATIVE
[**2107-9-4**] 05:34AM BLOOD PEP-Negative
.
DISCHARGE LABS:
[**2107-9-6**] 06:33PM WBC-8.8* RBC-3.23* HGB-10.3* HCT-28.6* MCV-89
MCH-31.8 MCHC-35.9 RDW-13.1 364 INR 1.2 PT 14.2* PTT 22.5
[**2107-9-6**] 06:33PM GLUCOSE-121* UREA N-13* CREAT-0.8 SODIUM-141
POTASSIUM-4.6* CHLORIDE-107 TOTAL CO2-20* ANION GAP-19
.
EKG demonstrated NSR with a rate of 96. Prolonged QRS, c/w
RBBB. No Q waves, and no ST changes or T wave inversions.
.
2D-ECHOCARDIOGRAM performed on [**2107-9-1**] (s/p drainage)
demonstrated: Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There is no pericardial effusion. IMPRESSION:
No pericardial effusion. Normal biventricular systolic function.
.
CXR ([**9-1**]): Retrocardiac opacity, likely due to atelectasis.
Left costophrenic angle excluded from the field of view,
otherwise no effusion. Catheter projecting over the left
inferior cardiomediastinal region of unclear etiology, correlate
clinically. ([**First Name8 (NamePattern2) 30217**] [**Doctor Last Name **])
.
CARDIAC CATH performed on [**2107-9-1**] demonstrated:
1. Initial pericardial pressure was approximately 24 mm Hg.
2. Successful pericardiocentesis with drainage of approximately
260 mm of straw colored fluid - sent to lab for analysis.
3. Final pericardial pressure was negative.
Cath Dx:
1. Tamponade
2. Successful pericardiocentesis.
Brief Hospital Course:
Patient is a 66 yo man with a h/o CAD, DM, and HTN, who presents
with pericardial and pleural effusions of unknown etiology.
.
1) Pericardial/pleural effusion: Patient presented with
pleuritic mid-sternal chest pain, complaining of C/P x 3 weeks.
Chest CT demonstrated pericardial effusion. Patient had an TTE
at [**Location (un) **] and was then transferred to [**Hospital1 18**], where he had a
pericardiocentesis. Approximately 260 cc of straw-colored fluid
was removed from the pericardium, and pressures indicated
tamponade physiology. Patient was found to have a large pleural
effusion, which was tapped on [**9-5**] and found to be an exudate.
Fluids were sent for cytology, gram stain, and cultures.
Cytology and cultures were negative. Patient was found to be
[**Doctor First Name **]+ and dsDNA +. He was seen by Rheumatology, who felt that
this was unlikely to be Lupus or other autoimmune serositis.
Patient's Lyme serology was also found to be equivocal and was
sent to the [**Hospital3 14659**] for further validation with Lyme Western
Blot testing. Antibiotic therapy was withheld until a
confirmatory diagnosis of Lyme could be made. A PPD was placed
and was read as negative on the day of discharge.
.
2) CAD/HTN: Patient has a h/o CAD. Recent cath showed Left Main
50-60% occluded and total occlusion of RCA. No active issues in
hospital. Patient was continued on Lipitor, Trandolapril, ASA
325, and Metoprolol XL 25 mg PO daily. Cardiology follow-up
appointment was made with Dr. [**Last Name (STitle) 73420**] in [**Location (un) **] on [**9-21**].
.
3) Diabetes: Patient discharged on his outpatient medications.
.
Medications on Admission:
Lipitor 20 mg daily
ASA 325 mg daily
Metformin 100 mg in the am and 1500 mg qhs
Celbrex 200 mg daily
Glipizide 10 mg [**Hospital1 **]
Trandalapril 1mg daily
Levaquin
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed.
Disp:*10 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
8. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Trandolapril 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 25 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*
11. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
12. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 6 weeks.
Disp:*42 patch* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial and pleural effusions
Discharge Condition:
Pending further evaluation
Discharge Instructions:
Follow-up as indicated below. Return to hospital if symptoms of
chest pain or shortness of breath return.
Followup Instructions:
Follow-up booked with
1) PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Sahay on [**2107-9-14**] at 11:45. [**Telephone/Fax (1) 79390**]. To
follow-up pending lab data, including Lyme PCR from [**Hospital1 **] Clinc
send-out.
2) Cardiol: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 73420**] in [**Location (un) **] on [**2107-9-21**] at 10:00.
[**Telephone/Fax (1) 79391**].
3) Outpatient [**Hospital 2225**] clinic [**Hospital1 18**] - TBA.
Completed by:[**2107-9-7**]
|
[
"433.10",
"433.30",
"423.3",
"414.01",
"272.4",
"423.9",
"401.9",
"511.8",
"250.00",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
10224, 10230
|
6950, 8594
|
368, 408
|
10307, 10335
|
3379, 3379
|
10489, 10992
|
2616, 2740
|
8810, 10201
|
10251, 10286
|
8620, 8787
|
10359, 10466
|
5555, 6927
|
2755, 3360
|
272, 330
|
438, 2165
|
3395, 4891
|
4973, 5539
|
2187, 2418
|
2434, 2600
|
4923, 4937
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,025
| 170,481
|
622
|
Discharge summary
|
report
|
Admission Date: [**2122-12-25**] Discharge Date: [**2122-12-29**]
Date of Birth: [**2067-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Headache, malaise, nausea, disorientation
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
This is a 55 year old gentleman with chronic hypocapnia, central
sleep apnea, episodic hyperventilati, onorthostatic hypotension,
and autonomic dysfunction who is suspected to have a syndrome
related either to mitochondrial disease, channelopathy, or an
uncharacterized metabolic pathway disturbance. He presented to
the ED after a particularly severe episode of his chronic
hypocapnia. These episodes have been going on for eleven years
and have been characterized by nausea, headache, malaise and
lightheadedness. Particularly bad episodes will lead to frank
disorientation, as this one did. The patient monitors his
end-tidal CO2 at home and his urinary pH. He reports that,
when his end-tidal CO2 is low or his pH is not sufficiently
alkalemic, he tends to get these episodes.
The only treatment that seems to have helped his symptoms
consistently is bicarbonate replacement.
On consultation with his sleep physician, [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) **], it
was decided that, given his uncharacterized syndrome, he would
be admitted to the MICU for intensive monitoring of his blood
gas and chemistries to further define the biochemical nature of
his syndrome. This originally was to have occurred next week.
He, however, had another episode of his hypocapneic syndrome
yesterday while vacationing in [**State 108**]. He was disoriented for
two hours. Home test of end-tidal CO2 during a hyperventilation
episode was in the 20's. His wife [**Name (NI) 653**] Dr. [**First Name (STitle) **] 6 hours
prior to admission and it was decided he should fly back to
[**Location (un) 86**] and present to the ED for admission to the MICU.
In the ED, initial vital signs T 99.7 P 94 BP 111/67 O2 97 on
2L. He was nauseated but no longer disoriented. He had taken
bicarbonate last about 8 hours previously. A VBG revealed
7.41/25/147/16. Bicarb was on chemistries which were otherwise
unremarkable He received zofran for nausea as well as one liter
IVF.
On presentation to MICU the patient reports his still feels his
usual symptoms of nausea, headache and lightheadedness. He
denies fevers or sick contacts. [**Name (NI) **] traveled to [**State 108**] last
week and does report his symptoms worsen with altitude or with
air travel.
Past Medical History:
1) Central sleep apnea
2) Coronary artery disease, single vessel disease on [**2116**]
catheterization: two bare metal stents to the OM2 vessel,
3) Hypertension, on antihypertensive medications x 6yrs
4) hyperlipidemia
5) Orthostasis, postural hypotension
6) Gout
7) Hypogonadotropic hypogonadism
8) Empty sella, nl pituitary function
9) Chronic kidney disease, stage III, baseline cr 1.1-1.3
10) Rapid cycling mood disorder
Social History:
He is married, with two children. There is no history of
tobacco, alcohol, or illicit drug use. He is a venture
capitalist and engineer.
Family History:
Mother died at age 72 with a neuromuscular disorder, dystonia,
and respiratory failure. She also suffered from hypertension
and obstructive sleep apnea.
His father died at age 64 from stomach cancer, but had also been
diagnosed with stage I renal cell carcinoma and had a CVA at age
59. Multiple family members with neurologic difficulties.
Physical Exam:
T 99.1; P 91; BP 125/70; RR 14; O2 95 on RA;
Gen: WD/WN male Caucasian in NAD, pleasant
Head: NCAT
Eyes: PERRL, EOMI, no scleral icterus
Mouth: Slightly dry MM
Neck: Supple, no bruits, no LND, no lymphadenopathy or
thyromegaly
Chest: CTA bilaterally
Cor: RR, nl S1S2, sinus rhythm on telemetry
Abd: Flat, NT
Ext: No edema, nl distal pulses.
Neurol: CN 2,3,4,5,6,7,9,10,11,12 grossly intact.
Normal strength and sensation in upper and lower extremities.
No nystagmus, dysdiachokinesis. Nl tracking
Reflexes somewhat sluggish (brachioradialis, biceps, patellar)
No pronator drift, tremor or asterixis.
Skin: No rash
Pertinent Results:
[**2122-12-25**] 10:00PM BLOOD
WBC-12.0* RBC-5.40 Hgb-16.0 Hct-44.7 MCV-83 MCH-29.6 MCHC-35.8*
RDW-13.4 Plt Ct-314
[**2122-12-28**] 05:18AM BLOOD
WBC-7.7 RBC-4.86 Hgb-14.8 Hct-41.3 MCV-85 MCH-30.4 MCHC-35.9*
RDW-14.0 Plt Ct-321
[**2122-12-25**] 10:00PM BLOOD
Glucose-128* UreaN-30* Creat-1.1 Na-140 K-3.7 Cl-109* HCO3-20*
AnGap-15
[**2122-12-28**] 07:30PM BLOOD
Glucose-116* UreaN-19 Creat-1.2 Na-140 K-3.8 Cl-111* HCO3-18*
AnGap-15
[**2122-12-25**] 10:00PM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9
[**2122-12-28**] 07:30PM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
[**2122-12-26**] 12:17AM BLOOD Ammonia-50*
[**2122-12-27**] 01:45AM BLOOD Ammonia-38
[**2122-12-26**] 03:27AM BLOOD
Type-ART Temp-37.3 Rates-/20 FiO2-21 pO2-88 pCO2-29* pH-7.42
calTCO2-19*
[**2122-12-26**] 06:21PM BLOOD
Type-ART pO2-110* pCO2-23* pH-7.52* calTCO2-19* Base XS--1
[**2122-12-29**] 01:05AM BLOOD
Type-ART pO2-119* pCO2-28* pH-7.38 calTCO2-17* Base XS--6
[**2122-12-26**] 12:26PM BLOOD Lactate-1.9 Na-139 K-3.6 Cl-104
calHCO3-21
[**2122-12-26**] 03:27AM BLOOD freeCa-1.07*
[**2122-12-28**] 04:32PM BLOOD freeCa-1.16
Brief Hospital Course:
55-year-old gentleman with chronic hypocapnic syndrome, central
apnea of unclear etiology believed to have an undefined
metabolic, mitochondrial, or channel-related syndrome.
1) Hypocapnic syndrome, unknown etiology for past 11 years. No
interventions currently beyond bicarbonate therapy. Previously
seen by many specialists including endocrine and renal.
Initially admitted to gather data x 48 hours. While inpatient
ABGs, electrolytes and urine electrolytes were collected every 2
hours x 24 hours, then every 4 hours x 24 hours. The only
appreciable intervention in his respiratory alkalosis was
improvement after oxycodone administration for a severe
headache. We also sent serum metanephrines, urine metanephrines,
and 24 HOUR urine 5-HIAA which were pending upon discharge. LP
performed, pH reported as 7.7 with protein of 83, ammonia sent
out. His CSF pH is unexplained, and may be artifactual.
Following his LP, we attempted collection of ABGs while patient
was using his CO2-rebreather device. Mr. [**Known lastname 1250**], however, was
unable to tolerate the attempt. After discussion of an overall
plan for diagnosis, he was discharged with follow-up for further
evaluation, as well as prescriptions for oxycodone and
ondansetron given that these were the only medications that
provided symptomatic benefit and ABG improvement during his
inpatient stay.
2) Orthostasis, long standing. Not an active problem while
inpatient, no intervention pursued.
3) Concern for potassium wasting syndrome, very high urine K and
persistent hypokalemia. Potassium was monitored while inpatient
and was never below 3.5.
4) CAD, no symptoms of ischemia. Known history of CAD s/p PCI
to OM2. Was continued on propanol and vytorin while inpatient.
He probably needs to restart his ACE-I, but this was deferred to
outpatient management.
5) Tremor. Not an active inpatient issue. Was continued on
propranolol while inpatient.
6) Mood disorder. During inpatient stay he was intermittently
very anxious with pressured speech. Expressed great frustration
about the lack of answers concerning his acid-base
abnormalities. SW was consulted to help with patient coping
while in the hospital. He was also continued on Topamax and PRN
Ativan.
7) Hypogonadism. Continued on outpatient Androgel. As this is
a nonformulary medication, he took his own medication while
inpatient.
Medications on Admission:
1) Clonazepam 1.5 daily,
2) Vytorin combined ezetimibe 10 mg, simvastatin 20 mg daily,
3) Flonase 2 puffs once daily as need
4) Lisinopril 10 mg daily,
5) Magnesium citrate 300 mg every four hours
6) Potassium citrate 200 mg every four hours
7) Propranolol ten milligrams twice daily,
8) AndroGel 25 mg once daily
9) Topamax 50 four times a day
10) Lisinopril 10 mg daily
11) Sodium bicarbonate one teaspoon four times daily
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
4. Clonazepam 1 mg Tablet Sig: 1-1.5 mg PO QHS (once a day (at
bedtime)) as needed: Insomnia.
5. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
7. Testosterone 1 % (25 mg/2.5 g) Gel in Packet Sig: One (1)
patch Transdermal Daily ().
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea for 3
days.
Disp:*12 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
# Central sleep apnea
# Chronic hypocapnia
# Orthostatic hypotension
# To-be-defined metabolic, mitochondrial, or channel disorder
.
Secondary dignosis
# Coronary artery disease
# Hypertension
# Hyperlipidemia
# Gout
# Hypogonadotropic hypogonadism
# ?Chronic kidney disease
Discharge Condition:
Stable
Discharge Instructions:
You were hospitalized for closer laboratory monitoring because
of your central sleep apnea and chronic hypocapnia. We took
regular blood samples to assess your blood chemistries.
.
We have called for an appointment for you with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 838**], BIDHC - MCC [**Location (un) **], [**Location (un) 2790**], [**Location (un) **],
[**Numeric Identifier 4774**], Phone: [**Telephone/Fax (1) 4775**], Fax: [**Telephone/Fax (1) 4776**]. Please call
them to set up an appointment as they know you will be a patient
of Dr. [**Last Name (STitle) 838**].
.
We have also made an appointment for you with Dr. [**Known firstname **] [**Last Name (NamePattern1) **],
your sleep specialist, on Friday, [**2127-1-1**]:40 pm at
[**Hospital Ward Name 23**] [**Location (un) 858**].
.
We have given you Oxycodone for pain which you can take as
needed for three days, and have given you ondansetron for nausea
which you can take as needed for three days. Please refer to
your prescriptions for the details of how to take these
medications. Otherwise, we have not changed your medications.
.
If you feel nauseous, have a headache, or have any other
symptoms that are concerning to you, call your doctor
immediately and go to the emergency room.
Followup Instructions:
Provider: [**Known firstname 177**] [**Last Name (NamePattern1) **] MD, Phone:[**Telephone/Fax (1) 612**]. Date/Time:
[**2123-1-1**], 12:40 pm. [**Hospital Ward Name 23**] [**Location (un) 858**].
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, Phone:[**Telephone/Fax (1) 4775**]. Please call
to set up your appointment.
.
Provider: [**Known firstname 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2123-2-17**] 10:00
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 4777**] & [**Doctor First Name 4778**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2123-9-2**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"272.0",
"272.4",
"V45.82",
"277.87",
"585.3",
"296.90",
"786.09",
"403.90",
"253.4",
"333.1",
"274.9",
"414.01",
"327.21",
"458.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9180, 9186
|
5436, 7823
|
358, 376
|
9523, 9532
|
4325, 5413
|
10864, 11663
|
3325, 3669
|
8298, 9157
|
9207, 9502
|
7849, 8275
|
9556, 10841
|
3684, 4306
|
277, 320
|
404, 2705
|
2727, 3153
|
3169, 3309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,249
| 164,729
|
23130
|
Discharge summary
|
report
|
Admission Date: [**2198-1-9**] Discharge Date: [**2198-1-26**]
Date of Birth: [**2119-3-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
left thoracostomy (from OSH)
History of Present Illness:
78yoM s/p mechanical fall on ice, slipped backwards, fell 3-4ft
and hit head. Went to [**Location (un) **], found to have left pneumothorax,
right subdural and ?epidural, chest tube placed. Hemodynamically
stable and pt transferred to [**Hospital1 18**] for further management.
[**Hospital1 18**] ED COURSE: CXR CT in place small left apical PTX, Head CT
with small right frontal subdural hematoma and left parietal
extraaxial hemorrhage vs meningioma, Cspine CT sclerotic focus
C7body and C2spinous process with possible malignancy.
Intubated for hypercarbia, acidosis, and decreased mental
status.
Past Medical History:
chf, cerebral concussion, parkinsons, copd, cva, cad/chf/mi
(last [**1-19**]), Vtach, AICD, prostate ca, cri, depression,
pacer
Social History:
wife in nursing home
daughter involved, lives alone
Family History:
nc
Physical Exam:
AVSS
intubated, maew, tracks, alert to commands
L surgical pupil, R RRL
Chest with markedly decreased breath sounds, mild rhonchi at
bases
RRR, nl s1s2, no mrg
soft nt mildly distended bswnl
neuro fully sensation to touch upper/lower extremities, obeys
commands, moves all 4 purposely, strenth [**4-19**] grip B, elbow flex
B, hip flex B, plantars flex B, facial muscles symmetric
Pertinent Results:
[**2198-1-23**] Blood NGTD
[**2198-1-24**] Catheter tip NGTD
[**2198-1-19**] UCx NGTD
[**2198-1-19**] Sputum Cx: yeast
[**2198-1-18**] stool CDiff pos
[**2198-1-17**] stool Cdiff neg
[**2198-1-15**], BCX x 2 NGTD
[**2198-1-15**] sputum Coag + staph; Klebsiella pna, pan-sensitive;
[**2198-1-13**] UCx levo R enterococcus
[**2198-1-9**] MRSA screen neg x 2
[**2198-1-13**] BCX CoPS
.
CT head [**1-9**] 1am
IMPRESSION: Stable study as compared to the prior scan from
[**2198-1-9**], at 12:19 AM. Recommend repeat non-contrast
scan in one week to differentiate between a meningioma versus an
extra-axial hemorrhage within the left parietal region. These
findings were discussed with the trauma resident caring for the
patinet today at 11AM.
CXR [**1-9**]
Comparison is made to a prior radiograph from earlier the same
day. An endotracheal tube has been placed with its distal tip
below the thoracic inlet. A left-sided chest tube terminates at
the left lung apex. A pacemaking device overlies the left chest
with pacer leads in stable position overlying the region of the
right atrium and right ventricle. Subcutaneous gas tracks along
the left lateral chest wall. The lungs are clear with no
parenchymal consolidation, pleural effusion, or pneumothorax.
several left sided rib fractures are seen.
IMPRESSION:
Lines and tubes in satisfactory position. Subcutaneous gas is
seen along the left chest wall with no pneumothorax identified.
T/L SPINE [**1-9**]
T-SPINE, 2 VIEWS: There is evidence of a chest tube. There is
some motion artifact, but no definite fractures are visualized.
Median sternotomy wires, clips, and pacer electrodes are
present. These are technically limited.
LUMBAR SPINE, 2 VIEWS: No visualized fractures. Residual
contrast is seen within the bladder.
Cannot exclude an interfissural location of the chest tube.
CT Cspine [**1-9**] 10am
IMPRESSION: This study was limited due to patient motion, but
there is no evidence of displaced fracture or compression
fracture. Sclerotic focus within the C7 vertebral body and the
spinous process of C2 of unknown significance. This should be
correlated with any prior imaging as well as history of
malignancy. Know left apical pneumothorax is visualized.
CT Head [**1-9**]
IMPRESSION: Small areas of subdural and possibly right
parenchymal hemorrhage. Lobular hyperdensity in the left
parietal region which may be extra-axial blood or a meningioma.
Further evaluation is recommended. These findings were discussed
with the trauma surgery and neurosurgery residents.
CXR [**1-10**]
IMPRESSION:
Extubated, satisfactory follow-up examination, no evidence of
pneumothorax.
CXR [**1-12**] wheezing
IMPRESSION:
1) Focal parenchymal opacities adjacent to acute rib fractures,
most likely representing areas of focal pulmonary contusion. A
small amount of pleural fluid or extrapleural hematoma is also
likely in this region.
2) No evidence of pneumonia.
CT HEAD [**1-25**]:
CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There is no
expansion of the reported subdural hematoma and no mass effect
from the extra-axial space on the brain. The area of decreased
attenuation in the left posterior temporo- occipital region also
appears unchanged from the examination of one day prior,
consistent with an area of infarct. The lateral ventricles are
symmetric and nondilated, and unchanged in size and
configuration from the previous examination. There is no
interval change in mass effect or shift of normally midline
structures. The basilar cisterns are patent. The visualized
portions of the paranasal sinuses and mastoid air cells are
normally pneumatized. No fractures are identified within the
surrounding osseous structures.
Although there is no change since prior exams, there is better
visualization of the superior aspect of the head and a
dural-based mass at the left vertex is seen, roughly 1.4x2.4cm
in size, and likely a meningioma.
IMPRESSION: Stable CT appearance of the brain from the
examination of [**2198-1-24**]. Left posterior
temporo-occipital infarct appears unchanged, as does a small
right frontal subdural collection. No evidence of acute
intracranial hemorrhage.
.
Carotid U/S: less than 40% stenosis b/l
.
ECHO:
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and/or RV.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Aortic valve not well seen. No AR.
MITRAL VALVE: Mitral valve not well seen. Mild to moderate
([**12-17**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA
systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
Technically suboptimal study.
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size
and free wall motion are normal. The aortic valve is not well
seen. No aortic
regurgitation is seen. The mitral valve is not well seen. Mild
to moderate
([**12-17**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic
hypertension. There is no pericardial effusion.
If more definitive information regarding global and and regional
biventricular
systolic function is desired, a cardiac MRI ([**Telephone/Fax (1) 9559**]) or
radionuclide
study is suggested.
.
Brief Hospital Course:
Shortly after arrival to ICU pt was extubated without
complication. Repeat Head CT demonstrated no change in the
subdural hematoma of the right frontal area and no change in
meningioma/CVA of left pariental area, neurosurgery signed off
for followup as an outpatient 2wks after discharge. HD2, chest
tube removed with no complication aand shortly after the patient
was transferred to the floor, eating well, drinking well,
ambulating to bathroom, but continued to have agitation
requiring a 1:1 sitter.
.
Once on the floor pt c/o intermittent chest pain, EKG with
slight variation of V3, enzymes sent, and cardiology consulted.
Pt had a NSTEMI but as SDH was so acute, was not treated with
anticoagulation or cath. He remained chest pain free without
intervention throughout the hospital course. Neurology consult
for meningioma, parkinsons, and agitation- recs for zyprexa, no
change in parkinson's meds, and outpt fup of meningioma. During
this time pt was brought back to the MICU. Around this time pt
developed increasing shortness of breath and diffuse inspiratory
and expiratory wheezes with decreased air movement- CXR clear
without edema, effusion, or infiltrate- and he was started on Q2
nebs for likely COPD exacerbation. Throughout all these events
with NSTEMI, COPD Exacerbation, the patient remained
hemodynamically stable with a lucid mental status and normal
neurologic exam. Pt was transferred to the medicine service
with neurology, neurosurgery, trauma, and cardiology following.
.
In regards to the NSTEMI, cardiology recommends cardiac
catheterization once patient stabilized, on outpatient basis, in
6 months.
.
In regards to the SDH, by most recent CT [**2198-1-25**], this is
improving and the neurosurgery team cleared him so start Lovenox
treatment for his left axillary vein thrombus.
.
In regards to the CVA, echo was without clot and Carotid U/S
showed only 40% stenosis. He was not started on Plavix in the
hospital at first because on the acuity of the SDH, and later
because he was already on anticoagulation with Lovenox and ASA
and was at considerable fall risk.
.
While on the medical floor, he was found to have a left axillary
vein thrombus with right cephalic vein thrombus, after clearance
from neurosurgery he started treatment on Lovenox. The plan is
to continue the Lovenox until either one month from start which
was [**2198-1-25**] or until he leaves rehab if that occurs before one
month.
.
In regards to his ICD, this was tested by EP and found to have
suboptimal lead function but unchanged from the last outpatient
check by Dr. [**Last Name (STitle) **] in 6/[**2196**]. It is recommended that the patient
see Dr. [**Last Name (STitle) **] within one month to recheck device.
.
In regards to infectious disease, pt developed a staph aureus
and klebsiella pneumonia while on the ventillator, associated
with a staph aureus bacteremia. This was treated with Levaquin,
and he is currently on day 10 of a 14 day course scheduled to be
complete on [**2198-1-30**]. He also developed a c.diff diarrhea, which
is improving and is treated with metronidazole. The plan is to
continue this for two weeks after discontinution of the
Levaquin.
.
Pt also had sundowning at night and was started on Zyprexa
standing dose at night with good effect.
.
Finally, the patient had blood in the urine, with foley in,
which will require outpt work-up.
.
At discharge all urine and blood cultures were without growth,
CXR showed no sign of pneumonia or pulmonary edema, CT of head
on Lovenox had resolving SDH.
.
Patient needs outpatient follow-up with Neurosurgery and
Cardiology.
Medications on Admission:
tolvaptan 30'
torsemide 20'
toprol xl 25'
folate 1'
detrol 4'
wellburtrin 150'
vytorin 10/40'
sinemet 10/100 x 2qam, x1qnoon, x1qhs
protonix 40'
aspirin 81'
coumadin 1 qs
xanax 0.5'''
estazolam 1qhs
foradil inh
spiriva inh
advair 500/50''
Discharge Medications:
1. Carbidopa-Levodopa 10-100 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
2. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q1-2H () as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: last dose [**2198-1-30**].
9. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
[**12-17**] puff Inhalation DAILY (Daily).
11. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours) for 1 months: please use only
while pt in rehab, upon discharge please discontinue - reason is
that pt is a fall risk when independent.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 weeks: from [**2198-1-26**] - [**2198-2-2**].
14. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day. Tablet(s)
16. NPH Insulin
15 units qam and 15 units qpm
17. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
18. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks: from [**2198-2-3**] - [**2198-2-10**].
19. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks: from [**2198-2-11**] - [**2198-2-17**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Subdural hematoma
Cerebrovascular accident
Acute Myocardial Infarction
Dibetes Mellitus
Dementia
COPD
Parkinson's
Infectious diarrhea
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Call your primary care doctor if you develop chest pain,
shortness of breath, or other concerning symptoms.
Followup Instructions:
-Followup with the trauma service one week after discharge at
the trauma clinic at [**Telephone/Fax (1) 56358**], call for an appointment.
-Followup with neurosurgery 2weeks after discharge for
evaluation of your subdural hematoma (head injury), call ([**Telephone/Fax (1) 18865**]
.
Follow up with Dr. [**Last Name (STitle) **] within one week of leaving the
rehabilitation facility.
Follow up with Dr. [**Last Name (STitle) **], your cardiologist, within one month of
leaving the rehabilitation facility - he will need to check your
defibrillator and also will need to schedule you for further
tests to see if you need a cardiac stent.
Completed by:[**2198-1-26**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,556
| 148,982
|
1429
|
Discharge summary
|
report
|
Admission Date: [**2126-11-16**] Discharge Date: [**2126-11-25**]
Date of Birth: [**2064-4-22**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Codeine / Zocor / Crestor / Lescol / Fosamax /
Percocet / Advair Diskus / Azulfidine / Celexa / Cymbalta /
Augmentin / Pradaxa / Statins-Hmg-Coa Reductase Inhibitors /
Phenergan / Penicillins
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
hypoxia, persistent fever
Major Surgical or Invasive Procedure:
- mechanical ventilation
- bronchoscopy
History of Present Illness:
62 y/o F with PMH of CAD s/p multiple PCIs (at least 9 DESs
placed in 8 separate PCIs since [**2118**]), paroxysmal AFib (on
warfarin), hypertension, hyperlipidemia, history of
pericarditis, severe RA (on prednisone 5, leflunomide,
remicaide), GERD, pulmonary fibrosis (but FVC 76% of predicted
in [**2121**] with DLCO 65% of predicted), and other issues, admitted
to OSH on [**2126-11-12**]. Initially presented with flu-like symptoms
and a subjective fever for about one week. In the ED there, CXR
showed baseline interstitial pattern and possible right basilar
infiltrate. She was noted to have a'red hot' leg in the ED,
but no obvious joint effusion. In the ED, she spiked a fever to
102.8, persisting and never falling below 100.8 during her
hospitalization. WBC was 15.4 (no bands), ESR>120, CRP>18.
Creatinine was 1.3 on admission, down to 0.9 with fluids. Flu
was negative and blood, urine, C. diff cultures have been
negative to date.
She was given levofloxacin and vancomycin for pulmonary and skin
coverage; antibiotics were broadened to levofloxacin,
ceftazidime and vancomycin IV and PO. Her SBP was in the 90s in
the ED, she was volume resuscitated and SBP improved. TTE and
OSH showed an EF of 50% without valvular lesions. SpO2s have
been in the low to mid 90s on 3L nasal cannulae. She has also
had bad joint pain during her hospitalization. CT chest showed
diffuse airspace disease, bilateral reticular changes of
uncertain etiology, with the differential including infection,
edema and fibrosis.
She was seen by rheumatology at the OSH, who felt she likely ha
a flare of her RA. Steroids were increased from prednisone 5mg
to 40mg. Leflunomide toxicity was also raised as a possible
etiology, but level is pending and it is unclear when it will
come back.
On the night of [**11-14**], she experienced chest pain which resolved
with 3x nitroglycerin. Troponin was elevated to 0.389, but with
no EKG changes. EKGs showed old left bundle branch block, but
no STT wave changes.Interventricular conduction delay with a QRS
of 93 was noted on subsequent EKGs. Her lasix was held given
recent [**Last Name (un) **], but other cardiac medications were maintained.
Anticoagulation with heparin or lovenox were thoguht to be
contraindicated in the setting of anemia and therapeutic INR.
On arrival to the MICU, she appears ill, unable to complete full
sentences and frequently short of breath. She was able to
corroborate the above history. She also reports possible tick
exposure at the [**Last Name (un) 8548**] and in the garden of her home in the last
few weeks. No sick contacts or recent travel. Reports pain in
neck and shoulders, intermittently also in her back. Reports
minimal cough, but acknowledges a runny nose.
Past Medical History:
- CAD w chronic angina
-- PCI to midLAD (DES) and RCA (DES) in [**10/2118**]
-- PCI to ostial LAD, ostial LCx and D1 (DES) in [**1-/2121**]
-- PCI to ostial LCx (DES) in [**7-/2121**] for ISR
-- PCI to prox-RCA (DES) in [**7-/2122**]
-- PCI to LCx (DES) for ISR and RCA in [**12/2124**] (NSTEMI)
-- PCI to RCAx2, LCx x1, LADx1 (DES) for ISR in [**6-/2125**]
-- PCI to RCAx2 and LADx2, LCx (DES) in [**10/2125**] (NSTEMI)
-- PCI to RCA (DESx2) in [**9-/2126**]
- Paroxysmal atrial fibrillation dx [**12/2125**]
- Hypertension
- Hyperlipidemia
- pericarditis
- Carotid artery disease (80%-[**Country **]) s/p CEA [**2122**]
- Severe RA since early adulthood
- Raynaud's disease
- Gastritis
- GERD c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 865**] esophagus
- Hiatal hernia
- Pulmonary fibrosis
- Asthma
- Recurrent LE cellulitis
- s/p multiple joint replacements (fused R wrist, titanium L
wrist)
- DJD s/p C4-5 neck fusion
- Chronic back pain
- Bilateral torn rotator cuffs
- s/p TAH for precancerous uterine lesion
- s/p tonsillectomy
- Anxiety/depression
- ? Bullous pemphigoid
Social History:
Lives with husband, retired. [**Name2 (NI) **] daughter is very involved in
her care
Smoking - former, quit 30 years ago
EtOh - rare
Illicit - none
Family History:
Father had his 1st CABG in his 50's, mother with PTCA at age 52
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.3 BP: 125/63 P: 87 R: 140/58 )2: 93% non-rebreathe
mask.
General: Tired, ill-appearing female in NAD. Unable to complete
full sentences, short of breath and coughing and gasping for
breath.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse loud coarse polyphonic crackles bilaterally,
worse at lung bases, but extending to 4/5ths of chest, with
apical sparing.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Right calf erythematous, edematous, with area of erythema
well within previously drawn boundaaries demarcating area of
cellulitis. Distal pulses palpable. Bilateral hand deformities
with ulnar deviation, MCP subluxation, boutonniere and swan neck
deformities.
Neuro: CNII-XII grossly intact. Tone, power, reflexes,
coordination, sensation intact and equal in all four
extremities.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.8 154/74 83 20 97% on 2.5L NC
Gen: pleasant, NAD
HEENT: open sores around mouth
Chest: diffuse inspiratory crackles throughout, but most notable
in the bases
CV: RRR, No murmurs, rubs, or gallops
Abdomen: soft, NT, ND, BS+
Extremities: Right leg with area of erythema that is now less
than the drawn boundaries demarcating area of cellulitis. Distal
pulses palpable. Bilateral hand deformities with ulnar
deviation, MCP subluxation, boutonniere and swan neck
deformities. wwp. 1+ edema in bilateral hands and on b/l feet
Neuro: A&Ox3.
Pertinent Results:
ADMISSION LABS:
[**2126-11-16**] 01:19AM PT-66.9* PTT-32.2 INR(PT)-6.1*
[**2126-11-16**] 01:19AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2126-11-16**] 01:19AM NEUTS-91* BANDS-0 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2126-11-16**] 01:19AM WBC-15.5*# RBC-3.11* HGB-9.2* HCT-29.0*
MCV-93 MCH-29.6 MCHC-31.8 RDW-16.1*
[**2126-11-16**] 01:19AM CALCIUM-8.0* PHOSPHATE-3.3 MAGNESIUM-1.7
[**2126-11-16**] 01:19AM CK-MB-7 cTropnT-0.08*
[**2126-11-16**] 01:19AM ALT(SGPT)-27 AST(SGOT)-41* LD(LDH)-422* ALK
PHOS-67 TOT BILI-0.4
[**2126-11-16**] 01:19AM GLUCOSE-102* UREA N-20 CREAT-1.2* SODIUM-137
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-20* ANION GAP-14
[**2126-11-16**] 05:21AM freeCa-1.09*
[**2126-11-16**] 05:21AM O2 SAT-69
[**2126-11-16**] 05:21AM LACTATE-1.6
[**2126-11-16**] 05:21AM TYPE-CENTRAL VE PO2-48* PCO2-46* PH-7.28*
TOTAL CO2-23 BASE XS--4
[**2126-11-16**] 06:25AM LACTATE-1.4
[**2126-11-16**] 06:25AM TYPE-ART TEMP-38.1 RATES-30/ PEEP-10 O2-100
PO2-78* PCO2-39 PH-7.33* TOTAL CO2-21 BASE XS--4 AADO2-602 REQ
O2-98 VENT-CONTROLLED
[**2126-11-16**] 10:49AM PT-75.0* INR(PT)-6.9*
[**2126-11-16**] 01:54PM CK-MB-4 cTropnT-0.11*
[**2126-11-16**] 01:54PM CK(CPK)-77
[**2126-11-16**] 06:27PM PT-15.5* PTT-26.8 INR(PT)-1.4*
[**2126-11-16**] 06:27PM VANCO-23.2*
[**2126-11-16**] 06:27PM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-1.6
[**2126-11-16**] 06:27PM CK-MB-4 cTropnT-0.09*
[**2126-11-16**] 06:27PM proBNP-3964*
[**2126-11-16**] 06:27PM CK(CPK)-86
[**2126-11-16**] 06:27PM GLUCOSE-176* UREA N-23* CREAT-1.3* SODIUM-137
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-20* ANION GAP-16
IMAGING:
- CXR ([**2126-11-16**]): Cardiomediastinal silhouette cannot be
evaluated. It is obscured by the lung abnormalities. Mid and
lower extensive lung opacities have markedly increased from
[**11-12**]. Differential diagnosis is broad including diffuse
multifocal pneumonia, ARDS. This could be superimposed to a
more chronic interstitial lung abnormality. There are small
bilateral pleural effusions.
- TTE ([**2126-11-18**]): The left atrium is normal in size. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the inferior septum and inferior
wall. The remaining segments contract normally (LVEF = 45-50 %).
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD (PDA distribution). Compared with the prior study (images
reviewed) of [**2126-10-17**], the overall findings are similar.
MICRO:
[**2126-11-19**] SWAB VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS -
NEGATIVE; VARICELLA-ZOSTER CULTURE- NEGATIVE
[**2126-11-19**] Direct Antigen Test for Herpes Simplex Virus Types 1
& 2 Direct Antigen Test for Herpes Simplex Virus Types 1 & 2-
{HERPES SIMPLEX VIRUS TYPE 1}
[**2126-11-16**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-NEGATIVE; Respiratory Viral Antigen
Screen-NEGATIVE
[**2126-11-16**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-NEGATIVE;
RESPIRATORY CULTURE-NEGATIVE; LEGIONELLA CULTURE-NEGATIVE;
POTASSIUM HYDROXIDE PREPARATION-NEGATIVE; Immunoflourescent test
for Pneumocystis jirovecii (carinii)-NEGATIVE; FUNGAL
CULTURE-NEGATIVE; ACID FAST SMEAR-NEGATIVE; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE: R/O HERPES SIMPLEX
VIRUS-PRELIMINARY
[**2126-11-16**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2126-11-16**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2126-11-16**] URINE URINE CULTURE-NEGATIVE
[**2126-11-16**] SPUTUM Immunoflourescent test for
Pneumocystis jirovecii (carinii)-NEGATIVE
[**2126-11-16**] SPUTUM GRAM STAIN-NEGATIVE; RESPIRATORY
CULTURE-NEGATIVE; LEGIONELLA CULTURE-NEGATIVE; FUNGAL
CULTURE-PRELIMINARY {YEAST}
[**2126-11-16**] MRSA SCREEN MRSA SCREEN-NEGATIVE
NOTABLE LABS
ASPERGILLUS GALACTOMANNAN - NEGATIVE
ANTIGEN B-GLUCAN - NEGATIVE
ANCA - NEGATIVE
Anti-GBM - NEGATIVE
DISCHARGE LABS:
[**2126-11-25**] 06:20AM BLOOD WBC-9.0 RBC-3.11* Hgb-8.7* Hct-26.8*
MCV-86 MCH-28.1 MCHC-32.5 RDW-18.7* Plt Ct-106*
[**2126-11-25**] 06:20AM BLOOD Glucose-74 UreaN-20 Creat-0.8 Na-134
K-4.0 Cl-100 HCO3-26 AnGap-12
[**2126-11-25**] 06:20AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.7
[**2126-11-24**] 05:20AM BLOOD Vanco-23.2*
Brief Hospital Course:
62 F with extensive PMH including CAD s/p multiple PCIs, pAFib
on coumadin, pulmonary fibrosis, rheumatoid arthritis,
transferred here from OSH with worsening hypoxia and persistent
fevers.
# Hypoxia: Thought to be multifactorial with contributions from
an infectious process, pulmonary hemorrhage in the setting of a
supra-therapeutic INR, and volume overload. CXR showed diffuse
puffy infiltrate b/l most consistent with ARDS. BAL was negative
for all infectious agents tested, and tick-borne panel was
negative. On bronchoscopy, blood was visualized, consistent with
pulmonary hemorrhage. She was intubated for airway protection,
kept on ARDS settings, treated for HCAP with
vancomycin/ceftazidine/levofloxacin for a total of 8 days, and
was diuresed with daily goal for -1-1.5L. She was transfused one
unit of blood on [**11-17**] and two units of FFP on [**11-16**]. Her INR
was supratherapeutic on admission and warfarin was discontinued
indefinitely. Workup for vasculitis including ANCA and anti-GBM
were negative. She improved on these interventions and was
successfully extubated. Her hematocrit remained stable for the
rest of her hospitalization. Immediately following extubation it
was noted that she had some stridor, but appeared comfortable.
Upon chin-lift maneuver, the stridor disappeared, suggesting a
supra-glottic cause. For this she was started on steroids. Her
stridor resolved the following day and the steroids was
discontinued. She was transferred to the inpatient floor where
she continued to do well. Her antibiotics was continued for a
total of 8 days. She was continued on PCP [**Name Initial (PRE) 1102**]. She
continued on diuresis with lasix as needed for volume overload.
# NSTEMI: On [**11-15**], she experienced chest pain and troponin
leak. She did not have EKG changes consistent with ischemia. She
was maintained on aspirin and plavix. She underwent an echo,
which was essentially unchanged from prior. Her troponins
trended down. Per cardiology recommendations, her aspirin was
decreased to 162mg daily and warfarin was held indefinitely.
# Fever: Reportedly she had persistent fever while in OSH.
However, she was afebrile during her stay at [**Hospital1 18**]. Differential
included infectious source such as pneumonia or cellulitis vs.
inflammatory secondary to rheumatoid arthritis. She was treated
as above for pneumonia, and her fever curve was trended.
# RLE Cellulitis: Improved with antibiotics and supportive care.
She was continued on vancomycin IV with plan to complete a 14
days course.
# HSV infection: positive culture from oral swab. BAL negative
for HSV. She was started on acyclovir with plan to complete a 7
day course. Ophthalmology consult was obtained with no sign of
HSV keratitis.
# Acute Kidney Injury: Resolved with IVF rehydration in OSH.
# Paroxysmal Atrial Fibrillation: Per discussion with
cardiology, the decision was made to not restart her coumadin in
the setting of pulmonary hemrrohage. She was maintained on a
beta blocker and home diltiazem for rate control.
# Anemia: Baseline Hct 27-31. Likely contributions from anemia
of chronic disease and acute hemorrhage. She was transfused for
a goal Hct>21.
#) Nutrition: poor nutrition due to painful oral ulcers and poor
denture. She was seen by speech and swallow who recommended
continuing with regular diet with ensure supplements. Her
nutrition improved as the oral ulcers improved with acyclovir.
# CHRONIC ISSUES:
-HTN: she was continued with metoprolol and home imdur and
diltiazem
-HLD: continued on niacin
-Gastritis/GERD: continued on pantoprazole
-RA: on infliximab every 6 weeks and leflunomide daily. She was
given home hydrocodone-acetaminophen, tylenol, and ultram.
-Anxiety/insomnia/depresion: continued on bupropion
TRANSITIONAL ISSUES:
-holding warfarin indefinitely. Continuing with aspirin and
plavix
-on acyclovir for a total of 7 days (last day on [**2126-11-26**])
-please ensure right leg cellulitis is improving, plan for
vancomycin for total of 14 days (last day on [**2126-11-29**])
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN pain
2. ALPRAZolam 0.25 mg PO BID:PRN anxiety
3. Aspirin EC 325 mg PO DAILY
4. Atenolol 25 mg PO QAM
hold for SBP <100 or HR<60
5. Atenolol 12.5 mg PO DAILY
in the evening
6. buPROPion HCl *NF* 300 mg ORAL DAILY
7. Cetirizine *NF* 10 mg Oral daily
8. Clopidogrel 75 mg PO DAILY
for the recommended duration
9. Diltiazem Extended-Release 180 mg PO DAILY
10. Fish Oil *NF* (docosahexanoic acid-epa;<br>omega
3-dha-epa-fish oil;<br>omega-3 fatty acids;<br>omega-3 fatty
acids-fish oil;<br>omega-3 fatty acids-vitamin E;<br>salmon
oil-omega-3 fatty acids) 120-180 mg Oral [**Hospital1 **]
11. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
12. leflunomide *NF* 20 mg Oral daily
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Pantoprazole 40 mg PO Q12H
16. Pravastatin 20 mg PO M-W-FRI
17. PredniSONE 5 mg PO DAILY
18. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
hold for sedation, rr<12
19. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
20. B Complex *NF* (B complex vitamins) 0 units ORAL DAILY
21. coenzyme Q10 *NF* 50 mg Oral [**Hospital1 **]
22. Furosemide 20 mg PO DAILY:PRN ankle edema
23. Infliximab 100 mg IV ONCE Duration: 1 Doses
every six weeks
24. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
pt dooses 3 caps daily
25. Niaspan Extended-Release *NF* (niacin) 500 mg Oral [**Hospital1 **]
26. Warfarin MD to order daily dose PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA)
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Aspirin 162 mg PO DAILY
3. buPROPion HCl *NF* 300 mg ORAL DAILY
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
5. Diltiazem Extended-Release 180 mg PO DAILY
6. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Pravastatin 20 mg PO M-W-FRI
10. PredniSONE 5 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
hold for sedation, rr<12
12. Acyclovir 300 mg IV Q8H
13. Artificial Tears 1-2 DROP BOTH EYES Q6H:PRN dry eyes
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheeze
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
16. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID mouth pain
17. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
18. ALPRAZolam 0.25 mg PO BID:PRN anxiety
19. B Complex *NF* (B complex vitamins) 0 units ORAL DAILY
20. Cetirizine *NF* 10 mg Oral daily
21. coenzyme Q10 *NF* 50 mg Oral [**Hospital1 **]
22. Fish Oil *NF* (docosahexanoic acid-epa;<br>omega
3-dha-epa-fish oil;<br>omega-3 fatty acids;<br>omega-3 fatty
acids-fish oil;<br>omega-3 fatty acids-vitamin E;<br>salmon
oil-omega-3 fatty acids) 120-180 mg Oral [**Hospital1 **]
23. Furosemide 20 mg PO DAILY:PRN ankle edema
24. Infliximab 100 mg IV ONCE Duration: 1 Doses
every six weeks
25. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
pt dooses 3 caps daily
26. leflunomide *NF* 20 mg Oral daily
27. Multivitamins 1 TAB PO DAILY
28. Niaspan Extended-Release *NF* (niacin) 500 mg Oral [**Hospital1 **]
29. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
30. Metoprolol Tartrate 12.5 mg PO Q6H
31. Vancomycin 1000 mg IV Q 24H
32. Polyethylene Glycol 17 g PO DAILY:PRN constipation
33. Senna 1 TAB PO BID:PRN constipatino
34. Prochlorperazine 10 mg PO Q6H:PRN nausea
35. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary: pneumonia, pulmonary hemorrhage, non-ST segement
elevation myocardium infarction, cellulitis, pulmonary edema,
HSV infection
Secondary: paroxysmal atrial fibrillation, rheumatoid arthritis,
anemia
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 8529**],
It was a pleasure taking care of you during your stay at [**Hospital1 1535**]. You were admitted to the
hospital because of a very bad infection and bleeding in your
lungs that required you to be intubated. Your infection was
treated with antibiotics and your warfarin was held due to the
bleeding in your lungs.
You also have a viral infection around your mouth causing sores.
You were treated with acyclovir to help with the infection.
Please continue with acyclovir for a total of 7 days (last day
on [**2126-11-26**]).
You also have an infection in your right leg that is being
treated with an antibiotic (vancomycin). You will need to
continue with this antibiotic for a total of 14 days (last day
on [**2126-11-29**])
Followup Instructions:
Please make sure you follow up with your primary care physician
Completed by:[**2126-11-26**]
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82,649
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Discharge summary
|
report
|
Admission Date: [**2139-8-10**] Discharge Date: [**2139-8-14**]
Date of Birth: [**2111-3-27**] Sex: M
Service: PLASTIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
Right brachial plexus injury with poor motor elbow flexion.
Major Surgical or Invasive Procedure:
Right pedicled latissimus transfer for restoration of right
elbow flexion [**8-10**]
History of Present Illness:
28 yo gentleman who suffered traumatic injury one year ago when
he was hit by a train. He has since undergone several orthopedic
procedures for correction of his multiple injuries. On this
occasion, he was admitted for muscle transposition for elbow
flexion.
Past Medical History:
s/p Struck by train on [**2138-5-28**]
-Left tibia fracture
-Pelvic fractures
-Right arm injury (partial internal amputation/radial nerve
palsy/vascular injury)
Social History:
Lives with wife, independent prior to train accident
Family History:
NC
Physical Exam:
Physical Exam:
v/s: AVSS
GEN: extubated
HEENT: MMM, neck is supple
CV: RRR
ABD: soft, NTND, +bs
LIMBS: No LE edema, cyanosis, clubbing
Pertinent Results:
Labs near time of discharge:
[**2139-8-13**] 03:17AM BLOOD WBC-11.5* RBC-3.68* Hgb-11.7* Hct-35.2*
MCV-96 MCH-31.7 MCHC-33.2 RDW-12.5 Plt Ct-241
[**2139-8-13**] 03:17AM BLOOD Glucose-115* UreaN-8 Creat-0.6 Na-138
K-3.7 Cl-105 HCO3-27 AnGap-10
[**2139-8-11**] 01:28PM BLOOD ALT-29 AST-26 LD(LDH)-189 AlkPhos-90
TotBili-0.2
[**2139-8-13**] 03:17AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2139-8-10**] and had a Right pedicled latissimus transfer for
restoration of right elbow flexion. The patient tolerated the
procedure well however following the procedure he failed the
cuff test, was therefore transferred to the ICU for monitoring.
He stayed in the ICU until POD 3 because of high vent settings
and IV access issues. He was then transferred to the floor once
these issues resolved.
Neuro: Post-operatively, the patient received Dilaudid IV with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient initially had high vent settings which
resolved. He was extubated on POD 3 and was stable from a
pulmonary standpoint; vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on POD#3. Intake
and output were closely monitored.
ID: Post-operatively, the patient was started on cefepime,
flagyl and levofloxacin for thought that pneumonia may have
caused his high oxygen requirement but was d/c'd home with
Duricef.
Prophylaxis: The patient did not receive prophylaxis as he has a
heparin allergy.
At the time of discharge on POD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
percocet
cialis
neurontin
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Please take while taking your narcotic pain medication to
prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*1*
4. Cialis Oral
5. Percocet 10-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: Please do not drive or operate
heavy machinery.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right brachial plexus injury with poor motor elbow flexion.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had surgery on [**8-10**] for a Latissimus dorsi muscle flap to
your right elbow.
-Activity as tolerated
-Splint to right upper extremity x 4 weeks, try to minimize
shoulder movement.
-Steri-strips on back (white "bandaid-like" material) will come
off on their own.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
3. Take your antibiotic as prescribed.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
5. 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.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
welling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] sometime next week. To
make an appointment please call ([**Telephone/Fax (1) 26412**].
Please go to the following appointments:
[**2139-10-13**] at 7:40am: ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
[**2139-10-13**] 8:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
|
[
"276.52",
"718.42",
"907.4",
"353.0",
"934.9",
"518.81",
"E929.1",
"995.94"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.24",
"83.77",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3903, 3961
|
1564, 3253
|
336, 423
|
4065, 4065
|
1159, 1541
|
6147, 6572
|
983, 988
|
3329, 3880
|
3982, 4044
|
3279, 3306
|
4216, 6124
|
1018, 1140
|
236, 298
|
451, 711
|
4080, 4192
|
733, 896
|
912, 967
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,133
| 109,649
|
48147
|
Discharge summary
|
report
|
Admission Date: [**2159-5-16**] Discharge Date: [**2159-6-1**]
Date of Birth: [**2108-12-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Known aneurysm, now enlarged in size
Major Surgical or Invasive Procedure:
1.Right sided pterional craniotomy for right-sided ICA
bifurcation aneurysm clipping.
2. Microsurgical dissection.
3. Duroplasty.
History of Present Illness:
The patient is a 50-year-old female that was found to have an
incidentally discovered right-sided ICA bifurcation aneurysm.
This aneurysm has been known for several years. It is followed
up by sequential scans. The patient has now undergone a formal
angiogram by Dr.[**Name (NI) 10136**] service on [**2159-4-5**]. The
catheter angiogram with gadolinium has confirmed a 9 x 5.5mm
bilobed aneurysm at the bifurcation of the right anterior and
middle cerebral arteries. It appears to have a wide neck
measuring approximately 4.5 to 5mm. Overall, the patient has
done well and remains clinically intact and stable. She has
done [**Location (un) 1131**] on the issue and decided that she does not want to
undergo coiling which is technically difficult with wide neck
aneurysms anyway. The patient opted to have an open surgery and
wants to have definite occlusion by clipping. She is seen for
surgical counseling in neurosurgery office.
Currently, she denies any new symptoms such as headaches,
nausea, vomiting, or dizziness. The patient has no seizures or
focal neurological deficits. She had persistent balance problems
secondary to spinal and cervical stenosis.
Past Medical History:
- DM type I x 29 years - last A1c 11.3 [**5-10**], followed at the
[**Last Name (un) **]. CHecks FS QID, vary widely from 40's to 400's.
- cardiomyopathy, EF 15-20% from TTE yesterday, on Coumadin
- CKD s/p transplant in [**2152**], Cr 1.9 to 2.9 range since [**1-9**]
- Intracranial right ICA aneurysm, diagnosed "several years
ago,"
gets yearly imaging. 5mm [**2154**], 8mm on [**2159-2-7**] MRA.
- History of C4-5 and C5-6 anterior decompression and fusion
after MVA [**2157**], Dr. [**Last Name (STitle) 363**]
- ulnar nerve impingement bilaterally
- Hypertension
- Hepatitis C acquired via transfusion for menses that were
hemorrhagic, now menopausal.
- Rotator cuff repair
- CMV [**2155**]
- E.coli UTI in [**12-11**]
- right carpal tunnel surgically released
Social History:
Pt Lives at home with son and his wife and their 4 children. Pt
works at [**Location (un) 686**] District Court
EtOH - used to drink, none in 9 years
Tob - 1ppd for 27 years, quit about 8 years ago
Family History:
Sister died of [**Name (NI) 101497**], many other family members with type 1 and 2
DM
Physical Exam:
VITALS: 97.8, 144/88, 98, 18, 98% RA, FS 99-210
GEN: no acute distress, pleasant woman that appears younger than
stated age
NECK: limited ROM
NEURO:
Mental status:
Patient is alert, awake, pleasant affect. Oriented to person,
place, time. Good attention - tells a coherant story.
Language is fluent with good comprehension, repitition, naming,
no dysarthria. No apraxia, agnosias, no neglect. Able to
calculate, no left/right mismatch. Registration [**4-10**] objects.
Recalls [**4-10**] objects after 3 minutes.
Cranial Nerves:
I: deferred
II: Visual fields: full to left/right/upper/lower fields.
Fundoscopic exam: discs flat, fundi clear, no hemorrhages or
exudates. Pupils: 3->2 mm, consensual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or ptosis.
- UPON DISCHARGE PERSISTANT R SIDED UPPER LID PTOSIS. NO OTHER
FACIAL ASSYMETRY
V: facial sensation intact over V1/2/3 to light touch and pin
prick.
VII: symmetric face
VIII: hearing intact to finger rubs
IX, X: Symmetric elevation of palate.
[**Doctor First Name 81**]: SCM and trapezius [**5-11**] bilaterally
XII: tongue midline without atrophy or fasciculations.
Sensory:
Normal touch, proprioception, pinprick. Decreased cold in a
stocking/glove distribution. No extinction to double
simultaneous stimulation.
Motor:
Wasting bilateral APB, FDI, EDB bulk, mildly increased tone
legs.
No fasciculations or drift. + postural tremor low amplitude
worse with motion. No asterixis.
D T B WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**]
RT: 5 4 5 5 5 5 5 4 5 4- 5 5 4+
LEFT: 5 4 4+ 5 5 5 5 4 5 4- 5 5 4+
Reflexes: + [**Doctor Last Name **] bilaterally. No Jaw jerk. Crossed
adductors. SLIGHTLY MORE HYPERREFLEXIC ON L PATELLAR.
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 3 3 tr 3 tr up
LEFT: 3 3 2 3 tr up
Coordination:
Normal finger-to-nose (tremor constant throughout testing, worse
with posture and action), heel-to-shin, RAMs.
Gait:
Gait is antalgic, favors the left leg.
Pertinent Results:
CXR [**5-17**]:
IMPRESSION: NG tube in left lower lobe segmental bronchus. This
has been communicated immediately to Dr. [**Last Name (STitle) **] at the time of
the review of the study at approximately 10 p.m. on [**2159-5-16**].
.
Angeography:
IMPRESSION: No evidence of perfusion to the clipped right ICA
bifurcation aneurysm. No evidence of residual aneurysm. The
right ICA, MCA, ACA and the major branches are patent.
.
CT [**5-18**]:
IMPRESSION: Again noted is intraparenchymal hemorrhage within
the right temporal lobe with surrounding edema that measures
slightly larger compared to prior study. Increase in
high-density material seen within the right frontal extra-axial
space with slight increase in leftward shift of midline
structures. Discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13013**] at 6:45 a.m. on [**5-18**], [**2159**].
.
NOTE ADDED AT ATTENDING REVIEW: The increase in extra axial
fluid is expected as fluid replaces air at the surgical site.
The slight change in the appearance of the post operative
hemorrhage in the temporal lobe does not necessarily reflect
increased bleeding.
.
[**5-19**] CT:
IMPRESSION: Stable appearance of right inferior frontotemporal
intraparenchymal hemorrhage with surrounding edema.
Post-surgical changes from right frontal craniotomy. No new
hemorrhage, hydrocephalus or increased shift of normally midline
structures is identified.
.
[**5-22**] CT:
FINDINGS: Examination is essentially unchanged from the previous
study. Again is noted increased density in middle cranial fossa
consistent with hemorrhage within the temporal lobe and/or
subjacent to it. There is some gas still seen in the right
frontal extra-axial compartment. Artifact to the aneurysm
clipping is again noted. There is low density in the head of the
caudate consistent with infarction. There are some malacic
changes in the right frontal lobe.
.
IMPRESSION: Stable appearance when compared to previous
examination.
.
[**5-24**] CXR:
The previously identified opacities in both lower lobes have
been markedly improving. The lungs are clear otherwise. The
heart and mediastinum are within normal limits. The right
jugular IV catheter remains in place. No pneumothorax is
identified.
.
[**5-24**] Renal US:
FINDINGS:
The right lower quadrant renal transplant measures 13.8 cm in
length, which is unchanged from the prior study. Cortical
echogenicity is likely within normal limits but may be mildly
increased. Cortical-medullary differentiation persists. There
are no renal masses, hydronephrosis, or calculi. Arterial flow
is identified within the upper, mid and lower pole wrist with
resistive indices up to 0.90 which are increased from the prior
study. Renal vein is patent. No perinephric fluid collections.
IMPRESSION:
Right lower quadrant renal transplant without hydronephrosis.
All vessels patent though resistive indices are slightly
increased from the prior study, which is nonspecific.
.
[**5-25**] EKG:
Sinus rhythm. Left atrial abnormality. First degree A-V block.
Left
bundle-branch block. Compared to the previous tracing of [**2159-5-19**]
no significant diagnostic change.
.
[**5-28**] US:
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the left internal
jugular, subclavian, axillary, brachial, and basilic veins were
performed. There is a small amount of non-occlusive thrombus
within the left internal jugular vein. The left subclavian,
axillary, and brachial veins are patent with normal flow,
augmentation, compressibility, and waveforms. The basilic vein
is patent.
.
IMPRESSION: Small amount of non-occlusive thrombus within the
left internal jugular vein. No evidence of left upper extremity
DVT.
Cx negative - BCx, UCx negative
.
[**5-31**] US:
LEFT UPPER EXTREMITY DVT STUDY: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**]
of the left IJ, left subclavian, left axillary, and left
brachial veins were performed. There is again noted a small
nonocclusive thrombus in the left internal jugular vein in the
neck, which is probably slightly decreased when compared to the
prior study. No new thrombus is identified. The other visualized
veins are unremarkable.
IMPRESSION: Persistent tiny nonocclusive thrombus in the left
internal jugular vein in the neck. It appears to be slightly
decreased when compared to the prior study.
.
CT [**5-29**]:
COMPARISON: Compared to the CT of [**2159-5-22**], there is
decreased density within the right temporal lobe hematoma,
indicating maturing hemorrhage. Low densities within the head of
the caudate and temporal lobes secondary to infarction are
stable. Mild edema and mass effect slightly reduced. The
ventricles are not dilated. The small extra-axial fluid
collection at the craniotomy site is stable with no evidence for
new intracranial hemorrhage. Post- surgical soft tissue swelling
is unchanged. Aneurysm clip related artifact again present.
IMPRESSION: Slight improvement from [**2159-5-22**] with no
evidence for new hemorrhage.
.
VRE/MRSA SCREENS NEGATIVE
.
Labs upon d/c:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2159-6-1**] 04:50AM 6.9 3.26* 8.8* 26.9* 82 26.9* 32.6 18.9*
611*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2159-5-28**] 05:57AM 68.7 22.7 5.5 2.8 0.4
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Microcy
[**2159-5-28**] 05:57AM 1+ 1+ 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2159-6-1**] 04:50AM 611*
HEMOLYTIC WORKUP Ret Aut
[**2159-5-28**] 05:57AM 1.7
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2159-6-1**] 04:50AM 137* 14 1.9* 146* 3.8 111* 26 13
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2159-5-29**] 06:09AM 354* 0.1
OTHER ENZYMES & BILIRUBINS Lipase
[**2159-5-25**] 06:25AM 20
CPK ISOENZYMES CK-MB cTropnT
[**2159-5-19**] 12:10AM 4 0.01
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2159-6-1**] 04:50AM 8.8 3.1 1.6
HEMATOLOGIC calTIBC Hapto Ferritn TRF
[**2159-5-29**] 06:09AM 87
LIPID/CHOLESTEROL Cholest Triglyc
[**2159-5-20**] 03:22AM 89
OTHER CHEMISTRY Osmolal
[**2159-5-22**] 03:17AM 314*
THYROID PTH
[**2159-5-23**] 01:43PM 54
NEUROPSYCHIATRIC Phenyto
[**2159-5-20**] 07:30AM 15.5
[**2159-5-20**] 03:22AM 17.1
TOXICOLOGY, SERUM AND OTHER DRUGS FK506 rapmycn
[**2159-6-1**] 04:50AM 4.9*
[**2159-6-1**] 04:50AM 5.8
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is 50 y.o. F with DM 1, s/p cadaveric renal
transplant '[**52**], admitted for clipping of right sided bilobed
middle cerebral artery bifurcation aneurysm on [**2159-5-16**],
complicated by left temporal contusion. Patient was observed
Neuro ICU for hemodynamic and close neurologic monitoring.
Failed 3 attempt of placement of NGT/OG for immunosuppressive
drug as well as for nutrition immediate postoperative period
with LLL PNA as complication. Post operative head CT revealed
right temporal contusion which has bees stable in appearance in
serial cat scans of the head. The course was complicated by
persistent somnolence attributed to Keppra and anemia and
improving ARF with resolving CHF.
..............................................................
.
Neuro: Her initial postoperative neurologic exam off sedation
showed normal extremity response to pain but right eye ptosis,
IIIrd nerve palsy. Pupils are sluggishly reactive 3-2mm
bilaterally. She had a cerebral arteriogram on [**2159-5-17**]. There
were no immediate complications during arteriogram. Arteriogram
revealed a surgical clip is seen in the region of the previously
seen ICA bifurcation aneurysm on the right. There is no
evidence of residual perfusion of this aneurysm. The superior
sagittal sinus, right transverse sinus, right sigmoid sinus and
upstream portion of the right internal jugular vein are widely
patent as well as the right ICA, MCA, ACA and the major branches
are patent. Patient remained with R eye ptosis, and improvement
in III nerve palsy that was presumed to be due to operation and
neurosurgery did not feel certain whether it was going to be
reversed. Patient with increased somnolence during the day and
several episodes of [**Last Name (un) 6055**]-stoke breathing suggesting central
apnea. She was evaluated by pulmonary service who also noted an
element for apnea and she was referred for outpatient sleep
study. R temporal contusion remained stable on CT, last one
[**5-29**] showed maturing hematoma without any evidence of new
hemorrhage. Patient with persistent somnolence although quickly
arrousable. The etiology of somnolence remained unclear and may
have been due to sleep apnea as described above. Patient was
also taken off Keppra after discussion with Dr. [**Last Name (STitle) **] and
somnolence improved slightly. She is to f/u with Dr. [**Last Name (STitle) **] in
6 months, CTA in 1 yr. There was no evidence of seizures while
in house.
.
# LLL PNA - Patient was found to have a LLL PNA on [**5-17**] CXR that
was obtained after
patient had a desaturation episode where her oxygen saturation
dropped to 86%. This may have been a complication of multiple
failed NGT placement attempts. Patient was initially placed on
Levo/Flagyl. Flagyl was subsequently discontinued. Her
saturation remained excellent on room air. Cultures were not
done as patient denied any sputum or fever. Repeat chest
radiograph on [**5-24**] showed marked improvement pneumonia and
pleural effusion. She completed 7 day course of Levaquin -last
dose 5/22.
.
Patient with DM nephropathy s/p renal transplant. Patient was
being followed by nephrology transplant service while in house.
Her creatinine at baseline is 2.0-3.0 with large fluctuations.
Patient's her creatinine was 2.9 on [**5-16**] preop, post arteriogram
peaked to 4.1, and was attributed likely due to peri-operative
hypotension and worsening renal failure. There was no evidence
of hydronephrosis on Renal ultrasound preformed on [**5-24**]. The
contrast during angiogram was unlikely to be a contributor since
Cr started rising 3 days after exposure. US evaluation of the
right lower quadrant renal transplant showed all vessels patent
though resistive indices are slightly increased from the prior
study, which is nonspecific. Microscopic urine sediment
confirmed ATN with FeNa 2.4 % on [**5-24**] with pr/cr of 1.7 .
Patient's Cr slowly improved to low 2.0s and she was restarted
on her regular CHF regiment included Losartan. Patient
tolerating small doses of Lasix prn as her renal function also
improved with diuresis. Patient was also continued on
sacrolimus/tacrolimus and the dosages were adjusted based on
daily values. Patient will f/u with Dr. [**First Name (STitle) 805**] as outpatient.
.
# Anemia - Patient with microcytic anemia. Work up revealed
guiac negative stool on [**5-29**]. FeStudies c/w nl Fe, low TIBC,
suggesting anemia of chronic diseases. nl B12/Folate [**2-12**].
Patient also noted to have low reticulocyte index, no
schistocytes on smear, LDH/hapto nl. She was continued on
Epogen and it was increased to compensate her anemia. Patient
was given 1 unit PRBC on [**5-26**] and her Hct remained stable for
the rest of her hospitalization. There was no evidence of
increasing hematoma on head CT and no other source of bleeding
was suspected.
.
# HTN - patient was managed on Metoprolol XL, Hydralazine and
Imdur were titrated off while she was restarted on Losartan and
subsequently Nifedipine CR was added to her regiment. Goal BP
was 140-150 to assure adequate renal perfusion.
.
# Pyuria - on [**2159-5-31**], although UCx was negative she was
empirically treated with cipro 250 [**Hospital1 **] x 7 days. Patient denied
any fever or urinary symptoms. She urinated well after removal
of the foley.
.
# LUE DVT - Patient was noted to have L arm swelling on [**5-28**].
Subsequent US showed non-occlusive thrombus in Left internal
jugular vein probably due to prior line placement. Patient's
was a high risk for anticoagulation due to guiac negative stools
but steadily decline hematocrit as described above. The risk
and benefits were discussed with the patient multiple times and
she agreed that the anticoagulation would be too risky not
knowing the source of her blood loss. Repeat US o [**5-31**] showed
tiny improved nonocclusive L IJ clot and it was decided to forgo
anticoagulation upon discharge with a knowledge of organizing
hematoma seen upon repeat CT.
.
# CHF - Patient with known nonischemic cardiomyopathy, and
initial volume overloaded likely due to worsening renal
function. Patient's trace edema improved with mild diuresis due
to prn lasix and while she was started on hydralazine and Imdur.
Patient's respiratory status was never compromised and slowly
her renal function improved. Patient subsequently was switched
from Hydral/Imdur to Losartan for afterload reduction. No Lasix
were Rx for home therapy. Patient will follow up with
Cardiologist @ [**Hospital1 2177**] or [**Hospital 1902**] clinic here. She may require
subsequent ICD eval and risk stratification.
.
# IDDM - patient Type I DM and was followed by [**Last Name (un) **] service
during her stay. She was maintained on insulin gtt while in the
ICU and subsequently switched to sliding scale with Lantus. Her
tight scale was maintained < 150 with at least 13 u Lantus even
when NPO.
.
# Full code
.
Follow up - patient will follow up with her renal doctor, her
PCP, [**Name10 (NameIs) **] and pulmonary clinic and also Dr.[**Last Name (STitle) **] in 6 months.
Medications on Admission:
tacrolimus 3", sirolimus 5', toprol XL 100', lipitor 20',
losartan 25', Zantac 75', Lantus/Novalog, tramadol 50',
?coumadin
Discharge Medications:
1. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for headache.
4. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*3*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
6. Tramadol 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day for 1 weeks.
Disp:*7 Tablet Sustained Release 24HR(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
8. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*1 cartridge* Refills:*3*
9. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*3*
10. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
11. Metoprolol Succinate 200 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO at bedtime.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*3*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
14. Epogen 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR.
Disp:*30 injection* Refills:*3*
15. Outpatient Physical Therapy
Please continue physical therapy 3x/week at home for as long as
needed
16. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
Disp:*90 Capsule(s)* Refills:*3*
17. Sirolimus 1 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
Disp:*210 Tablet(s)* Refills:*3*
18. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO qAM.
Disp:*120 Capsule(s)* Refills:*3*
19. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: 1-10 units
Subcutaneous qACHS: as per your sliding scale.
Disp:*2 bottle* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
R MCA aneurysm
R temporal lobe contusion
Acute Renal Failure
Chronic Renal Insufficiency - s/p renal transplant
Obstructive Sleep Apnea
Anemia
Acidosis
Congestive Heart Failure
Pneumonia
IDDM
Hypertension
Hepatitis C
Discharge Condition:
Stable. Pt afebrile. Ambulating with cane. Oxygenating well.
Tolerating PO.
Discharge Instructions:
Please take all your medicatios as instructed.
.
It is important to keep all your appointment and follow up with
them as scheduled.
.
Please seek immediate medical attention if you experiences a
worsening headache, nausea/vomiting, increasing
numbness/weakness in any of your extremities, or if you noticed
slurred speech or worsening swallowing.
Followup Instructions:
Follow up with PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - [**6-12**], @ 11:30 am.
[**Telephone/Fax (1) 1260**]
.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**], renal clinic, on [**2159-6-7**] @ 12
pm.
.
Follow up in sleep clinic once your symtpoms improved and call
[**Telephone/Fax (1) 16716**] to make an appointment. You will also need to make
a subsequent appointment with a pulmonary doctor - call ([**Telephone/Fax (1) 35871**] to make an appointment.
.
Follow up with Dr. [**Last Name (STitle) **] in 6 months. Call ([**Telephone/Fax (1) 88**] to
make an appointment.
.
Follow up with [**Hospital **] clinic ([**Telephone/Fax (1) 17240**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] -
[**6-8**] @ 11 am
.
Follow up with Dr. [**Last Name (STitle) 363**] re: your spine procedure. Call him to
make an appointment @ ([**Telephone/Fax (1) 11061**]
Completed by:[**2159-6-18**]
|
[
"250.01",
"293.0",
"511.9",
"428.0",
"998.11",
"996.81",
"486",
"327.23",
"453.8",
"V58.67",
"401.9",
"437.3",
"070.70",
"276.2",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.51",
"96.6",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
20867, 20938
|
11360, 18487
|
305, 439
|
21199, 21277
|
4838, 11337
|
21672, 22667
|
2661, 2748
|
18661, 20844
|
20959, 21178
|
18513, 18638
|
21301, 21649
|
2763, 2914
|
229, 267
|
467, 1638
|
3295, 4819
|
2929, 3279
|
1660, 2429
|
2445, 2645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,413
| 150,164
|
51756
|
Discharge summary
|
report
|
Admission Date: [**2172-7-30**] Discharge Date: [**2172-8-12**]
Date of Birth: [**2099-1-20**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Cardizem / Quinidine
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Odynophagia due to hypopharyngeal cancer
Major Surgical or Invasive Procedure:
Radical neck dissection, total laryngectomy, partial
pharyngectomy with RFFP, open G-tube and skin flap;
History of Present Illness:
73yo w/ sore throat and jaw discomfort. W/up revealed left
pyriform sinus lesion. Admitted to [**Hospital1 18**] after undergoing direct
laryngoscopy and pyriform sinus biopsy.
Past Medical History:
PMH:
1. Colonic adenoma. On screening colonoscopy, a single
semi-pedunculated 16mm non-bleeding polyp was found in the
proximal ascending colon. Polypectomy was performed with
complete retrieval of the polyp using a hot snare, pathology
revealed an adenoma.
2. Hemorrhoids with rectal bleeding.
3. Atrial fibrillation/Atrial flutter, diagnosed in [**2160**].
4. Pericardial effusion, found in [**2167**] on chest CT.
Pericardiocentesis performed.
5. CAD.
6. R kidney cyst.
7. Umbilical hernia.
8. Cholelithiasis.
9. Right upper neck liposarcoma.
9. Vocal cord squamous cell carcinoma, [**2165**]. treated with
radiation therapy.
10. Chronic hypercalcemia.
11. Inguinal herniorrhaphy.
12. Scalp folliculitis [**2163**].
13. Fasciotomy [**2162**].
14. Peripheral neuropathy.
15. Biclonal gammopathy.
16. Fatty liver.
17. Keratosis.
18. Glaucoma.
19. BPH.
Social History:
Drinks 2 glasses of scotch per day, reports a more significant
drinking history in the past of several cocktails/day. He lives
at home with his wife and reports no limitations in ADLs. He is
retired from working in the petroleum
industry and now plays golf 3 times per week.
Family History:
Family history: (patient was unsure of some details). Father
died at age 84.
Mother died at age 78 with a stroke. Has 5 siblings, 1
reportedly diagnosed with heart disease. Has 4 children, 1
diagnosed with valvular disease and a son with NIDDM.
Pertinent Results:
[**2172-8-12**] 05:29AM BLOOD WBC-12.2* RBC-3.05* Hgb-9.8* Hct-28.7*
MCV-94 MCH-32.0 MCHC-34.1 RDW-13.6 Plt Ct-359
[**2172-8-12**] 06:39AM BLOOD PT-13.5* PTT-35.0 INR(PT)-1.2
[**2172-8-12**] 05:29AM BLOOD Glucose-177* UreaN-30* Creat-0.8 Na-140
K-4.7 Cl-105 HCO3-28 AnGap-12
[**2172-8-12**] 05:29AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8
[**2172-8-11**] 05:53AM BLOOD TSH-0.60
Brief Hospital Course:
Operated at [**Hospital1 18**] on [**2172-7-30**]; uncomplicated surgery; transfer to
SICU where patient is trached and sedated; sedation
progressively decreased; on [**2172-8-6**]: transfer to the [**Hospital1 **];
Evolution course is satisfactory as patient is progressively
mobilized (up to 3x/d at time of discharge), various surgical
sites heal without complication, neck skin flap check is
performed twice daily to confirm patency of graft's artery and
vein, trach stoma is patent without tube (patient receives
electrolarynx), and speech and swallow testing authorizes
patient to start PO pureed food on [**2172-8-8**] in addition to
PEG-tube feed.
Significant medical events include:
- Neck: swelling and small hematoma in post op; followed by
plastic surgery which recommended no specific treatment;
- Cariovascular:
- BP: patient presents with elevated BP, requiring medication
adjustment (see medication list)
- Dysrythmias: monitored by telemetry, patient presents
multiple episodes of ~2 sec. pauses, acceptable given his
condition accoring to his cardiologist, prompting reduction of
his Metoprolol dosage (125 tid -> 100 tid) and halt of Digoxin.
He also presented one episode of ventricular tachycardia (4
systoles) on post op day 12. An echocardiography did not show
any change compared to his prior status (see attached report).
- Endocrinology:
high blood glucose titers have required the initiation of
insulin-based therapy:
Fixed dose: Glargine 15 Units at bedtime
Sliding scale: See attached sliding scale (dated [**2172-8-11**])
- Electrolyte: patient presented with hypernatremia corrected
after several days of q4h free water flush via PEG-tube;
hypomagnesiemia treated with Mg supplement. On date of transfer:
Na 140, Mg 1.8
- Warfarin treatment was started on [**2172-8-11**] with initial dose of
5 mg; INR on [**8-12**]: 1.2; needs to be adjusted with the goal of
INR [**3-19**].
- Nutrition: patient fed via PEG-tube; diet changed to
night-only cycle as he started PO pureed food on [**2172-8-8**];
Promote w/fiber full strength 100 ml/hr between 6pm and 6 am.
- Earlier in his hospitalization, patient developed decubitus
ulcers necessitating wound care.
Overall, positive patient evolution prior to his discharge to a
rehabilitation center for further improvement of his physical
capabilities while under adequate monitoring.
Medications on Admission:
(same as [**2172-7-16**] discharge)
1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily). Tablet(s)
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin Calcium 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
10. Nitroglycerin 6.5 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO bid () as needed for Anti-anginal.
Discharge Medications:
Aspirin 162 mg PO daily
Heparin 5000 Unit sc tid
Warfarin per PT/INR (started [**8-11**]; INR on [**8-12**]: 1.2)
Hydralazine HCl 25 mg PO q6h
Captopril 25 mg PO bid
Metoprolol 100 mg PO tid
Docusate sodium (liquid) 100 mg PO bid
Latanoprost 0.005% Ophtal. [**Male First Name (un) **] 1 drop OU HS
Dolasetron mesylate 12.5 mg IV q8h PRN nausea
Oxycodone-Acetaminophen Elixir [**6-23**] ml PO q4-6h PRN
Morphine sulfate 2-4 mg IV q3-4h PRN
Haloperidol 0.5-1.0 mg IV q4h PRN anxiety, agitation
Insulin SC: Glargine 15 U at bed time + sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Status post resection of hypopharyngeal squamous cell carcinoma
with bilateral modified radical neck dissection, R
hemithyroidectomy, total laryngectomy, L radical forearm free
flap ro R facial artery, STSG to R arm, #8 trach, PEG;
Discharge Condition:
Patient in good condition, awake and cooperative; ambulates with
help; Neuro: oriented, no focal neurological deficit excepted
speech/swallow due to surgical excision/reconstruction;Cardio:
chronic atrial fib/flutter; HR irregular, between 60-100; BP:
tendency to high BP ~160/60; occasional 2 sec. pauses; 1 episode
of v. tach (4 systoles), bilat. mild ankle edema on [**8-12**]; Resp:
via tracheal stoma, NAD, 02 sat. 96-100%, occasional
expectorations, ausculation: occasional rhonchi; recent CXR:
small left pleural effusion w/basal atelectasis, no infiltrate;
[**Last Name (un) **]: G-tube, bowel mvmt ok; GU: urinates ok; Neck: skin flap
well vascularized (check w/doppler); no erythema, tenderness,
heat; left hand: occasioanl pain and tingling in fingers (no
specific periph. nerve territory); capill. refill ok;
temperature: similar to very slightly colder than right hand; no
compartment syndrome but needs to be checked; Endocrine:
elevated blood glucose: high blood glucose titers have required
the
instauration of insulin-based therapy:
Fixed dose: Glargine 15 Units at bedtime
Sliding scale: See attached sliding scale (dated [**2172-8-11**])
BP: tendency to high blood pressure requiring adjustment of
medication;
Arrythmias: reccurent episodes of ~2 sec. pauses; 1 episode of
4-systole v. tach.; patient supervised by telemetry;
Discharge Instructions:
Physical therapy, respiratory PT,
Speech therapy (electrolarynx), swallowing PT,
Cardiac monitoring, telemetry
Airway care, G-tube care
Followup Instructions:
Please contact Dr [**Name (NI) 1837**] at [**Telephone/Fax (1) 37033**] to arrange f.up
appointment
Completed by:[**2172-8-12**]
|
[
"275.2",
"401.9",
"707.03",
"998.12",
"458.29",
"V15.3",
"196.0",
"148.1",
"250.00",
"518.0",
"427.31",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"29.4",
"38.93",
"96.6",
"43.19",
"30.4",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
6390, 6469
|
2517, 4888
|
328, 435
|
6745, 8094
|
2121, 2494
|
8278, 8409
|
1868, 2102
|
5817, 6367
|
6490, 6724
|
4914, 5794
|
8118, 8255
|
248, 290
|
463, 641
|
663, 1541
|
1557, 1836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,572
| 193,016
|
46570
|
Discharge summary
|
report
|
Admission Date: [**2141-6-29**] Discharge Date: [**2141-6-30**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with recent discharge from [**Hospital1 18**] ([**2055-6-16**]) for NSTEMI and
CHF, severe MR and Pulmonary HTN presenting with increased
dyspnea. During previous admission pt was started on Abx but
did not finish, as was deemed not to have PNA; she ultimately
improved with Lasix. 3 days PTA, son-in-law visited pt's
assisted-living facility and saw she was tachypnic. Today
daughter visited and saw that she was in severe respiratory
distress, with tachypnea and some wheezing. Patient has
Parkinson's disease and cannot given more history other than
that she is short of breath and denies headache, chest pain,
abdominal pain. She had not suffered any known illness since
discharge on [**6-20**]; there has been no sputum. Facility staff
administer all of her medications. Pt was brought by EMTs to
ED.
.
In the ED, initial vitals were 97.5 78 132/58 20 100% 15L. On
physical exam there were reportedly rales 75% up lungs
bilaterally. She improved with nebulizers, but still breathing
at 25-30 and requiring Venturi mask. Pt resisted BIPAP. Got
methylprednisolone 125mg and CTX/azithro. Lasix held due to
SBP<95. ECG showed atrial fibrillation, rate 60s, no ST
elevations, troponin 0.08 (downtrending from previous
admission), BNP 8673.
Past Medical History:
CHF: admitted [**Date range (1) 96195**] with dyspnea, found to have BNP [**Numeric Identifier **].
TTE revealed moderate to severe MR [**First Name (Titles) **] [**Last Name (Titles) **], severe pulmonary HTN,
and EF 55-60%. Symptoms improved with Lasix and she was
discharged to her [**Hospital3 **] facility. Torsemide and
spironolactone as outpatient.
- Coronary artery disease/NSTEMI: s/p 3V CABG in [**2123**]. In her
CHF hospitalization last month, troponin peak to 0.39 and EKG
with evidence of prior inferolateral MI. Given h/o severe
bradycardia and family's reluctance to place a pacemaker, a
beta-blocker was not started. She was started on high dose
atorvastatin and continued on ASA.
- Atrial Fibrillation w/ [**1-27**] second pauses and periods of
bradycardia to high 30s. On coumadin.
- Bacterial pneumonia (s/p hospitalization in [**6-/2139**]); daughter
reports that pt has had many PNAs, including Legionella,
beginning with one debilitating episode of several months before
the antibiotic era.
- Parkinsonism (essential tremor but no cogwheel phenomenon)
- Diabetes mellitus (currently not requiring treatment)
- Hypertension (well-controlled with baseline 120s/80s)
- Hyperlipidemia
- Acid reflux
- s/p TAH-BSO
- s/p cholecystectomy
- s/p bilateral cataract surgery
- hypothyroidism
Social History:
TOBACCO: 5 cigarettes per day, quit 40 years ago (~10PY)
ALCOHOL: denies due to medications.
OTHER DRUGS: denies. No intravenous drugs ever.
The patient currently lives alone in Springhouse ([**Hospital 4382**]) in [**Location (un) 538**] where she gets OT, PT, and medication
assistance. Also gets assistance in shower and while eating. Her
husband passed away in [**2129**]. She was a nurse at the [**Hospital3 **]
Hospital as a young woman. Her daughter is on the board of the
hospital and her son-in-law is a pediatrician; they visit her
very frequently and keep close track of her health issues.
Family History:
Diabetes: patient's mother and father, both late in life. Sister
living with diabetes.
Physical Exam:
General: Alert, NAD. Frail-appearing woman sitting quietly with
resting tremor and masked facies.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: JVP 9-10cm, shotty occipital and SCM lymph nodes.
CV: Hyperdynamic with palpable tap. In Afib, S1 S2, no
rubs/gallops. III/VI holosystolic murmur throughout precordium,
loudest at apex with radiation to axilla.
Lungs: Very mild wheezes. Rales in lower lung fields with
coarse crackles at apices.
Abdomen: soft, non-distended, diminished BS, no tenderness to
palpation, no rebound or guarding
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema.
Neuro: Patient intermittently attentive to examination.
CNII-XII grossly intact, [**3-30**] handgrip strength. Increased
resting tone in upper/lower extremities, with resting tremor.
1+ biceps/brachioradialis reflexes. No clonus. Downgoing toes.
Discharge Exam
General: Alert, NAD. Frail-appearing woman sitting quietly with
resting tremor
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: JVP 9-10cm, shotty occipital and SCM lymph nodes.
CV: Hyperdynamic with palpable tap. In Afib, S1 S2, no
rubs/gallops. III/VI holosystolic murmur throughout precordium,
loudest at apex with radiation to axilla.
Lungs: Lungs clear. Some dry cough intermittently, but patient
says this is her baseline and she usually requires nebs around
the clock.
Abdomen: soft, non-distended, diminished BS, no tenderness to
palpation, no rebound or guarding
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema.
Neuro: Patient intermittently attentive to examination.
CNII-XII grossly intact, [**3-30**] handgrip strength. Increased
resting tone in upper/lower extremities, with resting tremor.
1+ biceps/brachioradialis reflexes. No clonus. Downgoing toes.
Pertinent Results:
[**2141-6-29**] 03:45PM GLUCOSE-120* UREA N-41* CREAT-2.1* SODIUM-138
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-20* ANION GAP-19
[**2141-6-29**] 03:45PM estGFR-Using this
[**2141-6-29**] 03:45PM cTropnT-0.08*
[**2141-6-29**] 03:45PM proBNP-8673*
[**2141-6-29**] 03:45PM WBC-7.0 RBC-3.55* HGB-10.3* HCT-30.7* MCV-86
MCH-28.9 MCHC-33.5 RDW-15.3
[**2141-6-29**] 03:45PM NEUTS-63.5 LYMPHS-27.8 MONOS-5.4 EOS-2.0
BASOS-1.2
[**2141-6-29**] 03:45PM PLT COUNT-310#
[**2141-6-29**] 03:45PM PT-28.4* PTT-40.1* INR(PT)-2.7*
BCx: pending
CXR [**6-29**]
1. Interval resolution of the previously present pulmonary
edema.
2. Stable retrocardiac atelectasis.
3. Stable mild cardiomegaly.
Brief Hospital Course:
[**Known firstname 2155**] [**Known lastname 41171**] is a [**Age over 90 **]F with CHF, CAD, Afib, COPD, Parkinson's
who was brought to the ED from her [**Hospital3 **] facility for
respiratory distress and transferred to the ICU for presumed CHF
and/or COPD exacerbation. After receiving albuterol +
ipratropium nebulizers, methylprednisolone, azithromycin, and
CTX, her distress resolved and she quickly returned to her
baseline.
# Respiratory distress: sx responded to steroids and nebulizers;
pt now comfortable. Patient had no known history of recent
illness, no fever, no sputum production, and CXR showed only
improvement of prior effusions. The etiology of her respiratory
distress was felt to be mucus plugging. While COPD may have
complicated the clinical picture, the patient has no signs of
infection to suggest COPD exacerbation. The patient also has CHF
and pulmonary HTN, which may have made her even more suceptible
to acute respiratory disress. However, she was not felt to be
clinically volume overloaded and did no require diuresis to
improve. It was not felt that steroids or antibiotics were
necessary on discharge.
# HTN/diastolic CHF: TTE on previous admission reveals EF 55-60%
but with moderate-to-severe MR and pulmonary HTN. Clinical
picture is consistent with primarily left-sided HF: evidence of
pulmonary congestion with no peripheral edema (but elevated
JVP). Afib also contributes to diastolic failure. The patient
was seen by cardiology in the hospital, who recommended daily
weights on discharge, and stopping spironolactone for high K.
They also helped coordinate a follow up appointment soon after
discharge.
# Parkinson's: pt's PD limits communication. Per daughter, pt's
current level of interaction is her baseline.
# Hypothyroidism. home levothyroxine was continued
# CAD: continued home ASA, coumadin
# ?h/o Sz: no dx of seizure disorder per record; EEG [**2140-12-20**]
negative for sz but possibly with epileptogenic focusL continued
home keppra
Transition Issues
--DC Spironolactone
--Monitor Daily weights
Medications on Admission:
- Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
- Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **]
- Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation IH
QD
- Spironolactone 25 mg PO DAILY
- Torsemide 20 mg PO DAILY
- Amlodipine 10 mg PO DAILY Hold if SBP<100.
- Atorvastatin 80 mg PO DILY
- Aspirin 81 mg PO DAILY
- Warfarin - 2 mg PO SUN/TU/TH/SAT; 3mg PO MON/WED/FRI
- Carbidopa-Levodopa (25-100) 1 TAB PO TID
- Docusate Sodium 100 mg PO BID Hold if loose stools.
- LeVETiracetam 250 mg PO BID Take [**12-26**] Tab twice a day.
- Levothyroxine Sodium 25 mcg PO DAILY
- Ranitidine 150 mg PO DAILY
- Calcium Carbonate 500 mg PO TID
- Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours as needed for
shortness of breath, wheezing.
2. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
3. Symbicort 80-4.5 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation once a day.
4. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. warfarin 1 mg Tablet Sig: Three (3) Tablet PO MWF
(Monday-Wednesday-Friday): And take 2 tablets Sat Sun Tues
Thurs.
9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
three times a day.
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day: hold if loose stool.
11. levetiracetam 250 mg Tablet Sig: [**12-26**] Tablet PO twice a day.
12. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day.
15. Vitamin D3 400 unit Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY
COPD
Congestive Heart Failure
Possible mucus plug
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 41171**],
You were admitted to [**Hospital1 18**] with shortness of breath, which
improved rapidly. While this may be related to your heart
failure, we also think you may have had a plug of mucus blocking
one of the airways in your lung.
Your Visiting Nurse [**First Name (Titles) 4801**] [**Last Name (Titles) **] you every morning, and call
your heart failure doctor if your weight increases by 3 lbs.
MEDICATION CHANGES
Please STOP your spironolactone (it was causing your potassium
to be too high)
Followup Instructions:
Name: [**Last Name (LF) 22673**],[**First Name3 (LF) **] V.
Location: BIDHC [**Location (un) **] SUBACUTE CARE EXTENDED COMMUNITY
PRACTICE
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 14405**]
***The office will be by to visit you within a few days of your
discharge. IF you dont hear from them by Tuesday, please call
them direclty to arrange a visit.
Department: CARDIAC SERVICES
When: FRIDAY [**2141-7-7**] at 9:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"427.31",
"V45.81",
"E912",
"272.4",
"416.8",
"401.9",
"410.72",
"414.00",
"491.21",
"428.33",
"424.0",
"934.9",
"397.0",
"332.0",
"530.81",
"428.0",
"244.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10285, 10342
|
6190, 8257
|
272, 278
|
10443, 10443
|
5477, 6167
|
11178, 11889
|
3549, 3637
|
8991, 10262
|
10363, 10422
|
8283, 8968
|
10627, 11155
|
3652, 5458
|
212, 234
|
306, 1579
|
10458, 10603
|
1602, 2912
|
2928, 3533
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,571
| 108,110
|
14141
|
Discharge summary
|
report
|
Admission Date: [**2132-4-8**] Discharge Date: [**2132-4-11**]
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 7202**]
Chief Complaint:
Transferred from [**Hospital 100**] Rehab with acute shortness of breath
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
[**Age over 90 **] y.o. female with hx 3VD (99% LAD, 90% LCx, 100% RCA cath in
[**2128**]), refused CABG in past, h/o NSTEMI [**9-11**], CHF (echo [**3-15**] EF
15-20%, 3+ MR, mild AR), admitted for respiratory failure for
third time in last month. Precipitating factors for her repeated
CHF exacerbations are not clear. Patient denies medication
non-compliance or dietary indiscretions. Patient denies cough,
fever, chills, progressive dyspnea, chest pain, orthopnea or PND
prior to admission. Found at [**Hospital 100**] Rehab satting 74% on RA
150/80, 82, 28, 96.8 --> 100 % on NRB RR 30. In the ambulance
received 80 mg IV Lasix, NTG 0.4 SL x3, and magnesium. In ED
found to be in fulminant pulmonary edema, pale, diaphoretic, and
clammy. Put on CPAP and nitro gtt at 40 mcg. In the ED also
received Lasix 100 mg IV once and aspirin 600 mg. Intubated for
impending respiratory distress. Admitted to CCU. Briefly on
dopamine for BP support. Extubated the following day. Weaned off
pressors. Diuresed 1.6 L over CCU stay. Transferred to [**Hospital Unit Name 196**].
The patient was just admitted [**3-25**] -[**3-28**] with similar
presentation. Treated with diuresis and Levaquin for presumed
CAP.
Past Medical History:
1. CAD: 3VD, cath [**2128**] with 99% LAD, 90% LCx, 100% RCA stenoses.
Refused CABG. NSTEMI [**9-11**], hospitalization complicated by
cardiogenic shock requiring pressors and intubation and NSVT.
2. Ischemic cardiomyopathy: echo [**3-15**] EF 15-20%; severe global
LV HK, inferior AK, 1+ AR, [**4-11**]+ MR
3. CHF: Baseline 2 pillow orthopnea, chronic intermittent LE
edema. Numerous admissions for flash pulmonary edema. Most
recently discharge [**3-28**].
4. DM type II
4. HTN
5. Hyperlipidemia
Social History:
Lives at [**Hospital 100**] Rehab. She lost her husband almost 30 years
ago, and has 2 sons. [**Name (NI) 9464**] is a health care proxy. She denies
any history of smoking or alcohol use. No IVDU.
Family History:
non-contributory
Physical Exam:
When evaluated at the time of transfer out of the CCU:
99.4 BP: 96/54 P: 68 R: 24 O2 sat 100% on 2L
Gen: awake, alert, and oriented, in no apparent distress.
Neck: supple, JVP at 8cm
Lungs: Decreased breath sounds at both bases, with sort
bibasilar crackles.
CV: regular, Nl S1S2, II/VI HSM at apex.
Abd: soft, nontender, nondistended, with normoactive bowel
sounds.
Ext: trace LE edema
Pertinent Results:
Admission Labs:
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] WBC-12.9*# RBC-4.90# Hgb-14.2# Hct-44.3#
MCV-91 MCH-29.0 MCHC-32.1 RDW-14.2 Plt Ct-815*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] WBC-7.8 RBC-4.45 Hgb-12.9 Hct-38.6 MCV-87
MCH-29.1 MCHC-33.5 RDW-14.2 Plt Ct-647*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] Plt Ct-647*
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] Neuts-56 Bands-2 Lymphs-30 Monos-1*
Eos-8* Baso-2 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] Glucose-113* UreaN-36* Creat-1.5* Na-142
K-4.1 Cl-103 HCO3-25 AnGap-18
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] Calcium-9.3 Phos-4.3 Mg-2.1
[**2132-4-9**] 02:49PM [**Year/Month/Day 3143**] %HbA1c-PND
[**2132-4-8**] 11:20AM [**Year/Month/Day 3143**] Type-ART Rates-/18 Tidal V-500 FiO2-100
pO2-253* pCO2-48* pH-7.27* calHCO3-23 Base XS--4 AADO2-413 REQ
O2-72 Intubat-INTUBATED
[**2132-4-8**] 04:27PM [**Year/Month/Day 3143**] Type-ART pO2-129* pCO2-36 pH-7.43
calHCO3-25 Base XS-0
[**2132-4-8**] 11:59AM [**Year/Month/Day 3143**] Lactate-3.6*
[**2132-4-8**] 04:27PM [**Year/Month/Day 3143**] Lactate-1.3
_________________________________
Cardiac enzymes:
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] CK-MB-NotDone cTropnT-<0.01
[**2132-4-8**] 09:29PM [**Year/Month/Day 3143**] CK-MB-NotDone cTropnT-0.03*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] CK-MB-NotDone cTropnT-0.02*
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] CK(CPK)-41
[**2132-4-8**] 09:29PM [**Year/Month/Day 3143**] CK(CPK)-40
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] CK(CPK)-39
_________________________________
Other Labs:
[**2132-4-10**] 06:40AM [**Year/Month/Day 3143**] Iron-45 calTIBC-192* Hapto-108
Ferritn-353* TRF-148*
[**2132-4-9**] 02:49PM [**Year/Month/Day 3143**] %HbA1c-6.1*
_________________________________
Labs at the time of discharge:
[**2132-4-11**] 06:55AM [**Year/Month/Day 3143**] WBC-4.6 RBC-3.36* Hgb-10.0* Hct-29.2*
MCV-87 MCH-29.8 MCHC-34.3 RDW-14.0 Plt Ct-482*
[**2132-4-11**] 06:55AM [**Year/Month/Day 3143**] Glucose-97 UreaN-39* Creat-1.3* Na-138
K-4.2 Cl-105 HCO3-27 AnGap-10
[**2132-4-11**] 06:55AM [**Year/Month/Day 3143**] Calcium-8.6 Phos-3.9 Mg-2.2
_________________________________
Microbiology:
[**Year/Month/Day **] cultures 3/1/5: NGTD
Urine culture 3/1/5: <10,000 organisms
_________________________________
EKG: rate 100, nl axis, normal intervals, no R waves in V1-3,
left intraventricular conduction delay, secondary ST-T wave
changes in I, aVL, V6, no significant changes from prior EKG
CXR [**2132-4-9**]: There has been substantial interval clearing of the
patient's pulmonary edema.
Brief Hospital Course:
1. CHF exacerbation. This presentation and admission was similar
to the patient's prior admissions for pulmonary edema. There was
not clear etiology for her CHF exacerbation. The patient ruled
out for MI (she did have a small troponin leak in setting of
CHF). CXR on admission showed frank congestive heart failure.
The patent had to be intubated for impeding respiratory distress
in the ED and then was transferred to the CCU. She was diuresed
while still in the ED, and while she was in the CCU. Her beta
blocker, Imdur and ACE inhibitor were held because of
hypotension. She was on dopamine briefly for BP support (the
hypotension was felt to be secondary to aggressive diuresis). In
the CCU she diuresed 1.6 liters negative, with acceptable ABG's
on pressure support, and so was extubated. She was slightly
hypotensive after that (systolics in the 80s) and was placed on
dopamine for a day Once the dopamine was discontinued, her
regular medications were slowly restarted. She was placed back
on her lisinopril and restarted on her carvedilol. She was
continued with Lasix prn for a goal 500 to 1000 cc negative per
day (she usually responded to Lasix 40 mg IV). Her Lisinopril
dose was increased from 2.5 mg to 5 mg po QD for afterload
reduction given the patient's severe MR. [**First Name (Titles) **] [**Last Name (Titles) **] pressures
tolerated this increased dose. Imdur was discontinued as ACE
inhibitor felt to provide greater afterload reduction. Her Lasix
dose was increased to 60 mg po bid (she came in on 40 mg po
bid). She should be on no added salt diet. The patient may be a
candidate for spironolactone if her [**Last Name (Titles) **] pressures can
tolerate.
2. CAD. Patient with 3 vessel disease. She refused CABG in the
past. She ruled out for MI during this admission. Her troponin
was mildly elevated on admission likely in the setting of CHF.
She was continued on Aspirin, Ticlid (cannot take Plavix),
simvastatin (LFTs normal in [**9-11**] and were not rechecked given
likely elevation in the setting of hepatic congestion). The
patient was monitored on telemetry and had no events.
3. Acute on chronic renal failure. Patient with baseline CRI -
1.3-1.5. Her creatinine was elevated to 1.8 on admission, and
had come down to 1.3 by discharge likely secondary to improved
forward flow/renal perfusion.
4. Thrombocytosis. Likely reactive in the setting of acute
illness. Patient with h/o elevated platelets in past to 800's
now over 1000. Platelet count came down to [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 500 on the
day of discharge.
5. Anemia. The patient has chronic anemia. Her baseline HCT is
around 30. Patient's hematocrit was 44 on admission and dropped
to 31.5 on HD #3. Hemolysis labs were checked and were negative.
Iron studies were suggestive on anemia of chronic disease with
low normal serum iron, high ferritin, low TIBC and TRF. This
precipitous drops in hematocrits happened during her last 3
admissions. It is unclear why, as the patient's hematocrit
should go up with diuresis. She was not transfused during this
admission. Her HCT was at 29 by discharge which is about her
baseline. Would recommend rechecking Hct in the next two days to
ensure it is stable.
6. Cough. Patient afebrile. WBC normal. CXR negative for
infiltrate. Likely secondary to irritation post-intubation.
Patient felt symptomatically better with Benzonatate and
guaifenescin.
7. Code status. On Ms. [**Known lastname 42105**] prior admissions here, the
patient seems to have indicated that she wanted to be a DNR/DMI,
but this was reversed while she was at [**Hospital 100**] Rehab. During this
admission the patient stated on several occasions that she does
not want to be resuscitated or intubated. She is aware that her
son [**Name (NI) 9464**] feels that she should be full code. The patient
signed DNR/DMI form and was given a bracelet at the time of
discharge.
Medications on Admission:
Ecotrin 325 mg po qd
Lipitor 80 mg po qd
Coreg 3.125 mg po bid
Colace 100 mg po bid
Lasix 40 mg po bid
Atrovent qid
Imdur 30 mg po qd
Prevacid 30 mg po qd
Levaquin (finished [**4-4**] for CAP)
Zestril 2.5 mg po qd
MVI
Ticlid 250 mg po bid
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Ticlopidine HCl 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
6. 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*
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 7 days: for cough.
Disp:*21 Capsule(s)* Refills:*0*
8. Docusate Sodium 100 mg Tablet Sig: One (1) Capsule PO BID (2
times a day).
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
1. Congestive heart failure
2. Coronary artery disease
3. Mitral Regurgitation
4. Anemia of chronic disease
5. Thrombocytosis
6. Chronic renal insufficiency
Discharge Condition:
Maintaining oxygen sats in mid 90's on room air. Asymptomatic.
Tolerating diet and ambulation without difficulties.
Discharge Instructions:
Please continue to follow up closely with you doctors [**First Name (Titles) **] [**Last Name (Titles) 100**]
Rehab.
Please take all medications as prescribed. Please note that we
increased Lisinopril dose, stopped Imdur, and increased Lasix
dose to 60 mg po twice a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: [**2127**] liters per day
Followup Instructions:
Please continue to follow closely with you doctors [**First Name (Titles) **] [**Last Name (Titles) 100**]
Rehab.
Completed by:[**2132-4-11**]
|
[
"401.9",
"250.00",
"593.9",
"584.9",
"412",
"396.3",
"285.29",
"289.9",
"398.91",
"414.01",
"414.8",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
10815, 10880
|
5415, 9332
|
286, 298
|
11082, 11199
|
2733, 2733
|
11666, 11811
|
2288, 2306
|
9621, 10792
|
10901, 11061
|
9358, 9598
|
11223, 11643
|
2321, 2714
|
3922, 4368
|
174, 248
|
326, 1531
|
2749, 3905
|
1553, 2055
|
2071, 2272
|
4380, 5392
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,996
| 119,370
|
40173
|
Discharge summary
|
report
|
Admission Date: [**2198-1-24**] Discharge Date: [**2198-1-25**]
Date of Birth: [**2148-9-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Moxifloxacin / Minocycline /
Penicillins / Bactrim
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left Upper Extremity Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49F was at work in doctor's office earlier today, was unable to
move left hand and then felt tingling over her whole body. Next
she remembers waking in hospital. At OSH, she had second
witnessed seizure. She was given ativan, dilantin, decadron.
CT revealed 2x3 cm right frontal mass and she was transfrerred
here for further evaluation and treatment. Upon questioning does
endorse mild right frontal headache for couple days. Denies
visual changes, weakness, nausea, vomiting.
Past Medical History:
occassional oral herpes
Social History:
married, has daughter and 2 step-daughters. smokes 1/2ppd x 30
yrs and social EtOH.
Family History:
paternal grandfather died of lung ca father had MI, still
living; brother IDDM
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:[**7-7**] EOMs full with left lateral gaze nystagmus
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 6to4
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. L UE [**Doctor First Name **] 4+/5, tri [**6-7**], [**Hospital1 **] [**5-8**], grip 4+/5. Strength
full
power [**6-7**] RUE and B LE.Right pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
At Discharge: LUE weakness in bicep tricep and grip [**5-8**] delt
4+/5, o/w nonfocal
Pertinent Results:
[**1-25**] CT TORSO: no malignancy, read not finalized
[**1-25**] MRI BRAIN: Right Sided Dural based lesion, read not
finalized
Brief Hospital Course:
Pt admitted to the ICU for close neurological monitoring. She
was continued on dilantin and decadron. A CT torso and MRI brain
were requested to further evaluate her lesion and to rule out
metastatic disease.
On [**1-25**] after remaining stable, she was cleared for transfer to
the floor. She was stable on the floor and on the evening of
[**1-25**] she was deemed fit for discharge to home without services.
She will return electively for resection of her right frontal
lesion.
Medications on Admission:
asa 81 takes occasionally
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever,headache.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. 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*
4. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Frontal Brain Lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be as tolerated.
?????? You may shower
?????? 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.
?????? You should refrain from driving at this time.
Followup Instructions:
You will receive a phone call from our office regarding
scheduling of your surgery. if you have any questiosn before
that time please do not hesitate to call us at [**Telephone/Fax (1) 1669**]
Completed by:[**2198-1-25**]
|
[
"V49.81",
"729.89",
"780.39",
"788.30",
"305.1",
"V14.2",
"300.29",
"348.9",
"781.94"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3827, 3833
|
2668, 3150
|
379, 386
|
3904, 3904
|
2515, 2645
|
4626, 4851
|
1064, 1145
|
3227, 3804
|
3854, 3883
|
3176, 3204
|
4055, 4603
|
1160, 1313
|
2422, 2496
|
310, 341
|
414, 898
|
1565, 2408
|
3919, 4031
|
920, 946
|
962, 1048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,231
| 195,508
|
54184+59586
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-7-14**] Discharge Date: [**2121-7-22**]
Date of Birth: [**2058-5-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Cardiac Catheterization, Intraaortic Balloon Pump [**2121-7-14**]
emergency cabg x4 [**2121-7-16**] (LIMA to LAD, SVG to DIAG, SVg to
OM, SVG to RCA)
History of Present Illness:
63 year old male with history of ESRD on hemodialysis, IDDM,
htn, hyperlipidemia, peripheral arterial disease and bilateral
carotid artery disease (apparently tight right carotid) who was
admitted to [**Location (un) **] on [**7-10**] with worsening dyspnea, chest
fullness, transferred here on [**7-14**], underwent cardiac cath
showing 3VD (no intervention) now with hypotension, neck
stiffness and ST elevations V1-2, positive cardiac enzymes and
hypoglycemia.
.
Patient drove himself to [**Hospital **] Hospital with shortness of
breath, found to have elevated BNP at 2465, Trop 0.09-0.10,
Ck/MB
negative. EKG with new changes: right bundle and septal infarct
pattern. Echo at [**Location (un) **] on [**2121-7-11**] showed EF of 30-35%. He was
transferred here for cardiac cath on [**7-14**] which showed 3VD, no
intervention, but ultimate plan was for CABG. Given his
bilateral carotid disease, it was felt that this should be
further worked up. Carotid u/s showed 60% on right and 40% on
left. Given his dyspnea, orthopnea, he underwent an extra
dialysis run on [**7-15**] to remove additional fluid (2L removed). He
had been dialyzed on [**7-14**]. Referred for CABG.
Past Medical History:
Diabetes mellitus Type 2, dx at age 18
Hypertension
ESRD on dialysis since [**8-18**]
Multiple sclerosis tx by a neurologist in [**Location (un) **] with Avonex,
found on MRI, pt not symptomatic
Coronary artery disease diagnosed on CTA
Atrial and ventricular ectopy
Bicuspid aortic valve
R sided CVA with residual left-sided weakness, dx in [**2115**]
BPH
H/o nephrolithiasis
Hydronephrosis status post ureteral stents
H/o GI bleed
GERD
Hyperlipidemia.
Pulmonary infiltrates, most likely chronic aspiration, versus
Nocardia and vasculitis or sarcoidosis > currently investigated
Social History:
He is currently retired and lives alone. He does not drink
alcohol. He used to smoke cigarettes but he quit approximately
in [**2114**], 30pyrs.
Family History:
Mother with diabetes
Physical Exam:
VS Afebrile HR 64 BP 116/64 RR 20 Sat 96% RA
64" 45.4 kg
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 14 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. Scatterd basilar
crackles, without 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:
Cardiology Report ECHO Study Date of [**2121-7-16**]
PATIENT/TEST INFORMATION:
Indication: Abnormal ECG. Aortic valve disease. Chest pain.
Coronary artery disease. Hypertension. Left ventricular
function.
Status: Inpatient
Date/Time: [**2121-7-16**] at 13:44
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%)
INTERPRETATION:
Findings:
LEFT VENTRICLE: Mildly dilated LV cavity. Moderate-severe
regional left
ventricular systolic dysfunction. Severe regional LV systolic
dysfunction.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
hypo; anterior apex - hypo; lateral apex - hypo; apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Simple atheroma in aortic
root. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Focal
calcifications in ascending aorta. Normal aortic arch diameter.
Simple
atheroma in aortic arch. Focal calcifications in aortic arch.
Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic
aorta. Focal calcifications in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Moderately thickened aortic
valve
leaflets. No masses or vegetations on aortic valve. Mild AS
(AoVA 1.2-1.9cm2).
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Physiologic MR (within
normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure.
Conclusions:
PRE-CPB:
1. The left ventricular cavity is mildly dilated. There is
moderate to severe
regional left ventricular systolic dysfunction with severe
anterolateral
hypokinesis.. There is severe regional left ventricular systolic
dysfunction
with mild dilation of the LV cavity.. There is moderate
hypokinesis of the
remaining segments.
2. Right ventricular chamber size and free wall motion are
normal.
3. The aortic root is mildly dilated at the sinus level. There
are simple
atheroma in the aortic root. There are simple atheroma in the
ascending aorta.
There are simple atheroma in the aortic arch. There are focal
calcifications
in the aortic arch. There are complex (>4mm) atheroma in the
descending
thoracic aorta.
4. The aortic valve is bicuspid. The aortic valve leaflets are
moderately
thickened. No masses or vegetations are seen on the aortic
valve. There is
mild aortic valve stenosis (area 1.2-1.9cm2). No aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Physiologic
mitral
regurgitation is seen (within normal limits).
6. Large bilateral pleural effusions are seen.
POST-CPB: Pt is being AV pqaced and is on an infusion of Norepi,
Epi,
Milrinone
1. Biventricular function is slightly improved.
2. Aorta is intact post decannulation.
3. Other findings are unchanged.
Electronically signed by [**Known firstname **] [**Last Name (NamePattern1) 5209**], MD on [**2121-7-16**] 15:36.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 111051**])
CARDIAC CATHETERIZATION [**2121-7-14**]
1. Selective coronary angiography in this co-dominant
patient revealed severe native three vessel disease. The short
LMCA had
diffuse plaquing. The LAD was a twin system with the more
medial
anterior septum LAD having an ostial 80% and diffuse proximal
80%
disease. The Ramus was heavily calcified with severe diffuse
disease in
branch vessels. The LCX was heavily calcified with proximal
diffuse
disesease. There was mid 50% before OM1 and 70% after OM1. The
large
OM1 had proximal 50% disease and the distal AV groove LCX had
80%
disease. The RCA was heavily calcified with proximal diffuse
70-80%
with moderate pressure dampening. The mid RCA had 90% disease.
There
was no true PDA but multiple vessels seemed to run perpendicular
to the
inferior interventricular septum.
2. Resting hemodynamics revealed normal right and left filling
pressures with a preserved cardiac index. There was no gradient
across
the mitral or aortic valve. The systemic blood pressure was
normal and
there as no pulmonary hypertension.
3. LV gram deferred due to contrast load. Echo at [**Hospital **]
hospital with
EF 35% by report.
===================
ECHOCARDIOGRAPHY [**2120-7-15**]
The left atrium is normal in size. The estimated right atrial
pressure is
11-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is top normal/borderline dilated.
There is mild-to-moderate global left ventricular hypokinesis
(ejection fraction 40 percent). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated. Right ventricular systolic function is borderline
normal. The aortic root is mildly dilated at the sinus level.
There are focal calcifications in the aortic arch. The number
of aortic valve leaflets cannot be determined with certainty.
The aortic valve leaflets are mildly thickened. There is
systolic doming of the aortic valve leaflets, suggesting a
bicuspid aortic valve. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2121-5-15**], the left ventricular ejection fraction appears
somewhat further reduced. The aortic valve is probably bicuspid
and displays minimal stenosis.
============
LABORATORY
.
Hematology
[**2121-7-14**] 06:00PM BLOOD WBC-6.1 RBC-3.54* Hgb-11.0* Hct-32.6*
MCV-92 MCH-31.2 MCHC-33.9 RDW-15.9* Plt Ct-94*#
[**2121-7-14**] 06:00PM BLOOD Plt Smr-LOW Plt Ct-94*#
[**2121-7-15**] 07:05AM BLOOD Plt Ct-129*
[**2121-7-15**] 05:25PM BLOOD Plt Ct-133*
[**2121-7-16**] 03:39AM BLOOD Plt Ct-122*
.
Chemistry
[**2121-7-16**] 03:39AM BLOOD Glucose-151* UreaN-33* Creat-4.1* Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
.
Cardiac Biomarkers
[**2121-7-14**] 06:00PM BLOOD ALT-26 AST-11 CK(CPK)-36* AlkPhos-74
Amylase-31 TotBili-0.5 DirBili-0.1 IndBili-0.4
[**2121-7-15**] 07:05AM BLOOD CK(CPK)-252*
[**2121-7-16**] 03:39AM BLOOD ALT-20 AST-17 LD(LDH)-179 CK(CPK)-130
AlkPhos-69 TotBili-0.4
[**2121-7-15**] 07:05AM BLOOD CK-MB-41* MB Indx-16.3*
[**2121-7-16**] 03:39AM BLOOD CK-MB-10 MB Indx-7.7* cTropnT-1.15*
[**2121-7-14**] 06:00PM BLOOD %HbA1c-6.1*
Brief Hospital Course:
1. CAD:
Mr. [**Known lastname 111052**] had EKG changes suggetive of global ischemia with
multiple ectopic foci. Patient underwent cardiac catheterization
on [**2120-7-14**] that showed diffuse 3 vessel disease not amenable to
PCI. He was evaluated by cardiac surgery for CABG. On the
morning of [**2120-7-16**], the patient began to note neck pain and was
given 5mg of oxycodone. Shortly thereafter, he had hypotension
with BP 64/40, improving only to SBP of 80 with 500cc NS bolus.
Of note, he had dialysis the evening prior for volume overload.
EKG revealed new ST elevation in V1 and downward sloping ST
segment changes in V3-V6. He was started on dopamine at 5
mcg/kg/min on the floor and transferred to the CCU.
.
2. CHF - Pump Failure:
Patient had an echocardiogram that showed new LV dysfunction
since [**2121-5-15**], with a drop in EF from 50% to 40% with global LV
hypokinesis, with elevated RSVP. The patient developed an
elevation in CK from 36->252 the day after cath, which was
considered to be strain from volume overload, as it was not
accompanied by new EKG changes.
.
On [**2121-7-16**], after being transferred to the CCU for hypotension
requiring vasopressor support, he was *** sent to the cath lab
for insertion of an intraaortic balloon pump.
.
3. ESRD on HD
Dialysis schedule qMWF, but underwent additional session on
[**2121-7-15**] for volume overload, where 2L was removed by report.
.
4. DM-Hypoglycemia
Patient's regular insulin 75/25 was continued. The evening of
[**2121-7-15**], pt reported not eating as much. While hypotensive on the
morning of [**2121-7-16**], he was also hypoglycemic with at least two
fingersticks less than 40. He was given 1 amp of D50, and
increased his BS but then dropped back below 40, when he was
given another amp of D50.
.
5. Thrombocytopenia
On [**7-16**], taken to the OR and underwent emergency CABG x4 with Dr.
[**First Name (STitle) **]. IABP removed in the OR due to known aortic disease.
Transferred to the CSRU in stable condition on epinephrine,
levophed and milrinone drips. Extubated the next afternoon and
drips slowly weaned off.Renal service continued to follow him
throughout his stay for continued HD. Chest tubes removed on POD
#2 and transferred to the floor to begin increasing his activity
level. Pacing wires removed on POD #3.Beta blockade titrated
over the next few days. He had his routine dialysis treatment on
Monday, [**2121-7-21**], and tolerated it well. He is ready to be
discharged to rehab to progress with physical therapy and
increasing his mobility.
Medications on Admission:
Humalog 75/25 14 Units sc qAM and 16 Units sc qPM
Pravacid 30mg PO daily
Lopressor 25mg PO BID
Aggrenox 1 capsule PO BID
Clonidine 0.2mg PO Daily
Pravachol 80mg PO daily
Flomax 0.4mg PO daily
Avonex injection one time weekly
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
CAD s/p emergency CABG x4 with IABP
ESRD/HD
IDDM
elev. lipids
PVD
Bil. carotid dz.
CVA [**11-18**]; left vertebral artery stenosis
CHF
HTN
bicuspid aortic valve
multiple sclerosis
BPH
Discharge Condition:
stable
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams, powders or ointments on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call surgeon for fever greater than 100.5
Followup Instructions:
see Dr. [**Last Name (STitle) 25032**] in [**1-14**] weeks
see Dr. [**Last Name (STitle) 1016**] in [**2-15**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2121-7-22**] Name: [**Known lastname 18227**],[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 875**] Unit No: [**Numeric Identifier 18228**]
Admission Date: [**2121-7-14**] Discharge Date: [**2121-7-22**]
Date of Birth: [**2058-5-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
please see revised medication schedule
Medications on Admission:
Humalog 75/25 14QA/16QP
Prevacid 30'
Lopressor 25"
Aggrenox 1cap"
Clonidine 0.2'
Pravachol 80'
Flomax 0.4'
Avonex Qwk
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**First Name3 (LF) 1649**]: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet [**First Name3 (LF) 1649**]: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**First Name3 (LF) 1649**]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet [**First Name3 (LF) 1649**]: One (1) Tablet
PO Q6H (every 6 hours) as needed.
5. Carvedilol 6.25 mg Tablet [**First Name3 (LF) 1649**]: One (1) Tablet PO BID (2 times
a day).
6. Senna 8.6 mg Tablet [**First Name3 (LF) 1649**]: One (1) Tablet PO BID (2 times a
day).
7. Pravachol 80 mg Tablet [**First Name3 (LF) 1649**]: One (1) Tablet PO once a day.
8. Flomax 0.4 mg Capsule, Sust. Release 24 hr [**First Name3 (LF) 1649**]: One (1)
Capsule, Sust. Release 24 hr PO once a day.
9. Prevacid 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
10. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25)
Suspension [**Last Name (STitle) 1649**]: as directed Subcutaneous twice a day: 14 units
QAM
16 units QPM.
11. Avonex 30 mcg Kit [**Last Name (STitle) 1649**]: as directed Intramuscular once a
week.
Discharge Disposition:
Extended Care
Facility:
TBA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2121-7-22**]
|
[
"746.4",
"433.10",
"443.9",
"438.89",
"250.81",
"585.6",
"793.1",
"785.51",
"729.89",
"428.0",
"340",
"414.01",
"250.41",
"272.4",
"403.91",
"530.81",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"39.95",
"38.93",
"36.13",
"37.23",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
16985, 17135
|
10790, 13344
|
340, 495
|
14465, 14474
|
3424, 3480
|
14728, 15537
|
2485, 2507
|
15705, 16962
|
14258, 14444
|
15563, 15682
|
14498, 14705
|
3506, 7002
|
2522, 3405
|
281, 302
|
523, 1703
|
7034, 10767
|
1725, 2306
|
2322, 2469
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,151
| 177,966
|
9511
|
Discharge summary
|
report
|
Admission Date: [**2126-9-28**] Discharge Date: [**2126-9-28**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 81 year old male with
diabetes mellitus, hypertension, and severe aortic stenosis,
presenting with increasing shortness of breath times thirty
days. He tried sublingual Nitroglycerin times one which
helped but he kept having shortness of breath after a recent
discharge from C-Medicine for congestive heart failure
exacerbation. No chest pain, positive orthopnea, positive
paroxysmal nocturnal dyspnea, positive lower extremity edema,
positive constipation, no fever, chills, nausea, vomiting,
diarrhea or abdominal pain. He was brought in by EMS. He
had a urology appointment the day of admission so was more
active than usual. In the Emergency Department, he had some
relief with 40 mg of intravenous Lasix with 500cc of urine
output and given 162 mg of Aspirin after the patient had an
episode of chest pain which resolved. The patient was seen
by Cardiology who recommended gentle diuresis with addition
of low dose Dopamine as he did have severe aortic stenosis
and was preload dependent and was admitted to C-Medicine.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Hypertension.
3. Gout.
4. Severe aortic stenosis, valve area 1.1 with a gradient of
42 mmHg.
5. Coronary artery disease, status post myocardial
infarction in [**2110**], status post coronary artery bypass graft
with ejection fraction of 15 to 20%, 2+ mitral regurgitation.
6. Peripheral vascular disease.
7. Chronic Foley, status post transurethral resection of
prostate.
MEDICATIONS ON ADMISSION:
1. Captopril 50 mg three times a day.
2. Lopressor 50 mg p.o. twice a day.
3. Norvasc 5 mg once daily.
4. Lasix 20 mg twice a day.
5. Urecholine 25 mg three times a day.
6. Allopurinol 100 mg three times a day.
7. Colchicine 0.8 mg twice a day.
8. Aspirin 325 mg p.o. once daily.
9. Amaryl 1 mg p.o. twice a day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, ethanol or drug use.
Chest x-ray revealed cardiomegaly, positive pulmonary edema,
bilateral effusions.
PHYSICAL EXAMINATION: In general, the patient is in mild
respiratory distress. Vital signs revealed a temperature of
97, blood pressure 113/58, pulse 101, respiratory rate 20,
93% on four liters nasal cannula. Head - The pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. The oropharynx is clear.
Pulmonary - Rales one half way up bilaterally. Cardiac -
regular rate and rhythm, III/VI systolic ejection murmur
radiating to the carotids. Abdomen is soft, nontender,
nondistended, positive bowel sounds. Extremities - 2+
bilateral pitting edema. Neurologically, cranial nerves II
through XII are intact. Strength is [**3-24**] bilaterally.
LABORATORY DATA: White blood cell count is 5.8, hematocrit
30.4 which is baseline, platelet count 143,000, neutrophils
26%, bands 1%, 72% lymphocytes, Sodium 125, potassium 4.9,
chloride 94, bicarbonate 20, blood urea nitrogen 71,
creatinine 2.4, baseline is 2.4 to 2.6. CK 91, troponin less
than 0.3.
Electrocardiogram revealed left bundle branch block, but has
had left bundle branch block on most previous
electrocardiograms. Sinus tachycardia at 100 beats per
minute.
INITIAL ASSESSMENT: An 81 year old male with severe aortic
stenosis, coronary artery disease, status post coronary
artery bypass graft with ejection fraction of 15 to 20%,
presenting with shortness of breath and chest x-ray
consistent with congestive heart failure exacerbation.
Because of aortic stenosis, must be careful with diuresis as
he is preload dependent.
HOSPITAL COURSE: The patient was on the floor briefly when
he started to desaturate. The patient was paced on a 100%
nonrebreathing mask secondary to decreased oxygen saturation
and was hypotensive on Dopamine upon arrival. The patient
was assessed by the CCU team, was found to be tachycardic
with decreased blood pressure and was moved to CCU to attempt
noninvasive ventilation. Given that the patient had
previously made it clear that he was DNI, however, he was not
"Do Not Resuscitate". Upon arrival to the CCU, noninvasive
ventilation was initiated. The patient went into PEA arrest
and a cardiac code was called. ACLS protocol was begun. The
patient was DNI, however. Documentation of cardiopulmonary
arrest was provided. PEA continued. The patient's pulse
briefly returned. Upon further discussion with the patient's
family, the patient was made "Do Not Resuscitate". The
patient soon after lost his pulse and unsuccessful
resuscitation was started and shortly discontinued. The code
duration lasted from 07:40 to 07:57 a.m. Time of death was
7:57 a.m. on [**2127-9-28**].
DISCHARGE STATUS: Expired.
[**Name6 (MD) 475**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9632**]
Dictated By:[**Name8 (MD) 8279**]
MEDQUIST36
D: [**2127-3-17**] 15:57
T: [**2127-3-22**] 10:12
JOB#: [**Job Number 32345**]
|
[
"424.1",
"V45.81",
"428.0",
"414.8",
"401.9",
"250.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1612, 1973
|
3666, 5019
|
2130, 3648
|
116, 1159
|
1181, 1586
|
1990, 2107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,118
| 199,855
|
13586
|
Discharge summary
|
report
|
Admission Date: [**2116-12-14**] Discharge Date: [**2116-12-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 80 yo F who is independent in all her ADLs w/ PMH sig
for CAD s/p CABG & s/p LMain/OM1 stent on [**6-9**], DM, Afib, CHF w/
EF 40%, 3+MR, PVD, GERD, CRI w/ a bl Cr of 1.5, recent digoxin
toxicity who initially presented on [**12-14**] with 2 days of
generalized weakness, productive cough, low grade fevers, and
poor PO intake. In the ED, she was found to have a WBC of 18,
lacate of 6.3, SBPs in the 80s-90s, in rapid A-fib to the 120s,
and a CXR w/ a ?LUL infiltrate. As a result, she was begun on
the MUST sepsis protocol and started on empiric
levaquin/vancomycin/flagyl for a presumed pneumonia. She was
also noted on admission to be hyponatremic w/ a Na of 126,
hyperkalemic w/ a K of 6.2, acidotic w/ an anion gap of 22,
hypercalcemic w/ a Ca of 10.4, in acute renal failure w/ a Cr of
3.3, anemic with a 7 point Hct drop after only 7 hours, and a
mildly elevated troponin thought to be [**3-9**] demand ischemia. MICU
course notable for continued bleeding from RIJ site for which
she received a total of 5u PRBC (last [**12-15**]), 7u FFP to reverse
her coumadin coagulopathy, and a special suture by the surgical
team. Her HD stablized w/ fluids alone (no pressors ever
required). Because cultures remained negative, her vanc & flagyl
were d/c'd [**12-16**], and she was left only on levaquin.
.
Currently, pt without any complaints. Hasn't gotten out of bed
as yet. States her breathing is back to baseline and cough much
improved. Tol reg diet.
Denies F/C/CP/SOB/abd pain/diarrhea/LH/dizziness.
Past Medical History:
as above + appy, ccy. Baseline HCt 28-32. baseline Creat
1.3-1.6 although was 2.7 in [**11-9**]. GERD.
Social History:
functional @ home w/husband. no [**Name2 (NI) **]/etoh.
Family History:
NC
Physical Exam:
T 100.1 P 110-120 BP 104-64 R 20 O2 97 on 2L
Gen- fatigued, p[ale, lethargic but arousable
HEENT - Dry MM
Neck - EJ distended, supple
Chest - coarse BS with scattered crackles
Cor- tachy, III/VI SEM
Abd - S/NT/ND
Skin - warm dry, no rash, many eccymoses
Ext - toes cold
Pertinent Results:
[**2116-12-14**] 04:30AM WBC-18.1*# RBC-3.73* HGB-10.5* HCT-31.0*
MCV-83 MCH-28.3 MCHC-34.0 RDW-17.5*
[**2116-12-14**] 04:30AM NEUTS-87.4* BANDS-0 LYMPHS-7.2* MONOS-4.4
EOS-0.7 BASOS-0.4
[**2116-12-14**] 04:30AM PLT COUNT-345#
[**2116-12-14**] 04:30AM PT-21.1* PTT-36.8* INR(PT)-2.8
[**2116-12-14**] 04:30AM DIGOXIN-0.6*
[**2116-12-14**] 04:30AM ALBUMIN-4.4 CALCIUM-10.4* PHOSPHATE-5.2*
MAGNESIUM-2.1
[**2116-12-14**] 04:30AM CK-MB-2 cTropnT-0.04*
[**2116-12-14**] 04:30AM ALT(SGPT)-15 AST(SGOT)-22 CK(CPK)-69 ALK
PHOS-106 AMYLASE-59 TOT BILI-1.8*
[**2116-12-14**] 04:30AM GLUCOSE-258* UREA N-68* CREAT-3.6*#
SODIUM-122* POTASSIUM-6.2* CHLORIDE-75* TOTAL CO2-25 ANION
GAP-28*
[**2116-12-14**] 05:04AM LACTATE-6.3* K+-6.1*
[**2116-12-14**] 05:25AM LACTATE-3.4* K+-5.8*
[**12-18**]: Renal US: patent flow to both kidneys with no waveform
abnormalities. ?hyperechoic/hypoechoic mass in mid portion of
left kidney
Brief Hospital Course:
Assessment/Plan: 80F w/ resolved septic shock [**3-9**] presumed
pneumonia (although CXR unimpressive), iatrogenic acute blood
loss anemia [**3-9**] line placement, acute on chronic renal failure
likely [**3-9**] ATN, and troponin leak likely [**3-9**] demand ischemia.
1. Pneumonia- on admission, pt had a septic picture. She was
hypotensive, febrile, had a Lactate of 6. She was treated for
probable sepsis with fluid resuscitation, antibiotics
([**Last Name (un) **]/flagyl/vanco), and stress-dose steroids. Her hemodynamic
status quickly recovered, and she never required pressors. Her
sputum and blood cultures were negative, and CXR was not
impressive for an infiltrate (more consistent with CHF). She
remained afebrile with a falling white blood cell count. Her
Vanco/Flagyl were discontinued after 3 days. After transfer to
the floor, her levofloxacin was discontinued (as per the
attending) after 4 days of therapy. She remained afebrile and
stable. She was weaned off NC O2. Follow up CXR was more
consistent with pulmonary edema.
2. Anemia - While in the [**Hospital Unit Name 153**], she had a 7 point HCT drop 2/2 a
bleed from her right IJ line. She required 5 UPRBC, 7U FFP (to
reverse INR for her coumadin therapy), and a surgical suture to
control the bleeding. Her HCT remained stable after this
incident with no further bleeding for drop in hematocrit.
3. CAD - She had a troponin leak (to 1.29) with no significant
EKG changes or symptoms. This leak was thought to be [**3-9**] demand
ischemia in the setting of acute blood loss (from right IJ).
She was continued on ASA, metoprolol, lipitor,
hydralazine/lipitor (no ACE [**3-9**] poor renal function). She had
no symptoms of chest pain while on the floor.
4. CHF - Recent TTE at NEBH showed EF=40%. Her Lasix was
initially held due to her hypovolemia but was restarted as she
had signs of volume overload on CXR and on lung exam. She was
discharged on a dose of 80 mg Lasix (was on 120 as an
outpatient). This can be titrated up by her primary
cardiologist.
5. A-fib - She was rate-controlled on low dose beta blocker.
Her anticoagulation was initially held [**3-9**] her RIJ bleed. On
transfer to the floor, she was restarted on coumadin (bridged
with coumadin) for a goal INR [**3-10**]. She was discharged before her
INR was therapeutic, so she was bridged with Lovenox, to be
continued until her follow-up appointment on [**12-22**].
6. ARF - She presented with a creatinine of 3.6 (baseline
1.3-1.6). This was thought to be possibly secondary to ATN
(hypovolemia, acute blood loss). Her FeNA and FeBUN did not
suggest a prerenal etiology. Renal US showed patent flow to
both kidneys (done to evaluate for renal artery stenosis). A
hyperechoic/hypoechoic mass was seen in the midportion of her
left kidney. A CT or MRI as an outpatient is recommended to
follow up with this. On discharge, her creatinine had improved
to 2.3. Phoslo was used while in-house for hyperphospatemia but
was discontinued on discharge.
7. DM - Her glipizide and glucophage were initially held [**3-9**]
her ARF. She was covered with SSI while in-house with good
blood sugar control. She was discharged just on glipizide
(continued to hold glucophage [**3-9**] renal function). Her DM meds
can be titrated as an outpatient.
8. Electrolytes: She was hypercalcemic, hypokalemic, on
admission. These both resolved with hydration, repletion of K,
holding of lasix initially.
10. Proph - pneumoboots, bowel regimen, hep/coumadin were
continued in-house
11. Dispo - She was discharged after stabilization of her renal
function. Although PT recommended home PT, she refused this and
was discharged to home. She will follow up with her
cardiologist, Dr. [**Last Name (STitle) 11679**], on [**12-22**] at 3:30 pm.
Medications on Admission:
glucophage 1000 [**Hospital1 **]
glipizide 5 [**Hospital1 **]
asa
plavix 75 qd
coreg 6.25 qd
neurontin 400 mg TID
coumadin 5mg, 2.5 mg qod
ambien
Lasix 120 mg QD
Percocet PRN
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
Disp:*15 Capsule(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Lovenox 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous once
a day for 3 days.
Disp:*3 syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Septic Shock
CHF flare
Anemia
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all your medications as prescribed. The
following changes were made to your medications:
-Lasix dose was decreased to 80 mg/d (from 120)
-Neurontin dose was decrease due to your renal insufficiency
-Hydralazine and Isordil were added for your CHF
-Metformin was held secondary to your renal insufficiency
When you follow up with Dr. [**Last Name (STitle) 11679**], he can adjust these doses
if necessary.
2. Please follow up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11679**]
([**Telephone/Fax (1) 5455**]) on Tuesday, [**12-22**] at 3:30 pm. At this
appointment, you will need to have your INR checked as a measure
of your coumadin therapy.
3. You should have an outpatient CT/MRI to evaluate your
kidneys. On renal ultrasound during this hospitalization, there
was a possible mass on your left kidney that should be further
evaluated with a CT or MRI. Discuss this with Dr. [**Last Name (STitle) 11679**] at
your upcoming appointment.
Followup Instructions:
1. Follow up with your Cardiologist, Dr. [**Last Name (STitle) 11679**], on [**12-22**], at
3:30 pm. At this visit, you should also have your INR checked
to measure your coumadin therapy. He can also adjust your
medication regimen if he feels necessary.
2. You should have an outpatient CT/MRI to evaluate your
kidneys. On renal ultrasound during this hospitalization, there
was a possible mass on your left kidney that should be further
evaluated with a CT or MRI. Discuss this with Dr. [**Last Name (STitle) 11679**] at
your upcoming appointment.
|
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[
[
[]
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] |
[
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,875
| 184,772
|
35683
|
Discharge summary
|
report
|
Admission Date: [**2121-11-11**] Discharge Date: [**2121-11-15**]
Date of Birth: [**2041-11-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Abdominal pain (transfer from OSH for ERCP)
Major Surgical or Invasive Procedure:
ERCP [**2121-11-11**]
History of Present Illness:
79 yo M with h/o gallstone pancreatitis s/p ERCP X 3 with stent
placement and sphincterotomy, DM, CAD who presented to OSH on
[**11-10**] with epigastric and chest pain. Per OSH notes, the pain
came on suddenly in the morning of presentation, was described
as severe and non-radiating, and located in the patient's upper
abdomen and lower anterior chest. Initial VS were: 98.1 52
135/61 16 99%RA. He was given nitroglycerin with no
improvement in symptoms. He was admitted to the telemetry unit
and seen by the cardiology service. Initial EKG showed first
degree AV block, but no acute ST or T wave changes. Later in the
day, his EKG showed inferolateral ST changes interpreted as
repolarization abnormalities. He was managed medically, and
further cardiac work-up was negative including 3 sets of
negative biomarkers.
.
Given the patient's history of gallstone pancreatitis, the
patient underwent RUQ U/S, which showed a stone in GB neck, air
in the intrahepatic ducts, mild pericholecystic fluid, and a
thickened gallbladder wall. Labs were significant for WBC 7.4
with 42% bands on manual differential, tbili 6.1, dbili 1.2, AST
721, ALT 660, Cr 1.9 (up from 0.8). The patient's blood
pressure, which had been 130s systolic at presentation trended
down to 90s. He was started an Unasyn. Plavix and aspirin and BP
meds all were held on [**11-11**]. He was transferred to [**Hospital1 18**] for
ERCP and further evaluation. Vital signs at transfer were:
90's/50s HR: 80s RR: 18 O2 Sat: 98% RA.
.
ERCP at [**Hospital1 18**] showed multiple stones were seen at both main
intrahepatic ducts and CBD without stricture. Multiple stones
were extracted successfully from right and left main
intrahepatic ducts and CBD using a 8 mm balloon and copious pus
was drained.
.
On arrival to the ICU, VS: 86 86/53 10 96%RA. He is reporting
no abdominal pain or nausea. He reports feeling thirsty.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest 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:
- Diabetes
- Hyperlipidemia
- peripheral vascular disease
- Coronary artery disease (no stents)
- Hx of recurrent pancreatitis
- s/p ERCP X 3
- Hx of laryngeal ca tx with XRT in [**2100**]
- Hx of colonic polyps
Social History:
- Lives at home, retired mailman
- Tobacco: Quit smoking 20+ years ago
- Alcohol: [**12-1**] alcoholic drinks daily
- Illicits: None
Family History:
Father died of heart attack at age 65. Mother died of heart
disease at 85.
Physical Exam:
Admission exam:
Vitals: BP: 86/53 P: 86 R: 10 O2: 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, mildly tender in epigastrum,, mildly distended
distended, bowel sounds present, no rebound tenderness or
guarding GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2121-11-11**] 07:15PM BLOOD WBC-17.5*# RBC-3.67* Hgb-12.5* Hct-35.9*
MCV-98 MCH-34.1* MCHC-34.9 RDW-13.3 Plt Ct-123*
[**2121-11-11**] 07:15PM BLOOD Neuts-79* Bands-6* Lymphs-3* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-10* Myelos-0
[**2121-11-11**] 08:31PM BLOOD PT-21.5* PTT-37.2* INR(PT)-2.0*
[**2121-11-11**] 07:33PM BLOOD Glucose-158* UreaN-35* Creat-2.7*# Na-141
K-3.8 Cl-105 HCO3-19* AnGap-21
[**2121-11-11**] 07:33PM BLOOD ALT-426* AST-350* AlkPhos-117
TotBili-5.7*
[**2121-11-11**] 07:33PM BLOOD Calcium-7.7* Phos-5.0* Mg-1.0*
Imaging:
ERCP ([**11-11**]):
- The ampulla was s/p previous sphincterotomy.
- There was a small periampullary diverticulum.
- Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in complete opacification.
- A straight tip .035in guidewire was placed.
- Multiple stones were seen at both main intrahepatic ducts and
CBD. There was no stricture. CBD measured 6 mm.
- Multiple stones were extracted successfully from right and
left main intrahepatic ducts and CBD using a 8 mm balloon.
- Copious pus was drained.
- Given h/o questionable narrowing of CHD and stones in
intrahepatic -ducts seen on today's ERCP, cytology samples were
obtained for histology using a brush in the CHD to rule out
intraductal neoplasm.
- Otherwise normal ercp to third part of the duodenum.
.
PATHOLOGY-CBD BRUSHINGS:
Common bile duct, brushings:
NEGATIVE FOR MALIGNANT CELLS.
Reactive glandular epithelial cells and acute inflammation.
Microbiology:
URINE CX-NEGATIVE
BCX-PENDING/NO GROWTH
STOOL CX-NEGATIVE FOR C.DIFF.
.
ekg [**11-12**]:
Atrial fibrillation at a controlled ventricular rate.
Non-specific ST-T wave changes in leads V2-V6. Compared to the
previous tracing of [**2121-11-11**] no diagnostic interval change.
.
[**11-11**] EKG:
Sinus rhythm. Inferior and lateral ST-T wave changes may be due
to left
ventricular hypertrophy or myocardial ischemia. Clinical
correlation is
suggested. Compared to the previous tracing of [**2119-11-20**] the
findings are
similar.
[**2121-11-14**] 07:40AM BLOOD WBC-13.6* RBC-3.49* Hgb-12.1* Hct-33.5*
MCV-96 MCH-34.6* MCHC-36.1* RDW-13.7 Plt Ct-151
[**2121-11-13**] 03:44AM BLOOD WBC-17.7* RBC-3.72* Hgb-12.8* Hct-36.2*
MCV-97 MCH-34.5* MCHC-35.5* RDW-13.8 Plt Ct-131*
[**2121-11-14**] 07:40AM BLOOD WBC-13.6* RBC-3.49* Hgb-12.1* Hct-33.5*
MCV-96 MCH-34.6* MCHC-36.1* RDW-13.7 Plt Ct-151
[**2121-11-13**] 03:44AM BLOOD WBC-17.7* RBC-3.72* Hgb-12.8* Hct-36.2*
MCV-97 MCH-34.5* MCHC-35.5* RDW-13.8 Plt Ct-131*
[**2121-11-12**] 05:01AM BLOOD WBC-15.8* RBC-3.65* Hgb-12.5* Hct-35.3*
MCV-97 MCH-34.2* MCHC-35.3* RDW-13.8 Plt Ct-121*
[**2121-11-11**] 08:31PM BLOOD WBC-17.0* RBC-3.46* Hgb-11.8* Hct-34.1*
MCV-99* MCH-34.0* MCHC-34.4 RDW-13.9 Plt Ct-125*
[**2121-11-11**] 07:15PM BLOOD WBC-17.5*# RBC-3.67* Hgb-12.5* Hct-35.9*
MCV-98 MCH-34.1* MCHC-34.9 RDW-13.3 Plt Ct-123*
[**2121-11-14**] 07:40AM BLOOD Neuts-87.3* Lymphs-7.7* Monos-3.8 Eos-1.1
Baso-0.1
[**2121-11-13**] 03:44AM BLOOD Neuts-93.8* Bands-0 Lymphs-3.8* Monos-2.0
Eos-0.3 Baso-0.1
[**2121-11-12**] 05:01AM BLOOD Neuts-79* Bands-14* Lymphs-5* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2121-11-11**] 08:31PM BLOOD Neuts-72* Bands-9* Lymphs-3* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-10* Myelos-0
[**2121-11-11**] 07:15PM BLOOD Neuts-79* Bands-6* Lymphs-3* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-10* Myelos-0
[**2121-11-12**] 05:01AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2121-11-11**] 08:31PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2121-11-11**] 07:15PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-NORMAL Ovalocy-1+ Burr-OCCASIONAL
[**2121-11-15**] 06:09AM BLOOD PT-18.2* INR(PT)-1.7*
[**2121-11-14**] 07:40AM BLOOD Plt Ct-151
[**2121-11-14**] 07:40AM BLOOD PT-12.9* PTT-30.5 INR(PT)-1.2*
[**2121-11-13**] 03:44AM BLOOD Plt Ct-131*
[**2121-11-12**] 05:01AM BLOOD Plt Smr-LOW Plt Ct-121*
[**2121-11-12**] 05:01AM BLOOD PT-16.4* PTT-42.6* INR(PT)-1.5*
[**2121-11-11**] 08:31PM BLOOD Plt Smr-LOW Plt Ct-125*
[**2121-11-11**] 08:31PM BLOOD PT-21.5* PTT-37.2* INR(PT)-2.0*
[**2121-11-11**] 07:15PM BLOOD Plt Smr-LOW Plt Ct-123*
[**2121-11-12**] 05:01AM BLOOD Fibrino-558*
[**2121-11-15**] 06:09AM BLOOD Glucose-138* UreaN-26* Creat-1.2 Na-144
K-3.5 Cl-106 HCO3-28 AnGap-14
[**2121-11-14**] 07:40AM BLOOD Glucose-133* UreaN-28* Creat-1.3* Na-142
K-3.1* Cl-107 HCO3-27 AnGap-11
[**2121-11-13**] 03:44AM BLOOD Glucose-141* UreaN-35* Creat-1.7* Na-145
K-3.2* Cl-110* HCO3-24 AnGap-14
[**2121-11-12**] 04:03PM BLOOD Glucose-118* UreaN-40* Creat-2.1* Na-144
K-3.5 Cl-110* HCO3-23 AnGap-15
[**2121-11-12**] 05:01AM BLOOD Glucose-104* UreaN-41* Creat-2.6* Na-142
K-3.7 Cl-109* HCO3-21* AnGap-16
[**2121-11-12**] 12:58AM BLOOD Glucose-132* UreaN-40* Creat-2.7* Na-143
K-3.4 Cl-109* HCO3-20* AnGap-17
[**2121-11-11**] 08:31PM BLOOD Glucose-166* UreaN-37* Creat-2.8* Na-141
K-3.7 Cl-106 HCO3-20* AnGap-19
[**2121-11-11**] 07:33PM BLOOD Glucose-158* UreaN-35* Creat-2.7*# Na-141
K-3.8 Cl-105 HCO3-19* AnGap-21
[**2121-11-14**] 07:40AM BLOOD ALT-134* AST-40 LD(LDH)-255* AlkPhos-142*
TotBili-2.1*
[**2121-11-13**] 03:44AM BLOOD ALT-214* AST-101* LD(LDH)-207 AlkPhos-128
TotBili-2.8*
[**2121-11-12**] 04:03PM BLOOD ALT-273* AST-172* LD(LDH)-225 AlkPhos-112
TotBili-3.2*
[**2121-11-12**] 05:01AM BLOOD ALT-330* AST-261* AlkPhos-111
TotBili-4.4*
[**2121-11-12**] 12:58AM BLOOD LD(LDH)-182
[**2121-11-11**] 08:31PM BLOOD ALT-381* AST-322* AlkPhos-110
TotBili-5.6*
[**2121-11-11**] 07:33PM BLOOD ALT-426* AST-350* AlkPhos-117
TotBili-5.7*
[**2121-11-11**] 08:31PM BLOOD Lipase-12
[**2121-11-15**] 06:09AM BLOOD Calcium-8.7 Phos-1.9* Mg-1.8
[**2121-11-14**] 07:40AM BLOOD Calcium-8.5 Phos-1.8* Mg-2.0
[**2121-11-13**] 03:44AM BLOOD Calcium-7.5* Phos-2.3* Mg-1.9
[**2121-11-12**] 04:03PM BLOOD Calcium-7.9* Phos-1.9*# Mg-1.9
[**2121-11-12**] 05:01AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.8
[**2121-11-12**] 12:58AM BLOOD Calcium-7.1* Phos-3.8 Mg-1.8
[**2121-11-11**] 08:31PM BLOOD Albumin-3.3* Calcium-7.4* Phos-4.7*
Mg-1.0*
[**2121-11-11**] 07:33PM BLOOD Calcium-7.7* Phos-5.0* Mg-1.0*
[**2121-11-12**] 12:58AM BLOOD Hapto-117
[**2121-11-12**] 04:44PM BLOOD Lactate-2.1*
[**2121-11-12**] 05:35AM BLOOD Lactate-2.1*
[**2121-11-12**] 01:36AM BLOOD Lactate-2.4*
Brief Hospital Course:
79 yo M with h/o gallstone pancreatitis s/p ERCP in past with
stent placement/ sphincterotomy who presented with abdominal
pain, hypotension, leukocytosis/bandemia concerning for biliary
sepsis. Now s/p ERCP with stone extraction and pus drainage.
#. Septic Shock/Due to cholangitis with bile duct obstruction
and choledocholithiasis/transaminitis/leukocytosis- Patient
presented with hypotension, leukocytosis with bandemia and known
source (pus drained intrahepatically during ERCP). There was
also evidence of end-organ hypoperfusion as creatinine elevated,
urine output was low, and lactate was elevated. Patient was
bolused with fluids to maintain UOP>40cc/h, and did not require
pressors. Leukocytosis/bandemia trended down and pt became
afebrile. Lactate elevated with elevated creatinine likely
secondary to hypoperfusion, leading to ATN. Both lactate and
creatinine trended down and were normalized and at baseline,
respectively by HD 2. Blood and urine cultures both had no
growth to date, and on HD 3, antibiotics were narrowed from
pip/tazo to oral cipro/flagyl, with plan to treat for seven days
from day of ERCP ([**2121-11-11**]), ending [**2121-11-18**]. Final urine
culture was negative. BCX are still no growth to date at time of
discharge. Pt did not have any respiratory symptoms to suggest
PNA. Pt should have consideration of a cholecystectomy as an
outpatient given his prior ERCPs, ? history of gallstone
pancreatitis and now current cholangitis with
choledocholithiasis. Pt was sent up in surgical clinic for
evaluation (see below). Pt remained pain free on the regular
medical floor and his diet was advanced to regular without any
complications. Bile duct brushings were taken and were found to
be negative by pathology. Pt will need to have repeat LFTS done
in the outpatient setting to ensure downtrending. (His nitrates,
diuretics, ACEI, statins were helding during admission given his
hypotension, sepsis, and transaminitis).
#. Oliguric acute renal failure: Patient oliguric on arrival to
the ICU with creatinine rising from baseline 0.8 to peak of 2.8.
Patient was aggressively fluid resuscitated, and creatinine
trended down. Urine sediment with evidence of mild muddy brown
casts, consistent with ATN, likely secondary to renal
hypoperfusion. Creatine normalized and was 1.2 on day of
discharge. However, his diuretic and ACEI were held during
admission and not yet restarted upon discharge given that the
creatinine had just "normalized". Ucx was negative. Pt should
have repeat chemistry panel at PCP's office this week to ensure
continued improvement/stabilization.
#. Atrial fibrillation/flutter: On hospital day 2, patient was
noted to be in atrial fibrillation. Patient has no known
history of atrial fibrillation. He was hemodynamically stable
otherwise and asymptomatic. His home metoprolol was restarted,
initially at half home dose. Patient's rate was well
controlled. CHADS2 score was 3 for hypertension, age and DM.
Patient was started on coumadin on HD 3 and will follow up with
his PCP after discharge. Of note, pt is on asa and plavix
therapy. Should discuss with PCP and cardiologist the
risk/benefits/need for continuing all 3 agents with the risk of
bleeding. Pt was advised to follow up with his PCP and
cardiologist after discharge. Beta blocker resumed to home dose
50mg [**Hospital1 **] on discharge. PT WAS INSTRUCTED TO HAVE HIS INR CHECKED
ON MONDAY [**2121-11-17**]. PT IS ON CIPRO THERAPY WHICH COULD CAUSE
SUPRATHERAPEUTIC INR. PT WAS RECEIVING 4MG OF COUMADIN DAILY.
INR ON DISCHARGE WAS 1.7. PLEASE SEE THE ABOVE LAB SECTION FOR
INR TREND.
#. Coronary artery disease: Presented to OSH in [**7-5**] with ACS,
cardiac cath revealed multivessel CAD not amenable to
revascularization per cardiology c/s note from OSH. Managed
medically since that point. Trop neg X 3 at OSH. EKG at
baseline. Continued aspirin, plavix. Beta blocker, nitrate and
ACEi held initially in setting of hypotension and statin held in
setting of elevated LFTS. Upon discharge, pt was restarted on
his home dose 50mg [**Hospital1 **] metoprolol. Nitrate was still held given
recent hypotension but should be restarted ASAP after PCP
[**Name Initial (PRE) 13102**]. ACEI held given resolving ARF and hypotension. Statin
and zetia were held given transaminitis. These were not
restarted during hospitalization, but should be ASAP after LFTs
recheck in outpatient setting to ensure downtrending/resolution.
#. Diabetes: Metformin held in setting of [**Last Name (un) **], and blood sugar
was well controlled on insulin sliding scale. Pt instructed to
resume metformin upon discharge.
#. Hyperlipidemia: Statin and zetia held, as above, in setting
of elevated LFTs. This can be resumed in outpatient setting
after ensuring improvement/resolution of transaminitis.
#. Peripheral vascular disease: ASA and plavix resumed during
admission. Pt started on coumadin for afib as above. Pt should
continue to discuss with his PCP and cardiologist if asa/plavix
and coumadin are all indicated moving forward.
.
#dysuria/urinary frequency. Etiologies considered included UTI
and/or catheter related or due to BPH. Symptoms developed after
catheter removal. Pt is on cipro therapy for above that will
cover for typical UTI causing organisms. However, UCX [**11-14**] was
negative. Pt was able to void without difficulty and did not
have any pelvic or abdominal pain. He was continued on his
flomax therapy. He was encouraged to follow up with his PCP
after discharge to consider whether a urology referral is
indicated. Pt likely with urinary retention, but able to void
without pain.
.
#diarrhea-improved during admission. C.diff was negative. Likely
antibiotic effect.
.
#normocytic anemia-remained stable during admission. No signs of
acute bleeding or hemolysis. HCT 33.5 on discharge. Can conside
iron studies and/or colonoscopy in outpatient setting.
.
#thrombocytopenia-was likely due to acute illness/sepsis. Could
consider heparin effect but normalized despite heparin and was
151 on day of discharge.
.
TRANSITIONAL CARE
1.MONITORING OF INR AND ADJUSTMENT OF COUMADIN PRN
2.DISCUSSION OF NEED FOR ASA/PLAVIX/COUMADIN
3.REINITIATION OF NITRATE, STATIN, ZETIA, ACEI, AND DIURETIC
WHEN/IF BP ALLOWS AND CREATININE NORMALIZES
4.SURGICAL CONSULTATION FOR CONSIDERATION OF CCY
5.??UROLOGY C/S FOR BPH
6.FOLLOW UP OF LABS INR, CHEMISTRY/CR, LFTS
Medications on Admission:
home meds:
- ASA 81 mg daily
- Lansoprazole 30 mg qday
- Isosorbide Dinitrate 40 mg PO TID
- Metoprolol Tartrate 50 mg PO BID
- Ezetimibe 10 mg qday
- Tamsulosin 0.4 mg PO qday
- Indapamide 2.5 mg PO qday
- Simvastatin 40 mg PO qday
- Plavix 75 mg PO qday
- KCl 10 mEQ PO qday
- Fosinopril 10 mg qday
- Folic acid 400 mcg PO qday
- Metformin 500 mg [**Hospital1 **]
Discharge Medications:
1. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Hospital1 **]: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*0*
4. metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every
8 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
5. ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. folic acid 400 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
8. potassium chloride 10 mEq Tablet Extended Release [**Last Name (STitle) **]: One
(1) Tablet Extended Release PO once a day.
9. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
twice a day.
11. metformin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
12. Medications held at discharge.
These medications are HELD/STOPPED at time of discharge until
PCP follow up.
HOLD
isosorbide dinitrate 40mg TID
ezetimibe 10mg daily
indapamide 2.5mg daily
simvastatin 40mg daily
fosinopril 10mg daily
13. Outpatient Lab Work
INR/PT, chem 7, AST/ALT, bilirubin. To be drawn on [**2121-11-17**] with
results sent to PCP-
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Address: 37 G WHISTLESTOP MALL, [**Location (un) **],[**Numeric Identifier 81176**]
Phone: [**Telephone/Fax (1) 67627**]
Fax: [**Telephone/Fax (1) 81177**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Cholangitis
choledocholithiasis
sepsis
acute renal failure
.
CAD
DM2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with an infection of your gallbladder and bile
ducts due to a blockage and stones. An ERCP was done to relieve
the obstruction and you were treated with antibiotics, which you
will continue for one more week. During this time you also
suffered from kidney injury, which has recovered/improved.
Additionally, you were diagnosed with Atrial fibrillation (an
irregular heart beat) and were started on a blood thinner
(coumadin). Your blood will need to be checked regularly to
adjust this medicine. It is important that you follow up with
your PCP and cardiologist after discharge to continue to discuss
the need for all of your blood thinners (aspirin, plavix,
coumadin).
.
We recommend that you have an evaluation by a surgeon (see
below) to have consideration of removing your gallbladder.
.
Medication changes: (some of your medications wwere
changed/stopped this admission because your blood pressure was
low and your kidneys and liver were sick). It is of extreme
importance that you follow up with your PCP so that these
medications can be restarted ASAP.
1.STOP isosorbide dinitrate 40mg TID
2.STOP ezetimibe 10mg daily
3.STOP indapamide 2.5mg daily
4.STOP simvastatin 40mg daily
5.STOP fosinopril 10mg daily
6.START coumadin/warfarin 4mg daily
7.START ciprofloxacin 400mg [**Hospital1 **] for 6 days
8.START flagyl 500mg TID for 6 days.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Address: 37 G WHISTLESTOP MALL, [**Location (un) **],[**Numeric Identifier 81176**]
Phone: [**Telephone/Fax (1) 67627**]
**We were unable to schedule an appointment with your PCP. [**Name10 (NameIs) **] is
recommended you see your Dr [**Last Name (STitle) 176**] 1-3 days of your discharge
from the hospital. Please call your Dr [**Last Name (STitle) **] the number above on
Monday to schedule a follow up and coumadin check.**
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2121-12-5**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 79168**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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] |
icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,113
| 119,090
|
4900
|
Discharge summary
|
report
|
Admission Date: [**2149-4-28**] Discharge Date: [**2149-5-3**]
Date of Birth: [**2103-6-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Amoxicillin / Blood-Group Specific Substance /
Adhesive Tape
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Acute onset shortness of breath.
Major Surgical or Invasive Procedure:
Left medial malleolus debridement and bone biopsy.
History of Present Illness:
A 45 year-old woman with past medical history of diabetes,
dyslipidemia, hypertension, coronary disease s/p CABG in [**5-1**]
(LIMA-LAD, SVG-PDA, OMI-Diag) with known occlusion of 2 SVGs
with patent SVG to RCA and LIMA to LAD, diastolic CHF (EF
50-55%), ESRD s/p kidney transplant, who presents today with
acute onset shortness of breath.
Patient says the symptoms started on the morning of admission
with acute onset SOB that woke her from sleep. There was
associated chest tightness. Both symptoms improved markedly once
she sat up, but she continued to experience mild shortness of
breath so she called 911.
She was initially evaluated at [**Hospital6 33**] where she
was placed on a nitro drip (CP resolved) and BiPAP. She was
given 80 mg IV Lasix with unclear amount of urine output.
Cardiac enzymes were negative. She was then transferred to [**Hospital1 **]
for further care. Her vitals at time of transfer were T 98, BP
125/26, RR 32, sat 100% on BiPAP. In the ED she was noted to
have bibasilar crackles on exam. An EKG showed no ischemic
changes and CXR showed no clear infiltrate (by my read). She was
weaned off of BiPAP and placed on 2L oxygen by nasal cannula.
She was given one dose of levofloxacin 750 mg IV and Dilaudid 1
mg IV and admitted to the CCU given her tenuous respiratory
status. Urine output per [**Hospital1 **] records was 200 cc since arrival in
the ED. Her vitals at time of transfer were BP 151/60, HR 87,
satting 96% 2L, RR 16.
Of note, the patient was recently admitted and discharged two
weeks prior to this for worsening dyspnea. She was found on TTE
to have new severe mitral regurgitation and pulmonary
hypertension. A Swan-Ganz was placed that showed [**Hospital1 **]
pulmonary pressures, decreased SVR, and [**Hospital1 **] CO and CI. She
was tried on various meds to control her blood pressure and
reduce her afterload, including a nitroglycerine drip, a
nitroprusside drip, and IV hydralazine. With the afterload
reduction achieved by these medications, her dyspnea improved.
She was also diuresed with IV Lasix. Of note, while the patient
was in the CCU, she was evaluated by CT surgery for potential
mitral valve surgery in the future with plan for follow-up as
outpatient.
Of note, Lasix dose was recently decreased to 80 mg tablets
twice daily, every other day; this was decreased from one tablet
twice daily every day. This change was made one week ago by Dr.
[**Last Name (STitle) **].
In the interim since the last admission, patient reports that
she has been doing okay. This morning was her first episode of
shortness of breath.
Past Medical History:
s/p CABG in [**5-1**] (LIMA-LAD, SVG-PDA, OMI-Diag)
- known occlusion of 2 SVGs with patent SVG to RCA and LIMA to
LAD
- [**9-8**] PTCA of the LCx for recurrent CHF episodes
- Recent hospitalization [**2149-3-21**] for left ankle septic arthritis
L at ORIF site --> debrided in OR, cultures grew
coagulase-negative staph aureus (oxacillin resistance) and pt
d/c'ed on vanc. Hospitalization c/b pulmonary edema and
hyperglycemia treated with fluids.
- Diastolic congestive heart failure, EF 50-55%
- Diabetes Type I complicated by retinopathy (legally blind),
diabetic foot ulcers, hypoglycemic seizure, and gastroparesis
- ESRD s/p kidney transplant
- CAD s/p CABG [**2140**] and PTCA in [**9-8**]
- Hypertension
- Hyperlipidemia
- Hematemesis requiring multiple transfusions in [**2149-1-31**] at
[**Hospital6 **] in the setting of vomiting. No EGD done at
the time. Hct stable since then.
- PVD s/p R fem [**Doctor Last Name **] bypass graft, s/p L SFA [**Doctor Last Name **] ([**5-9**])
- Hx of intracranial bleed falling fall, [**2147**]
- Sarcoidosis
- Cataracts
- Depression
- s/p cholecystectomy
- s/p tubal ligation
- s/p left patella fracture
- s/p left wrist fracture
- s/p left ankle fracture, s/p ORIF [**10/2148**] complicated by
purulent drainage and OR debridement [**2149-3-25**].
Social History:
-ETOH: none
-Illicit drugs: smokes marijuana several times per week to help
with nausea and appetite
Family History:
There is no history of diabetes or kidney disease. Her father
had an MI at 74 and mother has hypertension. Grandfather had
leukemia and hypertension.
Physical Exam:
VS: T= 97.5, BP= 147/51, HR= 87, RR= 16, O2 sat= 94% 2L
GENERAL: cachectic woman appears older than stated age, resting
in bed in no acute distress
HEENT: PERRLA
NEURO: awake, alert and oriented
NECK: +JVD to angle of mandible
CARDIAC: RRR, normal s1/s2, holosystolic blowing murmur that
radiates to axilla consistent with known mitral regurgitation
LUNGS: bibasilar crackles
ABDOMEN: soft, non-tender
EXTREMITIES: no pitting edema; feet warm and perfused but
without palpable pulses; cast in place over left lower
extremity; this was removed to reveal a small ulceration over
medial malleolus with white tissue at base; no exudate or
surrounding erythema to suggest infection
SKIN: left lower extremity ulcer as above
Pertinent Results:
Labs at Admission:
[**2149-4-28**] 11:30AM BLOOD WBC-5.0 RBC-2.95* Hgb-8.2* Hct-25.9*
MCV-88 MCH-27.8 MCHC-31.6 RDW-15.9* Plt Ct-410
[**2149-4-28**] 11:30AM BLOOD Neuts-69.3 Lymphs-20.5 Monos-4.2 Eos-5.5*
Baso-0.6
[**2149-4-28**] 11:30AM BLOOD PT-12.6 PTT-24.1 INR(PT)-1.1
[**2149-4-30**] 04:00AM BLOOD ESR-4
[**2149-4-28**] 11:30AM BLOOD Glucose-180* UreaN-39* Creat-2.2* Na-136
K-4.6 Cl-102 HCO3-23 AnGap-16
[**2149-4-28**] 11:30AM BLOOD Calcium-9.6 Phos-2.3*# Mg-1.7
[**2149-4-29**] 04:58AM BLOOD CRP-7.8*
Labs at Discharge:
[**2149-5-3**] 06:16AM BLOOD WBC-3.5* RBC-2.77* Hgb-7.8* Hct-23.8*
MCV-86 MCH-28.1 MCHC-32.6 RDW-15.8* Plt Ct-443*
[**2149-5-1**] 04:55AM BLOOD PT-12.1 PTT-26.7 INR(PT)-1.0
[**2149-5-3**] 06:16AM BLOOD Glucose-176* UreaN-53* Creat-1.7* Na-136
K-4.4 Cl-100 HCO3-27 AnGap-13
[**2149-5-3**] 06:16AM BLOOD Calcium-9.3 Phos-4.5 Mg-1.9
Cardiac Enzymes:
[**2149-4-28**] 11:30AM BLOOD CK(CPK)-13*
[**2149-4-29**] 01:17AM BLOOD CK(CPK)-12*
[**2149-4-28**] 11:30AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 20434**]*
[**2149-4-28**] 11:30AM BLOOD cTropnT-0.02*
[**2149-4-29**] 01:17AM BLOOD CK-MB-1 cTropnT-<0.01
Vancomycin Levels:
[**2149-4-28**] 11:30AM BLOOD Vanco-8.9*
[**2149-4-29**] 06:31PM BLOOD Vanco-17.7
[**2149-5-1**] 04:55AM BLOOD Vanco-17.5
Tacrolimus Levels:
[**2149-4-29**] 04:58AM BLOOD tacroFK-5.2
[**2149-4-30**] 04:00AM BLOOD tacroFK-3.0*
[**2149-4-30**] 08:08AM BLOOD tacroFK-2.6*
[**2149-5-1**] 04:55AM BLOOD tacroFK-6.6
[**2149-5-2**] 05:42AM BLOOD tacroFK-5.5
Microbiologic Data:
Left ankle biopsy ([**2149-4-30**]): 11:25 am
TISSUE Site: ANKLE LEFT ANKLE.
GRAM STAIN (Final [**2149-4-30**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Final [**2149-5-3**]): NO GROWTH
Imaging Studies:
EKG ([**2149-4-28**]): Sinus rhythm. Low limb lead voltage. Since the
previous tracing the small R waves in leads V1-V2 are more
prominent, axis is more leftward and ST-T wave abnormalities are
more marked. Clinical correlation is suggested.
CXR ([**2149-4-28**]): FINDINGS: Single semi-upright portable view of
the chest was obtained. A right-sided PICC line is again seen,
terminating in the proximal SVC. Patient is status post median
sternotomy. Previously seen left lower lobe consolidation and
small left pleural effusion have essentially resolved with trace
left base residua of atelectasis and possible small amount of
consolidation. Surgical clips are seen overlying the right lung
base/breast. Cardiac and mediastinal silhouettes are unchanged.
Renal transplant ultrasound ([**2149-4-29**]): FINDINGS: Multiple
transverse and longitudinal son[**Name (NI) 1417**] of the renal transplant
were obtained. There is no hydronephrosis and no perinephric
fluid collection. The morphology is normal. Specifically, there
is no swelling, normal pyramids, and no pelvi-infundibular
thickening and normal renal sinus fat. The resistive brain
indices range from 0.63 to 0.72, essentially within normal
limits. Vascularity is symmetric throughout and venous drainage
is normal.
IMPRESSION: Unremarkable renal transplant ultrasound.
Left knee and ankle plain films ([**2149-4-29**]): AP and lateral
bedside views of left knee show a recent transverse fracture
across the patella with moderate fragment displacement. There
are posteromedial apparent [**Month/Day/Year 1106**] clips in the distal thigh
and proximal leg. Extensive [**Month/Day/Year 1106**] calcifications. I see no
comparison images of this knee and I have no history regarding
this exam. AP and lateral views of the left ankle are limited by
bedside technique and cast. There is extensive destruction of
the medial malleolus and adjacent distal portion of the tibia
with displaced fracture through the base of the medial
malleolus. There is associated soft tissue swelling and a single
clip in the proximal adjacent soft tissues. Laterally there is
an intramedullary pin through the distal fibula with two
fixation transverse screws extending across this rod into the
adjacent tibial metaphysis. No evidence of loosening of this
hardware. There is posterior subluxation of the talus on the
ankle mortise and ankle joint in AP projection shows valgus
deformity. Appearance is little changed from similar exam [**2149-4-7**].
IMPRESSION: Patellar fracture. Fractured medial malleolus with
associated
osteomyelitis very likely.
Transthoracic [**Year (4 digits) 461**] ([**2149-4-30**]): The left atrium is
mildly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
There is mild regional left ventricular systolic dysfunction
with mild hypokinesis of the basal to mid inferolateral
segments. Overall left ventricular systolic function is normal
(LVEF>55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The 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. The
mitral valve leaflets are mildly thickened. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Moderate to severe
(3+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior study (images reviewed) of [**2149-4-9**], the estimated
pulmonary artery systolic pressures are slightly lower. The
other findings are similar.
Brief Hospital Course:
In summary this is a 45 year-old woman with history of DM1, CAD
s/p CABG and PCI, ESRD s/p living-related kidney transplant in
[**10-31**], and recent hospitalization for shortness of breath
presumed due to worsening mitral regurgitation and pulmonary
hypertension who now presents with acute onset shortness of
breath.
# Shortness of Breath. Her presentation was felt to be
consistent with orthopnea and worsening congestive heart
failure. Other considerations were pneumonia, ACS, and PE. EKG
was unremarkable for ischemic changes and cardiac enzymes were
normal. CXR showed no evidence of pneumonia or infiltrate. She
was diuresed with 80 mg boluses of intravenous Lasix to which
she responded well. Oxygen was weaned as tolerated. She
underwent repeat transthoracic [**Month/Year (2) 461**] that showed severe
MR although no significant change from prior. Cardiac surgery
was consulted for further consideration of mitral valve
replacement. Her preoperative work-up is nearly complete,
although she will need cardiac catheterization prior to surgery.
Additionally, she will need repeat bone biopsy (see below) to
confirm that the left ankle infection has been properly treated.
At time of discharge she has resumed oral Lasix at a dose of 80
mg once daily. She has follow-up planned with cardiac surgery as
outpatient.
# Type I Diabetes. Her blood sugars were difficult to control
initially so the [**Last Name (un) **] service was consulted to help manage her
diabetes. They recommended adjustments to her Glargine dose and
Humalog sliding scale parameters (see medication changes below).
# History of Septic Arthritis of Left Ankle. The orthopedics and
infectious disease services were consulted for recommendations
regarding ongoing management of left ankle infection. X-ray
films were obtained with reports as described above.
Inflammatory markers were normal (see above). Orthopedics
performed a washout and bone biopsy, and the microbiologic
report showed no bacterial growth. A wound vac was placed by
orthopedics. Infectious disease recommended continuing her
vancomycin through [**5-2**] to complete a 6-week course, at
which point they recommended to stop both vancomycin and
Bactrim. In one to two weeks, she should have a repeat bone
biopsy off of all antibiotics to ensure that the infection has
been appropriately treated. Orthopedics (Dr. [**Last Name (STitle) **] will
schedule the procedure for one to two weeks following discharge.
Note that during this admission, her vancomycin levels were
therapeutic on a dose of 750 mg intravenously once daily.
# Diastolic Congestive Heart Failure (acute on chronic) and
Mitral Regurgitation. As above, she was diuresed with
intravenous boluses of 80 mg Lasix. She had a good response and
was discharged on 80 mg oral Lasix once daily. Labetalol dose
was reduced to 600 mg tid from 800 mg tid. She is not on an
ACE-inhibitor.
# Coronaries. Her EKG showed no evidence of ischemic changes.
Enzymes were cycled and negative. We continued her home aspirin,
Plavix, and atorvastatin.
# Rhythm. Sinus rhythm on EKG. There were no active concerns.
Electrolytes were repleted for a potassium of less than 4.0 and
magnesium of less than 2.0.
# S/p Kidney Transplant. Her creatinine was noted to be at the
recent baseline. Transplant nephrology was involved from the
start of this admission and recommended checking daily
tacrolimus levels and a transplant renal ultrasound with
doppler. The ultrasound was normal. Tacrolimus and prednisone
were continued at her home doses.
# Hypertension. We continue her home nifedipine dose. Labetalol
was decreased from 800 tid to 600 tid. Hydralazine was stopped
due to hypotension during this admission.
# Anemia. At baseline. There were no active concerns.
# Depression. There were no active concerns. We continued her
home Wellbutrin and citalopram.
# FEN. Diabetic, heart-healthy, low-sodium diet.
# Access. Right-sided PICC line.
# Prophylaxis. HSQ, bowel regimen, PPI.
# Code. Full code, confirmed with the patient.
# Contact. [**Name (NI) **] [**Name (NI) 20435**], mother/HCP, [**Telephone/Fax (1) 20436**]; HCP was
[**Name (NI) 653**] by phone and is aware of admission to CCU.
# Disposition. She was discharged home with visiting nurse
services.
Medications on Admission:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
2. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day. Tablet(s)
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Prochlorperazine 25 mg Suppository Sig: One (1) suppository
Rectal every twelve (12) hours as needed for nausea.
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO QMonWedFri.
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
20. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day). Disp:*90 Tablet(s)* Refills:*2*
21. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours). Disp:*240 Capsule(s)* Refills:*2*
22. Nifedipine 90 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet
Extended Rel 24 hr(s)* Refills:*2*
23. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred
Fifty (750) mg Intravenous every twenty-four(24) hours for 18
days: Dose should be adjusted based off of renal function. Labs
will be drawn weekly. Antibiotic course to end on [**2149-5-2**].
Disp:*1 quantity sufficient* Refills:*0*
24. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime. Disp:*1 month's supply*
Refills:*2*
25. Humalog insulin sliding scale
26. 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.
27. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
28. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
29. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day): hold for SBP<100 or HR<60.
Disp:*360 Tablet(s)* Refills:*2*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
4. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
pakcet PO DAILY (Daily) as needed for constipation.
9. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
19. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
20. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
21. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
22. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
23. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
24. Insulin Glargine Subcutaneous
25. Humalog Subcutaneous
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic congestive heart failure, secondary to mitral
regurgitation
Left medial maleolus ulcer, concern for osteomyelitis
Secondary diagnoses:
Insulin dependent diabetes mellitus
End stage renal disease s/p kidney transplant
Anemia related to chronic kidney disease
Discharge Condition:
Alert and oriented with stable vital signs, 98% on room air.
Discharge weight is 52.8kg (bed scale).
Discharge Instructions:
You came to the hospital because you were short of breath. It
was thought that this was due to your heart failure, which is
worsened by your mitral regurgitation (the heart valve that is
leaky). You were given medications to remove the fluid on your
lungs and you were able to breathe better.
We think that you should have your mitral valve replaced,
however, we do not want to do that until we are sure that your
foot ulcer is not infected. You had a bone biopsy while you
were here that showed no evidence of infection. However, you
were on antibiotics at the time. The infectious disease doctors
think that we can't know for sure if there is infection unless
you have a biopsy performed while not on antibiotics.
Therefore, we would like you to stop your antibiotics
(vancomycin and bactrim) and return in one week to have a repeat
biopsy. If there is no infection we will proceed with setting
you up for mitral valve repair.
***Someone from the ortho office will call you on Monday to set
up a time for your biopsy in one week. If you do not hear from
anyone on Monday, you will need to call the ortho office (see
below). Someone will also be coming to your house to change
your wound vac on Monday and every three days following that.
Please note the following changes to your medications:
** Change to Lasix 80mg daily
** STOP Bactrim (trimethoprim-sulfamethoxazole) until the
biopsy; please resume after the biopsy at your regular dose
** STOP Vancomycin
** STOP Hydralazine
** Change labetalol to 600mg three times a day.
** Change your lantus to 9 units in the morning and evening
** If you are not eating food, you should use your bedtime
insulin sliding scale. We have included an updated sliding
scale for insulin in your paperwork.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
It was a pleasure taking part in your care.
Followup Instructions:
1. Kidney Transplant:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-5-5**] 1:00
2. Cardiothoracic Surgery:
We suggest that you reschedule this visit for the end of [**Month (only) 547**].
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2149-5-5**] 1:00
3. Infectious Disease:
You will be called by the [**Hospital **] clinic to set up an appointment.
If you have not heard from them by the middle of the week,
please call [**Telephone/Fax (1) 457**] and ask for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
4. Orthopedics:
You will be called by the orthopedic clinic to arrange for a
bone biopsy and a follow-up appointment with Dr. [**Last Name (STitle) **]. If
you have not heard from them by Tuesday or Wednesday of next
week, please call them at [**Telephone/Fax (1) 1228**].
5. [**Last Name (un) **] Diabetes Center:
Please call ([**Telephone/Fax (1) 3537**] for an appointment with Dr. [**Last Name (STitle) 10088**]/
Nurse [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] at [**Last Name (un) **].
Completed by:[**2149-5-4**]
|
[
"414.02",
"262",
"V58.67",
"711.07",
"V42.0",
"905.4",
"V45.82",
"730.27",
"041.19",
"135",
"733.82",
"428.0",
"369.4",
"517.8",
"428.43",
"V85.0",
"584.9",
"707.13",
"285.21",
"E929.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.21",
"77.67"
] |
icd9pcs
|
[
[
[]
]
] |
20499, 20550
|
11175, 15433
|
363, 416
|
20889, 20992
|
5391, 5902
|
22931, 24210
|
4486, 4637
|
18424, 20476
|
20571, 20571
|
15459, 18401
|
21016, 22292
|
4652, 5372
|
20743, 20868
|
22321, 22908
|
6271, 7228
|
291, 325
|
5922, 6253
|
444, 3031
|
20590, 20722
|
3053, 4352
|
4368, 4470
|
7246, 11152
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,036
| 107,839
|
938
|
Discharge summary
|
report
|
Admission Date: [**2123-12-28**] Discharge Date: [**2124-1-1**]
Date of Birth: [**2052-5-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Percocet
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fatigue, cough
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 71 year old male with history of bilateral
spontaneous pneumothoraces, LUL blebectomy, found to have a LLL
PNA on admission. He presented with c/o six days of fatigue and
productive cough and a day of L sided pleuritic chest pain. On
the day PTA, he was seen by his PCP who prescribed him a
tetracycline. In the ED, the patient was saturating 100%RA and
CXR revealed a LLL infiltrate, so he was started on
Levofloxacin. His initial BP was 94/47 so he was given 2 L of
NS, causing his oxygen saturation to drop to the low 90s on NC.
His SBP transiently dropped to 67/32 and improved to the
90s-100s systolic after another L of NS. He was noted to have
diffuse rales, and was given CTX 1 gm IVx1 and started on CPAP.
.
In the MICU, he was quickly weaned to 2 L NC and his SBP came up
to the 100s. He received Lasix 10 mg IV x1. He was continued on
levofloxacin for treatment of PNA. His Creatinine improved from
1.7 back down to 1.3 after IV hydration. TTE performed on
[**2123-12-29**] showed a normal EF of 55% and no focal wall motion
abnormalities (although a poor quality study). Prior to
transfer, he was satting 95% 2LNC at rest, but would desat to
84% on 3LNC with ambulation. He remained afebrile in the MICU,
SBP 90s-110s, and HR 45-55.
.
At this time, the patient states he continues still have a mild
left lower chest pain with inspiration (improved from prior). He
also continues to have a productive cough with yellow sputum.
His appetite is improving again and his headaches have resolved.
.
Review of Systems:
He reports several pounds of weight loss over the past week. He
denies n/v, dysuria, diarrhea, constipation, headache.
Past Medical History:
#numerous spontaneous bilateral pneomothoraces; s/p LUL
blebectomy and right-sided decortication
#hypothyroidism
#hyperlipidemia
#s/p pharyngocele resection
#chronic renal insufficiency (baseline creatinine 1.3-1.5);
etiology unclear
Social History:
Former smoker since his teens until ~20 yrs ago; smoked 1 ppd
and [**3-6**] cigars/day. Drinks rare alcohol. Retired; formerly
worked as a retail manager. Lives with his wife and is
[**Name (NI) 6268**].
Family History:
Denies any family history of pneumothoraces or lung disease.
Denies any family history of diabetes or cancer.
Physical Exam:
T 96.1 BP 115/55 HR 58 RR 12 Sat 88% on ra, 95% on 2L nc
General: well-appearing elderly man, breathing comfortably and
speaking easily in full sentences
HEENT: OP clear; no scleral icterus
Neck: no carotid bruits; JVP 8cm; no cervical/clavicular
lymphadenopathy
Chest: coarse rales extending ~5-6cm from left lung base and
~1cm from right lung base; (+) egophany at left base
CV: regular rate and rhythm; normal s1s2; no murmurs, rubs, or
gallops
Abdomen: soft, nontender, nondistended, normal bowel sounds;
liver edge palpable ~1cm below costal margin; no splenomegaly
Extremities: warm, no cyanosis or edema, 2+ PT pulses
Back: no CVA tenderness
Skin: no rashes or jaundice
Neuro: alert, oriented x3, CN 2-12 intact, 5/5 strength in both
arms and legs
Pertinent Results:
Chest x-ray (portable) [**2123-12-28**]:
IMPRESSION: Worsening left parahilar and left lower lobe
pneumonic consolidation and new interstitial abnormality due to
interstitial pulmonary edema, most evident in the right lung.
.
Chest X-ray PA and Lateral [**2123-12-28**]:
IMPRESSION: Left lower lobe opacity concerning for pneumonia.
.
EKG [**2123-12-28**]:
Sinus bradycardia. Borderline P-R interval prolongation. J point
and
ST segment elevation diffuseness raises the possibility of
pericarditis.
However, ST segment elevations were present on tracing of [**2120-3-8**]
but
to a lesser degree. Left ventricular hypertrophy persists.
.
Transthoracic Echo [**2123-12-29**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a very small posterior pericardial effusion without
evidence of hemodynamic compromise.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2120-1-23**], a very small posterior pericardial
effusion is now present.
.
[**2123-12-31**]:
EKG
Sinus bradycardia. The P-R interval is prolonged. Diffuse ST
segment
elevation. Non-specific anterior ST-T wave changes. Compared to
the prior
tracing anterior ST-T wave changes are new. ST segment elevation
persists.
Brief Hospital Course:
Patient is a 71 year old man with a history of spontaneous
pneumothoraces and subsequent LUL lobectomy, who presented with
cough and pleuritic chest pain, found to have a LLL PNA, with
asymptomatic hypotension.
.
# LLL PNA: Patient presented with community-acquired bacterial
pneumonia, however there could have been a component of
post-obstruction in nature. He received levofloxacin while in
MICU, after getting dose of ceftriaxone in ED. Urine was
negative for legionella. Viral antigen test was negative for
influenza.
- He was to complete a 10 day course of levofloxacin 500 mg po
daily.
- Viral and sputum cultures demonstrated no significant growth
aside from oropharyngeal flora. Blood and urine cultures were
negative.
- Patient received influenza vaccination and Pneumovax
vaccinations.
- Patient was weaned off of oxygen with ambulatory saturation of
92-97% on room air at time of discharge.
-
.
# Hypotension: Patient's hypotension was of unclear in etiology
and he remained asymptomatic without tachycardia,
lightheadedness, or other symptoms. Orthostatics were checked
and were positive. Hypotension appeared finally respond to
several intravenous fluid boluses given over the course of his
stay. His output remained good, no lightheadedness, mentation at
baseline, intact.
.
Appears as though the patient's blood pressure was checked daily
after he got out of bed to chair, and it was felt that the low
readings obtained had to do with a strong component of
orthostatic hypotension. Patient did not have DM, Parkinsons,
MS, or other clear reason for autonomic dysfunction and did not
appear to be septic. A cortisol stimulation test was within
normal limits.
.
An echo completed during his MICU stay did not reveal any
significant pericardial effusion, and his EKG was relatively
unchanged. His primary care physician related his usual systolic
blood pressure was in the 100s to 110s, and at time of
discharge, his SBP was >100.
.
# Hypoxia: Patient needed oxygen initially, however he was able
to be weaned off of it by time of discharge. He remained
asymptomatic and did not feel short of breath. In the ED, he had
acute desaturation that was felt to be related to volume
resusitation, which may have just been too rapid. His TTE showed
normal EF and no focal WMA or diastolic dysfunction, but it was
a poor study. It is suspected that his hypoxia is likely
secondary to his PNA with possible mild pulmonary edema, but his
JVP is normal without other evidence of volume overload on exam.
.
# Chronic renal insufficiency: His baseline creatinine is
1.3-1.5. On admission his Cr was 1.7, which improved with
intravenous fluids and returned to his baseline at time of
discharge.
.
# Anemia: His hematocirt remained stable, although down to the
high 20s (29), from his baseline is 33-35. He had no evidence of
bleeding, and it was felt that at least in part the anemia was
worsened by dilutional effect.
- Iron studies, retic count, B12, folate were checked, and
studies consistent with anemia of chronic disease (low iron, low
TIBC).
.
# Sinus bradycardia: This appears to be chronic, per reports
from prior ECGs on the OMR. Nodal agents were avoided.
.
# Hyperlipidemia: Patient's statin was continued.
.
# Hypothyroidism: Levothyroxine was continued.
.
# Depression: Sertraline at 100mg was continued.
.
# Patient was full code during his admission. He was evaluated
by physical therapy and felt to be safe for discharge. Follow up
was arranged with his primary care physician.
Medications on Admission:
levothyroxine 88 mcg daily
atorvastatin (dose uncertain; "low dose" per patient)
sertraline (dose uncertain)
clonazepam ("low dose") qhs prn
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Resume your home dose.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please resume your home dose.
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed: Please resume home dose as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Left lower lobe pneumonia
Secondary Diagnoses:
- Prior spontaneous pneumothoraces
- Hypothyroidism
- Chronic renal insufficiency
- Hyperlipidemia
Discharge Condition:
Stable, evaluated by physical therapy and felt to be safe for
discharge.
Oxygen saturation 92% on room air and with ambulation. Systolic
blood pressure in 90s-100s.
Discharge Instructions:
You were admitted due a cough and fatigue. It was found that you
had a pneumonia. You were admitted to the intensive care unit
initially due to low blood pressure and low oxygen levels, both
of which returned to [**Location 213**] prior to discharge.
.
Please call Dr. [**Last Name (STitle) **] or return to the emergency room if you
experience any chest pain, shortness of breath, worsening
cough, fevers, chills, lightheadedness, dizziness, or other
concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **], at an appointment scheduled for you:
- Monday, [**1-10**] at 9:15 am.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"585.9",
"593.9",
"272.4",
"244.9",
"276.6",
"458.0",
"285.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9500, 9506
|
5288, 8783
|
317, 325
|
9717, 9884
|
3405, 5265
|
10406, 10728
|
2504, 2615
|
8974, 9477
|
9527, 9527
|
8809, 8951
|
9908, 10383
|
2630, 3386
|
9595, 9696
|
1890, 2010
|
263, 279
|
353, 1871
|
9546, 9574
|
2032, 2267
|
2283, 2488
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,760
| 138,535
|
46944
|
Discharge summary
|
report
|
Admission Date: [**2107-5-7**] Discharge Date: [**2107-5-19**]
Date of Birth: [**2038-2-4**] Sex: F
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Fall/syncope.
Major Surgical or Invasive Procedure:
EEG X2
ICU monitoring
History of Present Illness:
69 yo woman with h/o CHF, AFIB, ?seizure disorder, recently
discharged from rehab after recent hospitalization for
evaluation of seizure (felt ultimately to be facial tick), was
in USOH until lunch on morning of admission, when upon rising
from a chair, she felt lightheaded/dizzy and slid to the ground.
Her daughter was with her and helped her. No LOC, post-ictal
confusion, incontinence reportedly at the time. After being
helped back into her chair by her daughter, her symptoms
resolved over 5-10 minutes. Her daughter describes a second fall
in the evening, when upon standing to leave, she was again
LH/dizzy, and fell into her daughter who was getting her walker.
ROS notable for poor PO intake x1-2d. She otherwise denies f, c,
ns, ha, cp, sob, palpitation, n/v, abdominal pain, dysuria,
constipation, diarrhea. She has been living with one of her
daughters since d/c from rehab a week ago and was doing well
initially but not eating much recently. Also she has been
supervised some of the time but not all of the time at home. Up
until about [**Month (only) **] she was living independently at home, but
had a fall there and since then has been in the hospital (St
Vincents or Mass [**Hospital1 **]) or rehab or with her daughter.
Past Medical History:
1. paroxysmal atrial fibrillation: on coumadin in the past but
had some sort of life threatening bleed a few years ago so this
was stopped.
2. dCHF, TTE [**2-9**] with EF >55%, mild PA HTN.
3. Asthma
4. HTN
5. Obesity
6. DM2 - currently not on any medications, per OMR, has had
hypoglycemia w/insulin, was on orals in past.
7. OSA on BIPAP 15/5 with 2L home O2
8. CAD status post CABG
9. Hypercholesterolemia
10. COPD - on combivent only.
11. s/p ccy
12. s/p TAH
13. DVT [**10-13**]: unclear circumstances, at [**Name (NI) **]. Vincents: treated
with IVC filter
Social History:
Lives by herself in [**Hospital1 1559**]. Denies ever using tobacco. Used
to work in assembly line until back injury [**2096**].
Family History:
+CAD, DM
Physical Exam:
GENERAL: Pleasant, somnolent, chronically ill appearing female
in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= not elevated
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. repetitive lip smacking motions. CN 2-12 grossly
intact. Preserved sensation throughout. pt unable to cooperate
with neurological exam, however this is consistent with previous
neurological exams. [**5-10**] on left side. [**1-7**]+ reflexes, equal BL.
Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
EEG [**2107-5-11**]: IMPRESSION: This is an abnormal portable EEG
recording due to the left PLEDs with a frequency of .[**5-6**] Hz. The
slow background and even slower background with a lack of
predominant posterior rhythm on the left. The first abnormality
suggests cortical irritability associated with a
structural abnormality in the left hemisphere. The second
abnormality
suggests a mild encephalopathy and the third abnormality
suggests a
structural subcortical dysfunction in the left hemisphere. The
excessive beta activity is probably secondary to a medication
effect.
PLEDs are frequently associated with clinical or subclinical
seizures.
If the patient remains lethargic, long-term EEG monitoring may
be of
further diagnostic value in this patient.
.
Echo [**2107-5-12**]: The left atrium is elongated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 60-70%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2102-2-27**], no major change is evident.
.
CT Head [**2107-5-10**]: IMPRESSION:
1. No intracranial hemorrhage.
2. Asymmetric lateral ventricle size, left slightly larger than
the right, of unknown clinical significance or chronicity
without priors
.
CXR [**2107-5-10**]: IMPRESSION:
NG tube in good position with tip terminating in stomach
.
CXR [**2107-5-7**]: IMPRESSION: Limited radiograph. No evidence of
consolidation or effusion. If clinically indicated, dedicated PA
and lateral radiograph could be obtained for further evaluation.
.
Microbiology:
[**2107-5-7**] URINE CULTURE (Final [**2107-5-12**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2107-5-16**] 3:10 pm URINE Source: Catheter.
**FINAL REPORT [**2107-5-17**]**
URINE CULTURE (Final [**2107-5-17**]):
LACTOBACILLUS SPECIES. >100,000 ORGANISMS/ML..
.
Lab Results on admission:
[**2107-5-7**] 01:45AM BLOOD WBC-7.2 RBC-4.02* Hgb-12.1# Hct-35.5*
MCV-88 MCH-30.0 MCHC-34.0# RDW-14.5 Plt Ct-242
[**2107-5-7**] 01:45AM BLOOD Neuts-61.9 Lymphs-27.4 Monos-7.4 Eos-3.1
Baso-0.3
[**2107-5-7**] 09:13AM BLOOD PT-14.1* PTT-32.1 INR(PT)-1.2*
[**2107-5-7**] 01:45AM BLOOD Glucose-124* UreaN-61* Creat-1.4* Na-126*
K-3.8 Cl-82* HCO3-31 AnGap-17
[**2107-5-7**] 09:13AM BLOOD ALT-22 AST-59* CK(CPK)-183* AlkPhos-212*
TotBili-0.3
[**2107-5-7**] 01:45AM BLOOD cTropnT-<0.01
[**2107-5-7**] 09:13AM BLOOD CK-MB-2 cTropnT-<0.01
[**2107-5-8**] 05:30AM BLOOD calTIBC-146* VitB12-785 Folate-9.4
Ferritn-306* TRF-112*
.
Phenytoin Levels:
[**2107-5-7**] 01:45AM BLOOD Phenyto-20.2*
[**2107-5-7**] 09:13AM BLOOD Phenyto-22.5*
[**2107-5-10**] 06:00AM BLOOD Phenyto-9.3*
[**2107-5-13**] 05:51AM BLOOD Phenyto-12.3
[**2107-5-16**] 05:23AM BLOOD Phenyto-8.3*
[**2107-5-17**] 06:05AM BLOOD Phenyto-7.7*
[**2107-5-19**] 05:24AM BLOOD Phenyto-9.9*
.
ABGs:
[**2107-5-10**] 10:57PM BLOOD Type-ART pO2-66* pCO2-58* pH-7.41
calTCO2-38* Base XS-9
[**2107-5-18**] 02:41PM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-53* pH-7.31*
calTCO2-28 Base XS-0
Brief Hospital Course:
69-yo woman with h/o seizure d/o, CVA, recent hospitalization
for facial tics and another recent hospitalization for phenytoin
toxicity, admitted for near-syncope and falls, now s/p seizure
on the floor after stopping phenytoin on admission being
transferred out of the MICU to the floor for continued
observation given.
.
#. Seizure Disorder: Pt had witnessed seizure on the floor in
the setting of subtherapeutic phenytoin levels and being treated
for UTI with ciprofloxacin. The patient has had trouble with
phenytoin clearance, and was discontinued due to
supratherapeutic levels on admission. The patient's Keppra was
continued however. Neurology was consulted and recommended a
phenytoin load and starting phenytoin TID following. NCHCT w/o
acute abnormality for cause of seizure. The patient was also
started on zonisamide. However, the patient developed a fixed
delusion and hallucinations thought to be secondary to this
medication. Zonisamide was discontinued and she was changed
back to phenytoin with close monitoring of her levels.
Ciprofloxacin was changed to bactrim, see below. She had 24
hour EEG monitoring once she was transferred to the floor
without signs of overt seizure. On the regimen of keppra and
phenytoin, the patient did not have any subsequent seizures.
The patient does have right sided arm choreathetoid movements
consistent with the distribution of her previous stroke. It
seems according to Neurology that this movement is exacerbated
when she is agitated, and that she is able to suppress it when
she is not agitated. The patient will follow up with Dr. [**First Name (STitle) **]
as an outpatient. She will have phenytoin levels drawn at the
rehab facility and her level changed accordingly.
.
#. UTI: Asymptomatic, however UA showed evidence of UTI and
urine cultures grew both klebsiella and enterococcus. The
patient was initially treated with cipro, then changed to
bactrim given seizure. When the enterococcus was isolated,
amoxicillin was added to the regimen. The patient completed her
course of antibiotics while inpatient. Repeat urine cultures
did not show evidence of persistent infection.
.
# Hallucinations/Delusions: Thought to be secondary to
medication effect from zonisamide. This medication was
discontinued. The patient also had an element of delirium on
transfer from the MICU. All sedating medications including
oxycodone, oxycontin, trazodone, bethanechol were discontinued.
Her delirium resolved, however the fixed delusion remained. The
patient was treated with zyprexa PRN and standing at night. The
patient should continue on zyprexa 5mg at night for the next 4
days to assist with clearing her delusions, then as needed
following.
.
#. Normocytic Anemia: Baseline Hct [**2104**] ~35. Was 35 on
admission, trended down to ~25 in setting of IVF hydration, but
then stabilized. The patient was continued on her home Iron
supplements.
.
#. Urinary retention: Discontinued bethanechol given delirium
as above. Attempted to do voiding trials, however unsucessful.
The patient was transferred with a foley catheter in place. She
may need to follow up with Urology as an outpatient.
.
#. CAD: S/p CABG, unknown anatomy. The patient was continued on
ASA, metoprolol and statin.
.
#. Paroxysmal Atrial Fibrillation: The patient remained in NSR
during hospitalization. The patient was continued on metoprolol
for rate control. Started coumadin 2mg for anticoagulation.
The patient should have an INR checked on Monday, the results
sent to the on call physician for dose adjustment.
.
#. Chronic Diastolic CHF: Last documented echo in [**2102**], showed
EF 55%. Likely secondary to long standing hypertension. The
patient did not have evidence of decompensated heart failure
during her hospitalization. As she does not have signd of
systolic heart failure and was hypovolemic on admission,
diuretics were discontinued and were not restarted prior to
discharge.
.
#. HTN: The patient's blood pressure was well controlled during
her hospitalization. Continued on metoprolol only.
.
#. Hyperlipidemia: continued on home statin
.
#. DM2: Checked FSBS QIDACHS. The patient did not require basal
medications to control, used insulin sliding scale for
hyperglycemia.
.
#. COPD: continued on home combivent inhalers
.
#. OSA: Continued on home BiPAP setting.
.
#. DVT: s/p IVC filter placement. Started on coumadin while
inpatient.
.
#. ARF: The patient was clinically dry on exam on transfer from
the MICU. The ARF resolved with IV fluids, was likely prerenal.
.
#. Constipation: resolved s/p manual disimpation and aggressive
bowel regimen. Restarted bowel regimen once loose stools
resolved.
.
#. FEN: continued on regular, heart healthy, diabetic diet /
replete lytes PRN
#. PPx: SQ Heparin, PPI, bowel regimen
#. Access: PICC placed by IR
#. FULL CODE, confirmed w/ HCP
#. Communication: with daughters (HCP is [**Name (NI) 99565**] in [**Name (NI) 1559**] [**Telephone/Fax (1) 99566**])
Medications on Admission:
- keppra 750 mg po bid
- dilantin 200 po bid (9am, 5pm), then 100mg @ 9pm.
- zaroxolyn 2.5mg po qdaily
- lopressor 25mg po bid
- senna
- zocor 40mg po qdaily
- prilosec 20mg po qdaily
- urecholine 10mg po tid
- colace
- ferrous gluconate 240mg po bid
- lasix 40mg po [**Hospital1 **] d
- neurontin 100mg po tid
- heparin 5000u sc tid
- oxycodone 5-10mg po q6hr prn
- trazadone 50mg po qhs
- aspirin 325mg po qdaily
- combvient inhalers
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-7**]
Puffs Inhalation Q6H (every 6 hours).
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Simvastatin 40 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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime as needed for delirium for 4 days:
Can continue PRN following 4 days if persistent delirium.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Outpatient Lab Work
Please check dilantin, (phenytoin) Level on Monday. Please
contact Dr.[**Name (NI) 7029**] office with results, phone number ([**Telephone/Fax (1) 32465**]. Consider decreasing dose to 150mg [**Hospital1 **] if level is >
20.
.
Please check INR level on Monday as well. Goal [**2-8**]. Please
11. voiding trial
Please attempt voiding trial tomorrow [**2107-5-20**]. If large volume
after 8 hours, replace and attempt weekly until able to DC
foley, consider urology follow up if unable
12. Phenytoin 50 mg Tablet, Chewable Sig: 4.5 Tablet, Chewables
results.
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 77002**] Healthcare Center
Discharge Diagnosis:
Primary Diagnoses:
UTI
Seizure Disorder
.
Secondary Diagnoses:
Coronary artery disease
Cerebrovascular disease
Hypertension
Hyperlipidemia
Diabetes Mellitus Type 2
COPD
Discharge Condition:
The patient was hemodynamically stable, and afebrile prior to
discharge. The patient has choreathetoid movement of her right
arm at times on discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for possible seizures. You were
found to have a urinary tract infection and had witnessed
seizures while you were here. You were treated with antibiotics
for your urinary tract infection. You were treated with new
medications for your seizure disorder.
.
Medication Changes:
CHANGE Dilantin to 225mg twice a day
START Zyprexa 5mg at night for 4 days only, then as needed for
delirium
START Coumadin (warfarin) 2mg daily
STOP Oxycodone, Oxycontin
STOP Bethanechol
STOP Neurontin
STOP Lasix
STOP Zaroxolyn
STOP Trazodone
.
If you experience chest pain, shortness of breath, fever,
chills, seizures or any other concerning symptoms please seek
medical attention.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 92546**]
in the next 1-2 weeks. To schedule an appointment please call
[**Telephone/Fax (1) 99567**].
.
Please follow up with Dr. [**First Name (STitle) **] in Neurology on [**First Name9 (NamePattern2) 5929**] [**2107-6-9**] at 8:00am in the [**Hospital Ward Name 23**] Building [**Location (un) **] on the [**Hospital Ward Name 5074**]. The number to schedule an appointment is ([**Telephone/Fax (1) 32465**].
Completed by:[**2107-5-20**]
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
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2176, 2309
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,106
| 136,013
|
9696+56058
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-1-25**] Discharge Date: [**2145-2-12**]
Date of Birth: [**2090-1-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
transfer from OSH for difficult wean
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy
Lumbar Puncture
Dobhoff tube placement
Central Line placement
Temporary Tarsorrhaphy
Left eyelid surgery
History of Present Illness:
Pt is a 55 y/o F hx HCV treated with IFN, cyroglobulinemia with
progressively worsening peripheral myopathy followed by
neurology and dysphagia who was recently admitted to OSH for
planned peg due to dysphagia, poor PO intake and 5 pound weight
loss over past 3-4 months. During admission, she developed
hypoxia, fever and was found to have an aspiration pneumonia.
Sputum Cx grew serratia, E. coli, and staph. She required
intubation and was hypotensive requiring pressors X 2 days. She
is currently on day [**7-19**] of cefepime and has been off pressors X
4 days. Per ICU attd at OSH, she was difficult to wean from vent
presumably from neuromuscular weakness and is now s/p trach on
[**2145-1-25**] and currently on PS 15/5 30%. She received daily PS
trials but was not able to maintain sufficient tidal volumes
with PS below 10. She also received a muscle biopsy on [**2145-1-25**]
with results pending. She is transferred to [**Hospital1 18**] forfurther
neurologic evaluation.
.
Upon arrival to [**Hospital1 **], she reports feeling pain around her trach,
but no other complaints besides fatigue. Prior to her admission,
her husband denies any sick contacts, cold-like symptoms, no
unusual fevers/chills beyond those assoc with IFN. NO chest
pain, palp, abd pain, bladder/bowel incontinence. No
Diplopia/blurry vision/headache.
.
With review of OMR and OSH records, it appears that for past 6
months, she has had progressive weakness and DOE/SOB as well as
paresthesias of both legs to the knees and fingers. Prior to
this, she has no probalems. Also, she has had difficulty
swallowing X 3-4 months, decreased appetite and 30 pound weight
loss over last 2 months. He husband finally brought her in for
evaluation because she was not able to keep any foods down. Her
dysphagia started with solids and then progressed to liquids.
Past Medical History:
1. treated hepatitis C.
- diagnosed genotype 1a, [**2129**]
- treated with PEG interferon and ribavirin x 48 weeks ending in
[**5-11**]
- virologic relapse after 4 weeks leading to low dose PEG
interferon starting in [**1-12**] x 4 years, finished in [**1-16**]
- In [**6-16**] had a cryocrit of 6% so maintenance PEG interferon
restarted
- known cirrhosis
- known varices
2. Asthma.
3. Recent hoarseness which was evaluated by Dr. [**Last Name (STitle) **] in ENT
and was felt to be due to reflux esophagitis.
4. s/p choly
5. s/p appendectomy
6. hx venous thrombophlebitis 25 yrs ago
7. [**1-/2145**]: NSTEMI at [**Hospital3 **]
Social History:
The patient has smoked 2 packs a day for the past 30 years. She
does not use alcohol. She is married and has two sons. She does
not use any herbal medicines or supplements. She denies any drug
use.
Family History:
Her mother has diabetes with neuropathy. She does not have any
muscle problems or dysphagia in the family. Her mother had a
three-vessel CABG. There is no evidence of Parkinson's, MS,
strokes, seizures, or other neurologic diagnoses in the family.
Physical Exam:
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 114 (114 - 114) bpm
BP: 134/84(95) {134/83(95) - 134/84(95)} mmHg
RR: 22 (21 - 22) insp/min
SpO2: 99%
Ventilator mode: CMV/ASSIST
Vt (Set): 450 (450 - 450) mL
RR (Set): 14
PEEP: 5 cmH2O
FiO2: 50%
PIP: 17 cmH2O
Plateau: 17 cmH2O
SpO2: 99%
Ve: 9.3 L/min
General Appearance: Thin
Eyes / Conjunctiva: PERRL, conjunctival edema
Head, Ears, Nose, Throat: trach
Cardiovascular: (S1: Normal), S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : ant/lat)
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Trace, Left: Trace
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed, CN: unable to squeeze eyes, EOM minimal
upward gaze, PERRL 2mm-> 1 mm, tongue midline,
sternocleidomastoids [**4-13**], shoulder shrug: pt did not coorperate
fully
delt: unable to move against gravity
biceps: [**2-11**]
triceps: [**2-11**]
Finger ext [**3-14**]
hip flex: [**2-11**]
quads: exam difficult as pt not completely cooperating [**2-11**]
hams: [**2-11**]
foot plantar/dorsiflex: [**4-13**]
reflexes: brachoradialis: 3+ bil
patellar: 3+ bilt
achilles: unable to be elicited
Pertinent Results:
Micro:
[**1-26**] HCV Viral Load: Less than 30 IU/mL
[**2-6**] CSF Fluid: Negative gram stain and culture
[**2145-2-6**] BAL:
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 8 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 I
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
[**2-3**]: Blood Culture Negative
[**2-2**]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
OF TWO COLONIAL MORPHOLOGIES.
Anaerobic Bottle Gram Stain (Final [**2145-2-3**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name 24417**] ([**Numeric Identifier 32766**]) ON [**2145-2-3**]
8:15AM.
Aerobic Bottle Gram Stain (Final [**2145-2-3**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2-2**]: Blood Cultures Negative
[**2-2**]: Catheter Tip
WOUND CULTURE (Final [**2145-2-6**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
[**1-27**]: Left Eye Swab: Coag Negative Staph
=====================
IMAGES
[**2145-1-1**] EMG: Abnormal study. There is electrophysiologic
evidence for a mild proximally predominant myopathy with some
denervating features. There is also evidence for a mild to
moderate, chronic, sensorimotor, generalized polyneuropathy
which is axonal in nature and appears symmetric. Compared with
the prior study of [**1-13**], the polyneuropathy is new and the
myopathy is more clearly present.
[**2145-1-26**] Liver US:
1. Coarse hepatic echotexture consistent with cirrhosis without
focal
lesions.
2. Stable dilation of CBD.
3. Trace ascites, without sufficient fluid for safe bedside
paracentesis.
[**2145-1-27**] echo:
The left atrium is moderately 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 aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2-2**]: MRI Head w/ and w/o Contrast: CONCLUSION: No definite
brain abnormalities. Other extracranial findings and recommended
follow up studies as noted above.
[**2145-2-10**] Portable CXR:
IMPRESSION: AP chest compared to [**1-25**] through 26:
Only a small residue of peribronchial opacification at the lung
bases persists, was previously extensive with bibasilar
consolidation and interstitial infiltration that extended to the
level of both hila. Given the previous distention of the
pulmonary circulation and mediastinal veins there may have been
a component of edema previously, but none is present today. Very
small left pleural effusion persists. Heart size is normal.
Tracheostomy tube is in standard placement and a feeding tube
passes into the stomach and out of view.
Brief Hospital Course:
This is a 55 y/o F hx HCV on IFN, cryoglobulinemia, dysphagia,
progressive neuromuscular weakness followed by neurology now s/p
trach after intubation for aspiration pneumonia and persistent
difficulty weaning from vent.
# Sepsis/ARDS: On transfer from the outside hospital pt was
noted to be in septic shock requiring vasopressors. Suspected
source was pulmonary based on the history and appearance of
aspiration PNA pt was started a completed a course of Cefepime.
Pt was also noted to have ARDS and was treated with ARDS Net
protocol. Pt improved following course of Cefepime but was not
able to tolerate a wean off of the vent secondary to her
neuromuscular weakness which required a tracheostomy. On [**2-2**]
pt was also noted to have a large amount of bleeding around her
trach site which then developed into respiratory distress. A
Code Blue was called pt was intubated orally and was coded
during the ICU requiring a Cordis to be placed for 2u PRBC
transfusion and aggressive fluid resuscitation. Pt was intubated
from above and taken to the OR for a revision of the
tracheostomy. The inferior thyroid artery was thought to be
responsible for the bleed, in the OR it was suture ligated. A
BAL was performed at the same time which grew positive for
Pseudomonas likely secondary to colonization. As pt showed no
signs of Pneumonia and a clear x-ray prior to discharge pt was
not treated for the BAL culture.
# Myopathy/Neuropathy: Pt was transferred to [**Hospital1 18**] after being
intubated on [**1-25**] at an outside hospital for respiratory
distress and aspiration pneumonia following a progressively
worsening course of neuromuscular weakness, dysphagia and
peripheral neuropathy. During her hospitalization Neurology were
consulted with the initial thought that her NM weakness was
secondary to her mixed cryoglobulinemia from HCV, and possible
vasculitis. She had recently been seen by Neurology has an
outpatient where she received an EMG notable for mild
sensorimotor polyneuropathy as well as a myopathic process in
several proximal muscles (IP, biceps, infraspinatus, and
prominently in L3 paraspinals). Pt's neuropathy was thought to
be secondary to her IFN therapy which was stopped. During her
ICU course her NM weakness was significant enough that she did
not tolerate a vent wean and required a tracheostomy. Following
her transfer to the floor her strength slowly increased. Her
pattern of the prolong pprogressive weakness coupled with her
quick recovery was further worked up with Neurology, an
anti-MUSK antibody was sent and an LP was performed to obtain
CSF ACE and Lyme panel levels. At time of discharge levels were
still pending, given her recovery she will follow up with
Neurology as an outpatient. She still has lagopthalmos which may
be from residual CN VII weakness and presents an aspiration
risk.
- Recommend pt follow up with Neurology as an outpatient on
[**2145-2-26**] at 12:00.
# Corneal abrasion and conjunctivitis: Pt's residual weakness
still involves the ocular distribution, specifically
lagopthalmos. During hospitalization pt developed conjunctivits
of the left eye with a swab positive for coag negative staph.
Opthamology were consulted hand and placed a bandage contact
lens, she was also started on lacrilube ointment every 1hr,
lacrilube drops every 2hrs and Ciprofloxacin drops every 6hrs.
She will need to continue this regimen until she sees
Opthalmology, they will decide at that time further course of
antibiotics. Given the risk of exposure keratopathy pt underwent
a temporary tarsorraphy of her left eye which will need to be
evaluated by Opthalmology.
- Will need to follow up with Opthalmology Plastic Surgery at
Mass Eye, Ear Infirmary appointment on [**2145-2-19**] at 1415.
# Cirrhosis: Pt's last EGD performed [**8-/2144**] showed portal
hypertensive gastropathy but no varicies that required banding.
During hospitalization pt did not experience any GI bleed,
recommend avoidance of NSAIDs and [**Doctor Last Name **]-2 inhibitors. Pt was
initially started at 20mg Nadolol, dose was increased prior to
discharge for Variceal prophylaxis.
- Avoid NSAIDs, [**Doctor Last Name **]-2 inhibitors
- Continue Nadolol 40mg daily
- Continue Lansoprazole 30mg twice a day
# HCV: Pt has history of Hepatitis C, which she doesn't want
extended family to know about her Hepatitis. Her last HCV viral
load performed [**2145-1-27**] was negative. An abdominal U/S was also
performed during hospitalization which showed no ascites. Her
interferon therapy was held given the suspicion that this was
the causative [**Doctor Last Name 360**] for her neuropathy.
- Pt does not want extended family to know about HCV status
# Dysphagia: Pt had signs of dysphagia that was evaluated on
admission with a speech swallow study, ENT and Neurology consult
which showed laryngeal weakness. Based on her aspiration risk
and nutritional needs pt was given a Dobhoff tube. A PEG tube
was considered but deferred given pt's improvement with strength
and concern that the possibility of ascites would be further
complicated with a PEG already in place. Prior to discharge pt
was fitted and tolerated a PMV. A video swallow was performed
which showed reduced pharyngeal squeeze bilaterally, reduced
laryngeal elevation and penetration into the laryngeal vestibule
[**1-11**] to incomplete laryngeal valve closure. A Dobhoff tube was
placed under IR and pt was restarted on tube feeds.
- Oral care Q4 hours and ongoing speech/swallowing
rehabilitation and evaluation.
# Coag negative Stap Bacteremia: Following the code pt had a
blood culture positive for Coag negative staph that was also
cultured from the tip of her Cordis line. Pt was started and
completed a course of Vancomycin IV for 10 days. Prior to
discharge pt experienced no fevers and negative blood cultures
on [**2145-2-3**].
# Thrombocytopenia: Pt has chronic thrombocytenia with a 6 month
baseline ranging from 90-120's. On review of pt's admission note
it appears that the lowest plt count reported at the outside
hospital was 20, following course of ICU pt's thrombocytopenia
improved parallel to her overal progression. Prior to discharge
pt's platelet count was noted to be trending up to 258.
# Tracheostomy: As mentioned above tracheostomy was required for
prolonged intubation for failure to wean secondarty to her
neuromuscular weakness. Prior to discharge pt was saturating
>98% on trach mask FiO2 40%, will need to undergo a wean off of
the trach in rehab.
# Peripheral Neuropathy: Pt has chronic pain which is due to her
peripheral neuropathy which is thought to be secondary to her
interferon therapy. As an outpatient she was seen by the Pain
clinic who recommended Neurontin to 800 mg TID as well as a
future outpatient Lidocaine infusion. Given the need to check
her mental status the Neurontin was held and pt was given a
Fentanyl patch and liquid oxycodone as mentioned above for pain
control. Pt was also restarted on her Neurontin which an initial
dose of 300mg TID with goal to advance to 800mg TID over the
course of a week.
- Currently on Neurontin 300mg TID please titrate up to a goal
of 800mg TID over the next 7 days
- Pt titrated up to 50mcg Fentanyl patch, will need 50mcg new
patch starting [**2145-2-13**]
- Pt was being treated with Cymbalta 60mg daily prior to
admission and this is being held due to interaction with Cipro
and inability to crush tab for delivery via NG TUBE. We
recommend ongoing social work support and consideration of an
alternative SSRI that may be crushed and given via NG tube.
# Leukocytosis: Prior to discharge pt's WBC noted to be around
[**11-21**], pt has been afebrile. A chest x-ray showed no evidence of
PNA, pt's U/A suspicious for infection. Pt started on [**2145-2-12**]
on Ciprofloxacin will contact Rehab facility if culture shows
positive for Ciprofloxacin resistant strain.
- Recommend continuing 10 day course of Ciprofloxacin, last day
of treatment will be [**2145-2-20**]
- We will contact you if culture shows a Ciprofloxacin resistant
strain
# Smoking: Pt is a current smoking, during hosptialization pt
has required a Nicotine patch
- Recommend continuing Nicotine patch
#Prophylaxis: Pt was placed on pneumoboots for DVT prophylaxis
Medications on Admission:
Meds on Transfer:
artificial tears
ativan 1-2 mg Q8H PRN
Moxifloxacin 400 mg IV daily
Combivent Q4H
Cymbalta 60 mg daily
folic acid 1mg daily
erythromycin OU TID, day 1 = [**1-23**]
morphine PRN
nexium 40 mg IV BID
Cefepime 1 gm daily
reglan 5 mg Q6H PRN
Vit B1
chlorhexidine
Home Medications:
ALBUTEROL 1 -2 puff by mouth twice a day
DULOXETINE [CYMBALTA] 60 mg once a day
GABAPENTIN 600 mg TID
HYDROCODONE-ACETAMINOPHEN 10 mg-660 mg TID PRN
MONTELUKAST [SINGULAIR]
NADOLOL 20 mg daily
OMEPRAZOLE 20 mg [**Hospital1 **]
PEGINTERFERON ALFA-2B Q week
RANITIDINE 300 mg QHS
ZOLPIDEM 12.5 mg qhs prn
Discharge Medications:
1. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
3. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as
needed.
6. Multivitamin,Tx-Minerals Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
7. B-Complex with Vitamin C Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
8. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed.
9. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2)
Puff Inhalation QID (4 times a day).
11. Nicotine 7 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
14. Nadolol 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
15. Fentanyl 50 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
every seventy-two (72) hours.
16. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3
times a day).
17. Ciprofloxacin 0.3 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic QID
(4 times a day).
18. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Last Name (STitle) **]: One
(1) Appl Ophthalmic Q2H (every 2 hours).
19. Erythromycin 5 mg/g Ointment [**Last Name (STitle) **]: 0.5 Ophthalmic HS (at
bedtime).
20. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 mg PO Q4H (every 4
hours) as needed for pain.
21. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
22. Cipro 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day for 7
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Primary:
1. Bulbar weakness and neuropathy
2. Respiratory distress requiring tracheostomy
3. Tracheostomy related bleed
4. Severe Conjunctivitis and corneal abrasion
.
Secondary:
1. Asthma
2. HCV
3. Cirrhosis,
4. CAD & non-ST elevation Myocardial Infarction
Discharge Condition:
Stable, afebrile on tracheostomy, sating well in humidified
oxygen, left eye sewn shut to allow for corneal healing.
Discharge Instructions:
You were transferred to this hospital for progressive weakness
and after being treated for pneumonia which required a breathing
machine. As your weakness with breathing was prolonged you
required a tracheostomy in the ICU. Your strength has slowly
improved and you were able to be transferred to the regular
floor.
Whilst on the floor you underwent a swallow study which showed
you were not ready to take anything safely by mouth. You had
your left eye stitched closed due to eye infection and inability
to close the eye. You will need to see the Opthalmology Plastic
Surgeons Dr. [**Last Name (STitle) **] in [**State 32767**] Clinic on
[**2145-2-19**]. You will also need to follow up with the Neuromuscular
specialists Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 4638**] to follow up with your
weakness.
.
You will need to follow up with the liver specialists for
cirrhosis as shown below.
.
If you experience any fevers, chills, shortness of breath, chest
pain, vision loss please return to the Emergency Room.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 32768**] Date/Time:[**2145-2-19**]
1415 (Opthalmology Plastics)
Provider: [**Name10 (NameIs) 1220**] [**Last Name (STitle) **] AND [**Name5 (PTitle) **] Phone:[**Telephone/Fax (1) 2846**]
Date/Time:[**2145-2-26**] 12:00 (Neuromuscular physician)
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2145-3-11**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2145-3-11**]
9:40
Provider: [**Name10 (NameIs) 1220**] [**Last Name (STitle) **] AND [**Name5 (PTitle) **] Phone:[**Telephone/Fax (1) 2846**]
Date/Time:[**2145-2-26**] 12:00 (Neuromuscular physician)
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2145-3-11**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2145-3-11**]
9:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Name: [**Known lastname 5685**],[**Known firstname **] M. Unit No: [**Numeric Identifier 5686**]
Admission Date: [**2145-1-25**] Discharge Date: [**2145-2-12**]
Date of Birth: [**2090-1-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4091**]
Addendum:
Pt's urine culture noted to be negative, but C diff toxin assay
was positive. [**Name (NI) **] [**Hospital 4185**] [**Hospital **] Hospital in [**Hospital1 3983**] to
discuss results with physician. [**Name10 (NameIs) 5687**] with Dr. [**Last Name (STitle) 5688**] who stated
he had check a C. diff toxin assay yesterday which was negative.
It is unclear if the assay is check for both Toxin A and B,
recommended Flagyl which she is currently on. They will check
another C. Diff toxin assay tomorrow, she currently is showing
no diarrhea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4185**] [**Hospital **] Hospital
[**First Name8 (NamePattern2) 1558**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2301**]
Completed by:[**2145-2-15**]
|
[
"356.9",
"519.09",
"273.2",
"518.84",
"070.54",
"374.20",
"571.5",
"287.5",
"371.40",
"038.9",
"785.52",
"412",
"493.90",
"372.00",
"357.6",
"359.89",
"787.20",
"E933.1",
"507.0",
"995.92",
"288.60",
"414.01",
"041.19",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"08.52",
"31.3",
"31.74",
"96.04",
"33.24",
"96.71",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
23847, 24073
|
8878, 17111
|
351, 482
|
20456, 20575
|
4909, 8855
|
21655, 23824
|
3233, 3482
|
17761, 20057
|
20175, 20435
|
17137, 17137
|
20599, 21632
|
3497, 4890
|
17433, 17738
|
275, 313
|
510, 2347
|
2369, 3002
|
3018, 3217
|
17155, 17415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,116
| 166,965
|
13401
|
Discharge summary
|
report
|
Admission Date: [**2191-3-20**] Discharge Date: [**2191-3-24**]
Date of Birth: [**2138-2-5**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p [**First Name3 (LF) 39447**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 yo F s/p MVA - vehicle vs telphone pole. Car noted by
observer to be weaving prior to collision. +LOC. Became
combative. GCS [**8-3**]. Pt was intubated at the scene. No known
injuries but hypertensive at scene. FAST neg. +Etoh/cocaine.
Past Medical History:
Depression
Hepatitis C (needle sticks/blood transfusions)
Social History:
Nurse
Single
Family History:
Father: colon CA
Physical Exam:
On admission: 100.4 94 129/103 100% intubated
AT/NC
PERRL/TMs clear
Tachy, reg rhythm
S/NT/ND, BS +
Stable pelvis
+pulses
At discharge: 98.8 62 190/110 20 98%RA
RRR, No m/r/r
Stable crackles, no w/r/r
S/ND/NT, BS+
+Pulses, no c/c/e
Pertinent Results:
[**2191-3-20**] 10:03PM TYPE-ART PO2-148* PCO2-42 PH-7.31* TOTAL
CO2-22 BASE XS--4
[**2191-3-20**] 10:03PM LACTATE-2.0
[**2191-3-20**] 08:10PM TYPE-ART PO2-254* PCO2-43 PH-7.31* TOTAL
CO2-23 BASE XS--4
[**2191-3-20**] 08:10PM GLUCOSE-88 LACTATE-2.2* K+-3.7
[**2191-3-20**] 08:10PM freeCa-1.17
[**2191-3-20**] 04:25PM PO2-372* PCO2-29* PH-7.46* TOTAL CO2-21 BASE
XS--1
[**2191-3-20**] 04:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2191-3-20**] 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2191-3-20**] 04:10PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-FEW
EPI-[**2-26**]
[**2191-3-20**] 04:08PM TYPE-ART PH-7.40
[**2191-3-20**] 04:08PM GLUCOSE-105 LACTATE-2.8* NA+-143 K+-3.8
CL--108 TCO2-22
[**2191-3-20**] 04:08PM HGB-13.6 calcHCT-41 O2 SAT-90 CARBOXYHB-6*
MET HGB-1
[**2191-3-20**] 04:08PM freeCa-1.21
[**2191-3-20**] 03:55PM UREA N-16 CREAT-0.8
[**2191-3-20**] 03:55PM AMYLASE-81
[**2191-3-20**] 03:55PM ASA-5 ETHANOL-153* ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2191-3-20**] 03:55PM WBC-12.7* RBC-5.27 HGB-14.4 HCT-44.4 MCV-84
MCH-27.4 MCHC-32.5 RDW-14.5
[**2191-3-20**] 03:55PM PT-12.6 PTT-25.2 INR(PT)-1.0
[**2191-3-20**] 03:55PM PLT COUNT-361
[**2191-3-20**] 03:55PM FIBRINOGE-281
Brief Hospital Course:
1. s/p [**Name (NI) 39447**]
Pt was admitted to the trauma SICU initially and was intubated
at that time. Her neck CT was neg, Chest/Abd CT neg except L
adrenal mass, head CT neg. She remained stable and all exams
were neg, therefore pt was extubated on HD2. She was then noted
to have delirium and agitation and psychiatry was consulted.
Ativan was changed to prn and haldol was given 2mg q6h for
agitation. It was found that she had no outstanding trauma
injuries but her neck/c collar could not be cleared until her
delirium cleared. Delirium cleared on [**2191-3-23**] and pt was
transferred to the floor. Her vital signs remained stable. She
was able to ambulate, talk, was A&Ox4 and perform basic ADLs.
Case management and social work and psychiatry therefore
arranged for her transfer to an in-pt psychiatric unit for her
poly-substance abuse issues. She was medically cleared
2. Hep C
Her LFTs have been at baseline throughout her hospital stay and
clinically she was asymptomatic.
3. Psychiatric/Depression
As noted in #1. Pt initially combative/agitated/delrius. Now
resolved and being transferred to [**Hospital 882**] Hospital in-pt psych
[**Hospital1 **].
Medications on Admission:
None
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
3. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
4. Haloperidol 1-5 mg IV Q2H:PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
status post motor vehicle crash
Discharge Condition:
stable
Discharge Instructions:
Make and keep all follow up appointments.
Take all medication as prescribed.
Followup Instructions:
Please follow up with psychiatry as previously directed.
Please make an appointment with your primary care [**First Name8 (NamePattern2) **]
[**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 40684**] regarding a left adrenal mass that
was found during this admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2191-3-24**]
|
[
"305.60",
"070.70",
"305.00",
"E958.8",
"300.9",
"311",
"293.0",
"V71.4",
"E816.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3902, 3917
|
2372, 3553
|
303, 310
|
3993, 4001
|
1007, 2349
|
4126, 4573
|
710, 728
|
3608, 3879
|
3938, 3972
|
3579, 3585
|
4025, 4103
|
743, 743
|
884, 988
|
231, 265
|
338, 583
|
757, 870
|
605, 664
|
680, 694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,663
| 117,408
|
19905
|
Discharge summary
|
report
|
Admission Date: [**2195-12-9**] Discharge Date: [**2195-12-18**]
Date of Birth: [**2119-11-25**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 53735**] is a 76 year-old
man who has a history of hypertension, gastroesophageal
reflux disease, Paget's disease, has had a few episodes of
chest pain over the past few weeks. Yesterday he was
exercising and had severe chest pain, which lasted two to
three hours. He woke up with dull chest pain this morning
and presented to his primary care physician's office where he
had electrocardiogram changes, which included inferior Q
waves, ST elevations and T wave inversions. He underwent
cardiac catheterization at [**Hospital6 3872**] on the
day of transfer, which revealed left main with a high grade
lesion, left anterior descending coronary artery with 80%
osteal and 80% mid lesion, left circumflex with an 90% osteal
and 80% osteal obtuse marginal one lesion and an 80% osteal
obtuse marginal two lesion. The right coronary artery was
subtotally occluded with an 80% [**Last Name (LF) 48199**], [**First Name3 (LF) **] was estimated at 40%
with inferior wall akinesis. He is transferred from [**Hospital3 6454**] to [**Hospital1 69**] for coronary
artery bypass grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Paget's disease.
3. Degenerative joint disease.
4. Esophagitis.
5. Gastroesophageal reflux disease.
6. Status post transurethral resection of the prostate.
7. Status post left total knee replacement.
8. Status post right arm surgery.
9. Status post appendectomy.
PREOPERATIVE MEDICATIONS:
1. Terazosin 2 mg q.h.s.
2. Methyldopa 500 mg q.d.
3. Prilosec 20 mg q.d.
4. Ecotrin 325 q.d.
5. Fosamax 70 once a week.
6. Celebrex prn.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Positive for coronary artery disease.
SOCIAL HISTORY: Has forty pack year cigarette history. He
quit twenty years ago. Alcohol use is intermittent with two
drinks per evening. He lives with his wife who is disabled
and he cares for her.
PHYSICAL EXAMINATION: Vital signs heart rate 63. Blood
pressure 159/67. Respiratory rate 22. O2 sat 100% on room
air. General, elderly man in no acute distress. HEENT
pupils are equal, round and reactive to light. Extraocular
movements intact. Anicteric. Noninjected. Oropharynx is
benign. Neck is supple. No lymphadenopathy or thyromegaly.
Carotids are 2+ bilaterally without bruits. Lungs are clear
to auscultation. Cardiovascular regular rate and rhythm. S1
and S2 with no murmurs, rubs or gallops. Abdomen is soft,
nontender, nondistended. No masses or hepatosplenomegaly
with positive bowel sounds. Extremities warm and well
perfuse with no clubbing, cyanosis or edema. 2+ pulses
bilaterally. Neurological examination is nonfocal.
The patient underwent a transthoracic echocardiogram upon
arrival at [**Hospital1 69**]. TEE at that
time showed normal RV size and function, normal left
ventricular size with an EF of 35 to 40% with inferolateral
hypokinesis, mild mitral regurgitation, mild aortic
regurgitation, no pericardial effusion.
HOSPITAL COURSE: The following morning the patient was
brought to the Operating Room at which time he underwent
coronary artery bypass grafting. Please see the operative
report for full details. In summary the patient had coronary
artery bypass graft times five with a left internal mammary
coronary artery to the left anterior descending coronary
artery, saphenous vein graft to the PL and obtuse marginal
sequentially, saphenous vein graft to the posterior
descending coronary artery and saphenous vein graft to the
diagonal. The patient's bypass time was 139 minutes. His
cross clap time was 82 minutes. He tolerated the operation
well and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient had a mean arterial pressure of 90. He was in
normal sinus rhythm. He had Amiodarone at 1 mg per minute,
Propofol at 20 micrograms per kilogram per minute and
nitroglycerin at 0.5 micrograms per minute. The patient did
well in the immediate postoperative period. Sedation was
reversed. He was weaned from the ventilator and successfully
extubated. He remained hemodynamically stable throughout the
day and night of surgery. On postoperative day one the
patient remained hemodynamically stable and his Amiodarone
was transitioned to oral medications. His Swan-Ganz catheter
was discontinued.
Additionally the patient was noted to be confused and
agitated following extubation striking out at nurses.
Therefore he remained in the Intensive Care Unit for further
hemodynamic as well as monitoring of his neurological status.
On postoperative day two the patient remained occasionally
disoriented, but easily reoriented. Hemodynamically the
patient remained stable. He was off all intravenous
medications and it was felt that he was ready to be
transferred to the floor, however, there were no floor beds
available and the patient therefore stayed in the Intensive
Care Unit. On postoperative day three the patient remained
hemodynamically stable. His neurological status had improved
and he only had rare episodes of confusion. There were still
no floor beds available and he stayed in the Intensive Care
Unit until postoperative day four when he was transferred to
the floor for continuing postoperative care and cardiac
rehabilitation. Following transfer to the floor the
patient's Foley catheter was removed. He failed his initial
voiding trial and the catheter was replaced at that time.
The patient was restarted on his Terazosin and it was also
noted that the patient was having episodes of atrial
fibrillation with a heart rate to 120. He remained
hemodynamically stable throughout these episodes. On
postoperative day six the patient's Foley was again
discontinued. He did initially void following removal of his
Foley catheter, however, he had an episode of greater then
twelve hours without voiding. A bladder scan done at that
time showed greater then 900 cc of urine in his bladder. His
Foley was then reinserted and urology was consulted.
On postoperative day seven the patient had reached an
adequate activity level to be considered safe and ready for
discharge to home and on postoperative day eight the patient
was discharged to home with visiting nurses services.
At the time of discharge the patient's physical examination
revealed vital signs temperature 99. Heart rate 69, sinus
rhythm. Blood pressure 134/62. Respirations 18. O2 sat 98%
on room air. Weight preoperatively a 74.4 kilograms, at
discharge is 82 kilograms. Neurologically alert and oriented
times three, moves all extremities, follows commands.
Respirations clear to auscultation bilaterally. Cardiac
regular rate and rhythm. S1 and S2 with no murmurs. Sternum
is stable. Incision with Steri-Strips open to air clean and
dry. Abdomen soft, nontender, nondistended with normoactive
bowel sounds. Extremities are warm and well perfuse with 1+
edema bilaterally. Saphenous vein graft site with
Steri-Strips covered with dry sterile dressing.
Laboratory data on discharge, hematocrit 26.2, sodium 135,
potassium 4.2, BUN 26, creatinine 1.1, glucose 101.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times five with left internal mammary
coronary artery to the left anterior descending coronary
artery, saphenous vein graft to the PL and obtuse marginal
sequentially, saphenous vein graft to the posterior
descending coronary artery, saphenous vein graft to the
diagonal.
2. Hypertension.
3. Paget's disease.
4. Degenerative joint disease.
5. Esophagitis.
6. Gastroesophageal reflux disease.
7. Status post transurethral resection of the prostate.
8. Status post left total knee replacement.
9. Status post right arm fracture.
10. Status post appendectomy.
11. Atrial fibrillation.
12. Status post transurethral resection of the prostate.
13. Urinary retention.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Prilosec 20 mg q.d.
3. Terazosin 3 mg q.h.s.
4. Metoprolol 50 mg b.i.d.
5. Lasix 20 mg q.d. times two weeks.
6. Potassium chloride 20 milliequivalents q.d. times two
weeks.
7. Vioxx 25 mg q.d. prn.
8. Fosamax 70 mg q week.
9. Amiodarone 400 mg q.d. times one week and then 200 mg
q.d. times one month.
FO[**Last Name (STitle) 996**]P: The patient is to have follow up in the wound
clinic in two weeks. Follow up with the urology resident
clinic in one to two weeks. The patient is to call with an
appointment. Follow up with Dr. [**Last Name (STitle) **] in three to four 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:[**Doctor Last Name 9076**]
MEDQUIST36
D: [**2195-12-18**] 11:22
T: [**2195-12-18**] 11:43
JOB#: [**Job Number 53736**]
|
[
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"788.20"
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icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
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1823, 1862
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,973
| 132,336
|
4032
|
Discharge summary
|
report
|
Admission Date: [**2182-5-19**] Discharge Date: [**2182-5-23**]
Date of Birth: [**2120-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide
Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin /
metoclopramide / Doxepin / Doxepin / Doxepin
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year old female with complex past history including with a
history of type 1 diabetes status post renal transplant x 3 and
pancreas transplant currently anuric on peritoneal dialysis,
recent sepsis secondary to cellulitis and urosepsis, CABG
complicated by pericardal effusion presenting from
rehabilitation with fever and hypotension.
Patient had been feeling fine at rehab, no complaints. ? dry
cough over last three days. This morning she [**First Name3 (LF) 5058**] with chills
and was found to have a fever of 103. Blood pressure at EMS
arrival was systolic of 70, mentating, no chest pain or
shortness of breath, no headache change in vision or neck pain,
no abdominal pain, no cough, no dysuria.
On arrival to the ED VS: T 102.1 HR 64 BP 76/42 HR 18 98% RA.
Exam notable for diffuse erythema and warmth of the entire right
lower extremity with no crepitus, mild tenderness to palpation,
compartments are soft, no neuromotor or vascular deficit. Labs
significant for WBC count of 5.8 with 92% neutrophils, Hct 26.
Lactate 2.2. Blood culures drawn. Straight cath performed for
urine, but results not yet available. FAST U/S showed no
pericardial effusion, full collapse of IVC with respiratory
variation. CXR unremarkable. Given 2L NS and BP improved to HR
91 BP 91/41 RR 14 SpO2 100RA. Given vanc, metronidazole,
hydrocortisone 100mg IV. Admitted to ICU for septic shock.
On arrival from the ED, she was mildy diaphoretic, but
comfortable, talking on her cell phone.
.
Review of systems:
as above.
Denies sore throat, abdominal pain, further diarrhea, blood in
stools, change in urinary output, dysuria, any other skin
changes, feeling confused.
Past Medical History:
CHF; EF 25% in [**2182-1-23**]
# h/o severe MR s/p repair in [**2179**]
# NSTEMI [**7-/2181**], s/p [**Year (4 digits) **] to LAD [**9-/2181**]
# CABGX5 vessel [**1-/2182**]
# s/p renal transplant ([**2157**])
-- c/b chronic rejection
-- second renal transplant ([**2160**])
# s/p pancreas transplant
-- with allograft pancreatectomy ([**5-/2174**])
-- redo pancreas transplant ([**6-/2175**])
-- admission for acute rejection ([**7-/2180**]), resolved with
increased immunosupression
# Diabetes mellitus type I
-- c/b neuropathy, retinopathy, dysautonomia
-- no longer requires regular insulin after the pancreas
transplant, but has been given SS while on high-dose prednisone
in house
# Autonomic neuropathy
# Sleep disordered breathing
-- Unable to tolerate CPAP; uses oxygen 2L NC at night
# Osteoporosis
# Hypothyroidism
# Pernicious anemia
# Cataracts
# Glaucoma
# Anemia of CKD, on Aranesp in the past
# R foot fracture c/b RLE DVT
# Chronic LLE edema
# Recurrent E. coli pyelonephritis
# s/p anal polypectomy ([**5-/2176**])
# s/p bilateral trigger finger surgery ([**8-/2178**])
# s/p left [**Year (4 digits) 6024**] ([**8-/2179**])
Social History:
Child psychiatrist, on disability. Has been in and out of
hospitals in the last 8 months. Was longest at [**Hospital3 **],
most recently at [**Location (un) **] in [**Location (un) **]. Mobile with
wheelchair but unable to do transfers.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Father with MI at 57.
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
General: Alert, oriented, drowsy, responding appropriately to
questions
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Few rales at LL base, but otherwise clear.
CV: Normal rate and regular rhythm, 2/6 SEM at USB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Peritoneal
[**Last Name (un) **] in place, no skin changes or tenderness surrounding the
site.
GU: No foley
[**Last Name (un) **]: 2+ edema, warm, well perfused, no clubbing. RLE with
erytehma warmth and tenderness, no crepitus.
Neuro: CNII-XII in tact. Grossly in tact
.
Discharge Exam:
CV: RR, no m/r/g
Lungs: some rales at b/l bases
Abd: S/NT/ND, PD cath c/d/i
[**Last Name (un) **]: 2+ pitting edema to the thighs
Pertinent Results:
Admission Labs:
[**2182-5-19**] 12:45PM BLOOD WBC-5.8# RBC-2.46* Hgb-8.2* Hct-26.5*
MCV-107* MCH-33.2* MCHC-30.9* RDW-23.0* Plt Ct-258
[**2182-5-19**] 12:45PM BLOOD Neuts-92.9* Lymphs-4.1* Monos-1.8*
Eos-1.0 Baso-0.2
[**2182-5-19**] 12:45PM BLOOD Glucose-80 UreaN-59* Creat-5.8* Na-135
K-3.5 Cl-92* HCO3-25 AnGap-22*
[**2182-5-19**] 12:45PM BLOOD ALT-17 AST-39 AlkPhos-65 TotBili-0.2
[**2182-5-19**] 12:45PM BLOOD Lipase-21
[**2182-5-19**] 12:45PM BLOOD cTropnT-0.39*
[**2182-5-19**] 12:45PM BLOOD TSH-41*
[**2182-5-20**] 05:25AM BLOOD T4-3.6*
[**2182-5-19**] 01:17PM BLOOD Lactate-2.2*
Discharge Labs:
[**2182-5-23**] 05:00AM BLOOD WBC-4.2 RBC-2.82* Hgb-9.5* Hct-30.3*
MCV-107* MCH-33.8* MCHC-31.5 RDW-22.8* Plt Ct-232
[**2182-5-23**] 05:00AM BLOOD Plt Ct-232
[**2182-5-23**] 05:00AM BLOOD PT-12.2 INR(PT)-1.1
[**2182-5-23**] 05:00AM BLOOD Glucose-138* UreaN-62* Creat-5.8* Na-131*
K-3.3 Cl-93* HCO3-27 AnGap-14
[**2182-5-23**] 05:00AM BLOOD ALT-13 AST-32 AlkPhos-54 TotBili-0.1
[**2182-5-23**] 05:00AM BLOOD Calcium-7.0* Phos-5.3* Mg-1.9
Micro:
-[**5-21**] Blood cx NGTD
-[**2182-5-19**] 12:45 pm BLOOD CULTURE - Positive in [**12-24**] bottles
Anaerobic Bottle Gram Stain (Final [**2182-5-20**]):
GRAM NEGATIVE ROD(S). -> E.Coli
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
-Ucx ([**5-19**]): Proteus
-Culture of DIALYSIS FLUID ([**5-19**])
Cell count: WBC 12 / RBC 3 / PMNs 70% / Lymphs 4% / Monos 25% /
Eos 1%
GRAM STAIN (Final [**2182-5-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
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 (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
-[**2182-5-22**] 1:45 pm NAIL SCRAPINGS
POTASSIUM HYDROXIDE PREPARATION (HAIR/SKIN/NAILS) (Final
[**2182-5-23**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (HAIR/SKIN/NAILS) (Preliminary):
Imaging:
CXR ([**5-19**]):
IMPRESSION:
1. In comparison to [**2182-5-3**] exam, moderate left pleural
effusion, mild
interstitial pulmonary edema, and cardiomegaly is unchanged.
2. Left lung base consolidation, likely collapse or
superimposed infection.
3. Right lung base peripheral opacity more conspicuous since
prior exam and may represent infection, infarction or organizing
pneumonia.
ECHO ([**5-20**]): pending Well seated mitral annular ring with mildly
increased gradient. Mild-moderate mitral regurgitation. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction suggestive of multivessel CAD.
Compared with the prior study (images reviewed) of [**2182-4-16**],
global left ventricular function is slightly improved. Mitral
valve morphology and severity of mitral regurgitation are
similar.
RLE U/S: No right lower extremity deep venous thrombosis
CT A/P w/o IV contrast: 1. No loculated fluid collections
evident on limited exam. No bowel wall thickening to explain
source of bacteremia.
2. Small-to-moderate left pleural effusion with adjacent
compressive
atelectasis new since the prior exam. Small right pleural
effusion.
3. New nonhemorrhagic perironeal dialysis fluid/ascites.
Extensive anasarca.
4. Increased density in the gallbladder may represent small
stones or high density sludge, however the gallbladder is not
distended and there is no evidence to suggest acute
cholecystitis.
5. Focal dilated bowel loop in the right lower quadrant appears
to be either related to an anastomosis or blind limb.
Brief Hospital Course:
ID: 60 year old female with a complicated past medical history
including DMI, on peritoneal HD, s/p pancreas transplant, CHF
who presents with GNR bacteremia of unclear source.
# Severe Sepsis with GNR bacteremia:
Patient was initially admitted to the MICU for hypotension and
sepsis. In light of positive blood cultures, this is likely the
source of sepsis. Blood culture grew out E.coli though urine
culture was positive for Proteus so the source of the initial
bacteremia is still unclear. [**Name2 (NI) **] was started on meropenem
and her fever curve and blood pressures improved. She was
transferred to the floor where subsequent surveillance blood
cultures were negative. TTE was negative for endocarditis. RLE
thigh pain was not felt to be likely source as area did not look
cellulitic on exam. RLE U/S was negative for clot as well. CT
Abdomen and Pelvis showed some atelectasis and small effusion on
the left but no abdominal sources of infection. Patient will
continue on meropenem for a fourteen day course and will have
infectious disease follow-up.
CHRONIC ISSUES
# ESRD:
On peritoneal dialysis at baseline which was continued here.
Also continued on nephrocaps and lanthanum per home regimen.
Also continued on fluconazole, acyclovir, and midodrine. Will
follow-up with outpatient nephrology.
#DM1 s/p pancreas transplant: Received stress dose steroids on
presentation. On the floor, she was maintained on her home dose
tacro, cellcept, prednisone. Daily tacro levels were within
normal limits. Continued on gabapentin. Did not require insulin
during her stay.
# sCHF: TTE here showed improvement of EF. No signs of acute
exacerbation.
# Afib: Remained in sinus on amiodarone and warfarin. Her INR
was subtherapeutic on discharge so her dose will need
adjustment.
# CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] and CABG: Continued on ASA, plavix and
statin.
# Hypothyroidism: TSH was elevated and T4 was low so her
levothyroxine dose was increased to 125mcg.
# Glaucoma: Continue home eye drops and methazolamide.
.
TRANSITIONAL ISSUE
- Follow-up with outpatient dermatology, nephrology, and ID
- Follow-up nail culture
- Repeat INR this week and adjust coumadin accordingly
- Repeat TSH in 6 weeks to evaluate efficacy of new
levothyroxine dose
Medications on Admission:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours): both eyes.
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. midodrine 10 mg Tablet Sig: 1.5 Tablets PO three times a day.
5. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
8. acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
11. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
12. Cosopt 2-0.5 % Drops Sig: One (1) drop Ophthalmic once a
day: both eyes.
13. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
14. Epogen 20,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
15. fluconazole 100 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
16. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
18. Artificial Tears Drops Sig: 1-2 drops Ophthalmic four
times a day as needed for dry eyes.
19. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
20. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
21. gabapentin 100 mg Capsule Sig: One (1) Capsule PO once a
day.
22. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
24. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day): Both eyes.
25. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
([**Doctor First Name **],TU,TH).
26. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,WE,FR,SA).
27. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
28. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever/pain.
29. vancomycin 500 mg Recon Soln Sig: 1250 (1250) Recon Solns
Intravenous EVERY 3 DAYS (Every 3 Days).
30. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
31. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Clopidogrel 75 mg PO DAILY
7. Creon 12 2 CAP PO TID W/MEALS
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
9. Fluconazole 100 mg PO MWF
10. Fludrocortisone Acetate 0.1 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 100 mg PO Q48H
13. Lanthanum 500 mg PO TID W/MEALS
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Methazolamide 50 mg PO TID
hold for sbp < 100
17. Midodrine 15 mg PO TID
18. Mycophenolate Mofetil 500 mg PO BID
19. Nephrocaps 1 CAP PO DAILY
20. Omeprazole 20 mg PO BID
21. PredniSONE 5 mg PO DAILY
22. Tacrolimus 1 mg PO Q12H
23. Warfarin 1 mg PO DAILY16
24. Lactaid *NF* (lactase) 3,000 unit Oral TID
25. Epoetin Alfa 20,000 UNIT IV ONCE Duration: 1 Doses
Please give [**5-24**]
26. Acetaminophen 325-650 mg PO Q6H:PRN pain
27. Simethicone 40-80 mg PO QID:PRN gas/bloating
28. Meropenem 500 mg IV Q24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
E. coli bacteremia
Anemia of Chronic Renal Disease
ESRD on peritoneal dialysis
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 to the hospital with fevers and low blood
pressure and found to have a blood stream infection from E.
coli. You improved with antibiotics and fluids. A midline IV
line was placed for your continued IV antibiotics at rehab.
Please follow-up with your nephrologist and ID specialist as
below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
Increased levothyroxine as your thyroid levels were low.
Started meropenem antibiotic to treat your bloodstream
infection.
Followup Instructions:
Department: TRANSPLANT
When: MONDAY [**2182-6-10**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: WEDNESDAY [**2182-6-12**] at 9:30 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DERMATOLOGY AND LASER
When: THURSDAY [**2182-6-20**] at 11:00 AM
With: [**Doctor Last Name **],KATHEEN [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
|
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384, 391
|
463, 1944
|
4600, 5172
|
6724, 8483
|
14840, 14984
|
2146, 3291
|
3307, 3601
|
6675, 6690
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
957
| 145,966
|
26118
|
Discharge summary
|
report
|
Admission Date: [**2162-3-22**] Discharge Date: [**2162-3-30**]
Date of Birth: [**2089-4-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain and dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2162-3-22**] - Mitral Valve Replacement(31mm CE Permount Pericardial
Bioprosthetic Valve), CABGx1(vein graft to first obtuse
marginal), and MAZE Procedure
History of Present Illness:
Mr. [**Known lastname 1617**] is a 72 y/o man with a three year history of MR
followed by serial echocardiograms at the [**Hospital6 **]. A
recent echocardiogram in [**Month (only) **] revealed severe MR with a
flail posterior leaflet. He was admitted to the VA and underwent
a TEE which was stopped due to NSVT vs. SVT. Cardiac
catheterization in [**2162-1-17**] confirmed 4+ MR. Angiography
revealed a 70% lesion in the circumflex and a 50% lesion in the
LAD. Mr. [**Known lastname 1617**] was seen in clinic and now presents for surgical
management of his coronary artery disease and mitral
regurgitation.
Past Medical History:
MR, CAD, BPH, Hyperlipidemia, HTN, SVT vs. NSVT preoperatively,
History of severe nose bleeds, Lipoma, s/p Appendectomy, s/p
Tonsillectomy, s/p Umbilical Hernia repair
Social History:
Retired. Lives with wife in [**Name (NI) **]. Quit smoking in [**2102**] after
[**1-18**] ppd starting in middle school.
Family History:
Brother with PPM/PTCA/Stent. Father with [**Name2 (NI) 64806**].
Physical Exam:
Vitals: BP 160-180/ 80, HR 45-50
GEN: WDWN gentleman in NAD
SKIN: Warm, dry, multiple nevi and small lipomas
HEENT: NCAT, PERRL, Anicteric sclera, mild cataracts, OP benign
NECK: Supple, no JVD
LUNGS: Clear, mild kyphosis
ABD: Benign, obese.
NEURO: Nonfocal
Pertinent Results:
[**2162-3-30**] WBC-10.8 Hct-28.0* INR 1.9
[**2162-3-29**] WBC-12.3* RBC-3.37* Hgb-10.6* Hct-30.4* MCV-90 MCH-31.5
MCHC-34.9 RDW-13.3 Plt Ct-460*
[**2162-3-30**] UreaN-18 Creat-1.2 K-5.3*
[**2162-3-28**] BLOOD Calcium-8.7 Mg-2.6
Brief Hospital Course:
Mr. [**Known lastname 1617**] was admitted to the [**Hospital1 18**] on [**2162-3-22**] for surgical
management of his mitral valve and coronary artery disease. On
the day of admission, he was taken to the operating room where a
mitral valve replacement, coronary artery bypass grafting and a
MAZE procedure were performed. The operation was uneventful but
his operative course was complicated by traumatic foley
placement secondary to his BPH. For surgical details, please see
seperate operative note. He required flexibile cystoscopy for
placement of foley and was started on a [**Doctor Last Name **] drip for
hematuria. After the operation, he was brought to the CSRU for
invasive monitoring. Given his history of SVT and Maze
procedure, Amiodarone was resumed. Within 24 hours, he awoke
neurologically intact and was extubated. Initially hypoxic, his
oxygenation improved with diuresis. On postoperative day two, he
transferred to the SDU. Low dose beta blockade was resumed and
diuresis was continued. On postoperative day five, he
experienced new onset slurred speech and left facial droop. His
systolic BP at the time of neurologic event was in the 90's to
low 100's. A stat head CT scan and MRI/MRA were obtained and the
neurology service was consulted. Head MR found no evidence of
acute infarction or abnormalities except slightly diminished
flow signal within the right Sylvian middle cerebral artery
branches compared to the left side, while CT scan showed no
intracranial hemorrhage or mass effect. Carotid noninvasive
studies found no evidence of significant carotid stenoses and
showed appropriate antegrade flow in the vertebral arteries. All
afterload agents were temporarily discontinued including
Amiodarone in order to maintain cerebral perfusion and avoid
further hypotension. Warfarin anticoagulation was also
initiated. Based on the above studies, the neurology service
suspected a TIA secondary to decreased cerebral perfusion. His
neurological status improved and returned to baseline within 24
hours. Amiodarone and low dose betablockade were eventually
resumed. Warfarin was dosed daily for a goal INR between 2.0 -
2.5. He remained mostly in a normal sinus rhythm but
intermittent paroxysmal atrial fibrillation versus SVT were
noted on telemetry. The rest of his hospital course was
uneventful and he was medically cleared for discharge to home on
postoperative day eight. At discharge, his BP was 117/55 with a
HR of 84. His oxygen sat was 98% on room air and his chest x-ray
showed small bilateral pleural effusions. All surgical wounds
were clean, dry and intact. He was voiding without difficulty
and his hematuria had completely resolved. He will eventually
need to follow up with Dr. [**Last Name (STitle) **] as an outpatient for
diagnostic EP study in the near future.
Medications on Admission:
Amiodarone 400mg Qd
Lopressor 25mg [**Hospital1 **]
Aspirin 325mg QD
HCTZ 25mg QD
Fosinopril 40mg QD
Serax 15mg QHS
Fish oil
Calcium
Vitamins
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QPM: Take as
directed by MD. Daily dose may vary according to INR.
Disp:*30 Tablet(s)* Refills:*2*
6. Senna Laxative 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
MR, CAD, Postop Atrial Fibrillation/SVT, Postop TIA, Hematuria,
BPH, Hyperlipidemia, HTN, SVT vs. NSVT preoperatively, History
of severe nose bleeds, Lipoma
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) You may wash you incisoin and pat dry. No swimming or bathing
until it has healed.
5) No lotions, creams or powders to wound until it has healed.
6) No lifting greater then 10 pounds for 10 weeks.
7) No driving for 1 month.
8) Take Warfarin as directed. Followup with Dr. [**Last Name (STitle) 8521**] for
dosing.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in [**4-21**] weeks, call for appt.
Follow-up with Dr. [**Last Name (STitle) 8521**] for coumadin dosing.
Follow-up with Dr. [**Last Name (STitle) **], call for appt.
Follow up with Dr. [**Last Name (STitle) 6630**], call for appt
Completed by:[**2162-4-16**]
|
[
"599.4",
"997.02",
"600.00",
"427.1",
"414.01",
"435.8",
"396.8",
"996.76",
"799.02",
"599.7",
"214.9",
"427.31",
"276.6",
"401.9",
"997.1",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94",
"39.61",
"37.33",
"36.11",
"60.94",
"88.72",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
6327, 6385
|
2112, 4921
|
355, 515
|
6586, 6593
|
1858, 2089
|
1499, 1565
|
5113, 6304
|
6406, 6565
|
4947, 5090
|
6617, 7141
|
7192, 7501
|
1580, 1839
|
281, 317
|
543, 1154
|
1176, 1345
|
1361, 1483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,288
| 183,849
|
24385
|
Discharge summary
|
report
|
Admission Date: [**2191-7-28**] Discharge Date: [**2191-8-7**]
Date of Birth: [**2129-3-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Aortic Aneurysm
Major Surgical or Invasive Procedure:
repair of ascending aortic aneurysm
History of Present Illness:
This is a 62 year old woman who was found to have an asecnding
aortic anerysm. She had a AVR in [**2179**], for which she is
anticoagulated. The aneursym was found to be 5.6 cm and was
foudn on an echo. She is otherwise doing well, and is without
complaint at this time
Past Medical History:
AVR (rheumatic fever)
Lymphedema
Social History:
Former tobacco user
Family History:
+ for early MI
Physical Exam:
HR 60 BP 107/87 RR18 Sat 99%
NAD
RRR, mechanical sounds
CTA
Abd: benign
Ext: warm, well perfused
Pertinent Results:
[**2191-7-28**] 04:40PM BLOOD WBC-5.5 RBC-4.07* Hgb-12.3 Hct-35.8*
MCV-88 MCH-30.2 MCHC-34.3 RDW-13.6 Plt Ct-205
[**2191-7-28**] 04:40PM BLOOD PT-14.7* PTT-26.5 INR(PT)-1.4
[**2191-7-28**] 04:40PM BLOOD Glucose-85 UreaN-13 Creat-0.8 Na-139
K-3.6 Cl-104 HCO3-26 AnGap-13
[**2191-7-28**] 04:40PM BLOOD ALT-14 AST-23 LD(LDH)-283* AlkPhos-61
Amylase-64 TotBili-0.7
[**2191-7-28**] 04:40PM BLOOD Albumin-4.5 Calcium-9.9 Phos-3.0 Mg-1.9
[**Last Name (NamePattern4) 4125**]ospital Course:
The patient was admitted to the hospital for a pre-op
cathertization and heparinization. She did well prior to the
surgery, and the cath was uneventful, it was used for pre-op
planning. She went to the OR on HD5, for aortic repair, the
surgery was uneventful, see Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] operative report
for more detail. Post op, she was admitted to the CSRU, where
she was extubated without difficulty. She was maintatined on
lopressor/lasix, and the chest tubes were kept in untill POD 3.
At HIT was sent for low platelets. Her coumadin was restarted
on POD 2, and her INR was brought to a goal of [**3-17**]. She was
sent to the floor, and PT was consulted, who felt she could go
home. She was sent home on POD 6, tolerating diet well.
Medications on Admission:
ASA
Conjugated Estrogens
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO at
bedtime.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**]
Discharge Diagnosis:
Ascending aortic aneursym
Discharge Condition:
Good
Discharge Instructions:
Seek medical attention if you experience increasing pain,
shortness of breath, dizzyness or any other sign that is
concering to you. You should take all of your medications as
described. You should follow up with your PCP for checking of
your INR, as you have done before your surgery
[**Last Name (NamePattern4) 2138**]p Instructions:
Call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office for an appointment in 2 weeks. You
should see your PCP for following your INR
Completed by:[**2191-8-8**]
|
[
"287.5",
"202.80",
"V58.61",
"441.2",
"398.90",
"V43.3",
"496",
"429.4",
"V17.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.61",
"88.72",
"37.22",
"38.45",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
3023, 3079
|
306, 344
|
3149, 3155
|
906, 1338
|
755, 771
|
2252, 3000
|
3100, 3128
|
2202, 2229
|
3179, 3467
|
3518, 3699
|
786, 887
|
1389, 2176
|
251, 268
|
372, 646
|
668, 702
|
718, 739
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,038
| 113,198
|
13464
|
Discharge summary
|
report
|
Admission Date: [**2107-5-19**] Discharge Date: [**2107-5-25**]
Date of Birth: [**2027-6-12**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Zocor
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath and cough
Major Surgical or Invasive Procedure:
Cardiac catheterization with no intervention
History of Present Illness:
79-year-old with a history of CAD, with 2VD not candidate for
CABG s/p PCI with stent to ostial LAD [**1-/2107**] with residual known
proximal 80% Lcx in addition to a history of systolic CHF, COPD
and OSA who was transferred from the OSH after admission for
NSTEMI complicated by VT/VF which resolved with shock on the day
of transfer.
.
Mrs. [**Known lastname 40800**] presented to OSH yesterday ([**5-18**]) due to
worsening SOB, cough productive of whote phlegm and parasternal
chest pain which was related to cough and deep breathing but not
to exertion or rest without coughing. The cough had troubled her
for the preceeding two weeks. This was also associated with some
fatigue and chills but not with fever or night sweats. She
denied nasal congestion, sinus pain, ear pain, throat pain,
heartburn, diarrhea or urinary symptoms.
.
She reported orthopnea X 2 pillows, paroxysmal nocturnal
dyspnea, nocturia X [**1-5**]. These have been stable in recent days
prior to admission. She denied any lower extremity swelling.
.
On review of systems, she complained of chronic arthritic pains.
Otherwise, she denied any nausea or vomiting, diaphoresis,
fevers, prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
hemoptysis, bloody stools and fevers. All of the other review of
systems were negative.
.
Cardiac review of systems was notable for absence of ankle
edema, palpitations, syncope or presyncope.
.
At the OSH, her admission vitals were as follows: BP 116/60 HR
79 RR 29 SaO2 89% on 2L. She exhibited signs of florid heart
failure (CXR findings and a BNP 1300) and had positive cardiac
enzymes (Trop 4.96). Impression was a NSTEMI. She got 2 units of
blood as her Hct was 26. She was also diuresed overnight with
Lasix 80mg [**Hospital1 **]. As there was suspicion of a GI bleed (Blood on
per-rectal examination, guaiac positive), all anticoagulants and
antiplatelets were stopped and she was admitted to the ICU.
Today ([**5-19**]) In the early PM, after eating lunch she was found
to be unresponsive and in VTach/VFib. She was given CPR and then
defibrillated x1 into normal sinus rhythm. The downtime was <1
minute. She was then put on a 50% venti mask and she remained
hemodynamically stable. An amiodarone gtt was started. She was
transferred to [**Hospital1 18**] for consideration of catheterisation.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Coronary Artery Disease with previous NSTEMI
- Mitral valve prolapse with trace mitral regurgitation
- Congestive Heart Failure
- CABG: Evaluated for surgery but not a suitable candidate.
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2107-1-1**]: 2VD in ostial LAD and proximal circ s/p ostial LAD
stent with DES. No intervention to proximal circ. Procedure
complicated by femoral AV fistula that resolved.
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Peripheral Vascular Disease
- Carotid Disease s/p bilateral carotid endarterectomy (f/u Dr
[**Last Name (STitle) 26438**]
- Chronic Obstructive Pulmonary Disease on home oxygen therapy
(2L/min) and chronic respiratory failure: Last PFT's Moderate
restrictive ventilatory defect with a marked gas exchange
defect. The DLCO is reduced out of proportion to the reduction
in TLC which suggests an interstitial process. per pulmonary
note: has severe COPD with superimposed restriction, severe
emphysema by CT scan, obesity, probably OSA.
- Chronic Kidney Disease (Stage III) with atrophic right kidney
and episodes of acute renal insufficiency
- Gastroesophageal Reflux Disease
- Fatty liver and ?liver cirrhosis
- Gout
- Rheumatoid Arthritis
- Thrombocytopenia ?ITP
- Anemia of chronic disease
- Rhabdomyolysis
- Diverticulosis of urinary bladder
- Bladder polyp s/p removal
- Morbid obesity
- Obstructive Sleep Apnea (Clinically Suspected)
- History of Bone marrow suppression to methotrexate
- History of shingles
- Small left adrenal nodule
Social History:
- Family: Lives alone. Widowed as husband recently died from
leukemia. Has a supportive family.
- Occupation: Used to work in a variety of jobs but now retired
on disability.
- ADLs: Could walk a block before she got breathless. Can dress
herself but with much difficulty.
- Tobacco history: Ex-smoker, quit 20 years ago.
- ETOH: Denied.
- Illicit drugs: Denied.
Family History:
- She has 3 sibilings who died of MIs. A brother passed away at
59 suddenly due to MI. Another brother has had multiple MIs s/p
CABG but passed away after the surgery. Her sister had double
bypass CABG but also passed away after the surgery.
- Otherwise, no family history of arrhythmia, cardiomyopathies,
or sudden cardiac death.
Physical Exam:
On Admission:
GENERAL: NAD.
HEENT: Normocephalic. No trauma to head. Sclera anicteric.
PERRL. No change in oropharynx.
NECK: Supple, no JVD. Thyroid gland not enlarged.
CARDIAC: Normal S1, S2. No S3 or S4. No carotid bruits.
LUNGS: Symmetric. [**Hospital1 **]-basilar crackles. Few expiratory wheezes.
ABDOMEN: Soft, mild tenderness in left lower quadrant but no
rebound tenderness, no palpable masses. No bruits.
EXTREMITIES: 1+ pitting pre-tibial edema. No cyanosis /
clubbing.
SKIN: No rash or eruptions.
PULSES: Diminished pulses over posterior tibial and dorsal pedal
arteries bilaterally.
NEURO: No focal deficits.
.
On Discharge
GENERAL: NAD.
HEENT: Normocephalic. No trauma to head. Sclera anicteric.
PERRL. No change in oropharynx.
NECK: Supple, no JVD. Thyroid gland not enlarged.
CARDIAC: Normal S1, S2. No S3 or S4. No carotid bruits.
LUNGS: Symmetric. CTA with scant bibasilar crackles.
ABDOMEN: Soft, nontender, nondistended no palpable masses. No
bruits.
EXTREMITIES: 1+ pitting pre-tibial edema. No cyanosis /
clubbing.
SKIN: No rash or eruptions.
PULSES: Diminished pulses over posterior tibial and dorsal pedal
arteries bilaterally.
NEURO: No focal deficits.
Pertinent Results:
CBC Trend:
[**2107-5-19**] 06:20PM BLOOD WBC-12.5* RBC-3.11*# Hgb-10.4*#
Hct-31.4*# MCV-101* MCH-33.6* MCHC-33.3 RDW-19.5* Plt Ct-219#
[**2107-5-20**] 06:33AM BLOOD WBC-11.0 RBC-3.06* Hgb-10.0* Hct-31.4*
MCV-103* MCH-32.8* MCHC-32.0 RDW-19.2* Plt Ct-199
[**2107-5-21**] 03:27AM BLOOD WBC-9.7 RBC-2.93* Hgb-10.1* Hct-29.8*
MCV-102* MCH-34.4* MCHC-33.7 RDW-18.7* Plt Ct-194
[**2107-5-22**] 08:50AM BLOOD WBC-10.3 RBC-3.13* Hgb-10.3* Hct-32.9*
MCV-105* MCH-32.8* MCHC-31.2 RDW-18.3* Plt Ct-177
[**2107-5-23**] 07:45AM BLOOD WBC-9.7 RBC-3.16* Hgb-10.4* Hct-33.1*
MCV-105* MCH-32.8* MCHC-31.2 RDW-17.8* Plt Ct-195
[**2107-5-24**] 07:15AM BLOOD WBC-11.6* RBC-3.09* Hgb-10.2* Hct-31.8*
MCV-103* MCH-33.1* MCHC-32.1 RDW-17.5* Plt Ct-167
[**2107-5-25**] 05:45AM BLOOD WBC-8.7 RBC 2.90* Hgb-9.5* Hct-29.6* MCV
102* MCH 32.7* MCHC 32.1 RDW-17.4* Plt Ct-193
.
Chemistry Trend:
[**2107-5-19**] 06:20PM BLOOD Glucose-112* UreaN-51* Creat-2.0* Na-142
K-4.0 Cl-101 HCO3-30 AnGap-15
[**2107-5-20**] 12:01AM BLOOD Glucose-119* UreaN-54* Creat-2.2* Na-141
K-3.7 Cl-100 HCO3-29 AnGap-16
[**2107-5-20**] 06:33AM BLOOD Glucose-125* UreaN-59* Creat-2.3* Na-140
K-4.1 Cl-99 HCO3-31 AnGap-14
[**2107-5-21**] 03:27AM BLOOD Glucose-195* UreaN-63* Creat-2.1* Na-140
K-4.0 Cl-102 HCO3-28 AnGap-14
[**2107-5-22**] 04:25AM BLOOD Glucose-154* UreaN-61* Creat-1.7* Na-141
K-4.4 Cl-103 HCO3-26 AnGap-16
[**2107-5-23**] 07:45AM BLOOD Glucose-127* UreaN-73* Creat-2.5* Na-139
K-4.7 Cl-101 HCO3-30 AnGap-13
[**2107-5-24**] 07:15AM BLOOD Glucose-117* UreaN-81* Creat-2.6* Na-137
K-4.5 Cl-99 HCO3-28 AnGap-15
[**2107-5-25**] 05:45AM BLOOD Glucose-135* UreaN-81* Creat-2.2* Na-135
K-4.2 Cl-98 HCO3-28 AnGap-13
.
Coags:
[**2107-5-19**] 06:20PM BLOOD PT-14.8* PTT-22.4 INR(PT)-1.3*
[**2107-5-22**] 08:50AM BLOOD PT-13.8* INR(PT)-1.2*
.
LFTs
[**2107-5-19**] 06:20PM BLOOD ALT-23 AST-47* LD(LDH)-337* CK(CPK)-94
AlkPhos-64 TotBili-0.7
[**2107-5-24**] 07:15AM BLOOD CK(CPK)-347*
.
Biomarkers Trend:
[**2107-5-19**] 06:20PM BLOOD CK-MB-10 MB Indx-10.6* cTropnT-0.88*
proBNP-[**Numeric Identifier 40801**]*
[**2107-5-20**] 12:01AM BLOOD CK-MB-6 cTropnT-0.89*
[**2107-5-20**] 06:33AM BLOOD CK-MB-6 cTropnT-0.93*
[**2107-5-21**] 03:27AM BLOOD cTropnT-1.41*
[**2107-5-22**] 04:25AM BLOOD CK-MB-4 cTropnT-1.50*
[**2107-5-23**] 07:45AM BLOOD CK-MB-7 cTropnT-1.41*
[**2107-5-24**] 07:15AM BLOOD CK-MB-5
.
HgA1c:
[**2107-5-19**] 06:20PM BLOOD %HbA1c-5.2 eAG-103
.
Cholesterol Panel
[**2107-5-19**] 06:20PM BLOOD Triglyc-74 HDL-57 CHOL/HD-2.0 LDLcalc-44
.
TSH
[**2107-5-19**] 06:20PM BLOOD TSH-2.4
.
ECG ([**2107-5-19**] 5:37:24 PM)
Sinus rhythm with atrial premature beats. ST-T wave
abnormalities. Since the previous tracing of [**2107-1-16**] atrial
premature beats are new. ST-T wave abnormalities are more
marked. Clinical correlation is suggested.
TRACING #1
.
ECG ([**2107-5-20**] 8:23:28 AM)
Sinus rhythm. ST-T wave abnormalities. Since the previous
tracing atrial premature beats are no longer seen. Rate is
decreased. ST-T wave abnormalities persist.
TRACING #2
.
ECG ([**2107-5-22**] 3:24:00 AM)
Sinus rhythm. Prolonged Q-T interval. Anteroapical T wave
inversions suggestive of myocardial ischemia. Clinical
correlation is suggested. Compared to the previous tracing of
[**2107-5-20**] precordial T wave inversions are less pronounced.
.
ECG ([**2107-5-23**] 9:07:36 AM)
Sinus rhythm with an atrial premature beat. Low lateral
precordial T wave amplitudes and minor ST-T wave abnormalities
in the lateral limb leads. Since the previous tracing of [**2107-5-22**]
ST-T wave abnormalities are now less prominent in the lateral
precordial leads and more prominent in the lateral limb leads at
a faster rate. The atrial premature beat is new.
.
IMAGING:
CHEST (PORTABLE AP) ([**2107-5-19**] 6:11 PM)
FINDINGS: In comparison with study of [**1-16**], there is enlargement
of the
cardiac silhouette with pulmonary vascular congestion.
Retrocardiac
opacification most likely represents atelectasis with small
effusion, though the possibility of supervening pneumonia would
have to be considered in the appropriate clinical setting.
.
CHEST (PORTABLE AP) ([**2107-5-23**] 8:37 AM)
The cardiac silhouette remains enlarged, similar from prior
study. There is pulmonary vascular congestion and bilateral
diffuse opacifications, which likely represents a combination of
pulmonary edema and pleural effusion, but infectious process
cannot be excluded in the appropriate clinical setting. No
pneumothorax is noted. The mediastinal and hilar silhouettes are
stable.
IMPRESSION:
1. Unchanged pulmonary vascular congestion and pulmonary edema,
but pneumonia cannot be excluded in the appropriate clinical
setting.
2. Bilateral pleural effusion is unchanged from prior study.
.
Portable TTE (Complete) ([**2107-5-21**] 10:21:55 AM)
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is low normal (LVEF
50%) secondary to mild hypokinesis of the inferior, posterior,
and lateral walls (the anterior septum and anterior free wall
are hyeprdynamic). Right ventricular chamber size and free wall
motion are normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. Compared with the findings of the prior
report (images unavailable for review) of [**2107-1-7**], mild
posterior and lateral hypokinesis is now present.
.
Cardiac Cath ([**2107-5-20**])
Coronary angiography showed right dominant system.
LMCA- Short, normal
LAD- Stent widely patent, no significant disease
LCX- Mild proximal disease, no significant other disease on
limited
views.
RCA- Mild diffuse disease only.
FINAL DIAGNOSIS:
1. Widely patent LAD stent
2. Mild non-significant CAD/ no culprit for NSTEMI.
Brief Hospital Course:
Ms [**Known lastname 40800**], a 79-year-old with a history of CAD, with 2VD not
candidate for CABG, s/p PCI with stent to ostial LAD ([**1-/2107**])
with residual known proximal 80% Lcx in addition to a history of
systolic CHF, COPD and OSA who was transferred from an OSH after
admission for NSTEMI + CHF exacerbation complicated by VT/VF
which resolved with shock on the day of transfer.
.
# NSTEMI.
Patient has a history of CAD with 2VD per cath in [**2107-1-1**];
patient is not a candidate for CABG due to high surgical risk in
the setting of severe COPD. Patient underwent an elective PCI at
that time with stent to ostial LAD [**1-/2107**] with residual known
proximal 80% Lcx. Patient presented to OSH [**5-18**] with lateral and
inferior EKG changes and raised troponins suggestive of a new
NSTEMI compatible with LCx distribution. She was transferred to
[**Hospital1 18**] for cardiac catheterization. She was continued on an IV
Heparin gtt and started ASA 325 mg PO, clopidogrel 75 mg PO
daily, atorvastatin 80mg daily. Patient underwent cardiac cath
on [**5-23**] which demonstrated widely patent LAD stent, mild
non-significant CAD and no culprit for NSTEMI. TTE demonstrated
normal left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is low normal (LVEF 50%) secondary to mild
hypokinesis of the inferior, posterior, and lateral walls (the
anterior septum and anterior free wall are hyperdynamic).
Patient remained chest pain free throughout remainder of her
stay.
.
# Acute decompensated sytolic CHF (NYHA Class III): On
presentation to OSH CXR showed florid pulmonary congestion.
Patient was diuresed in OSH with IV lasix. BNP = 1300. Likely
decompensated due to ischemia. On arrival patient with above
baseline O2 requirement (nasal canula at 5L; 2L at home).
Patient intermittently diuresised with Furosemide 20 mg IV. On
HD3 patient creatinine elevated and decision made to hold to
diuresis. Patient was started on ACEi and continued on beta
blocker.
.
# RHYTHM. She developed an episode of VTach/VFib possibly as a
complication of her recent NSTEMI. The downtime was <1 minute.
This required CPR and defibrillation x1 which subsequently
converted her to normal sinus rhythm. She was monitored on
telemetry without further event.
.
# COPD: Chronic Obstructive Pulmonary Disease on home oxygen
therapy (2L/min) and chronic respiratory failure. Last PFT's
Moderate restrictive ventilatory defect with a marked gas
exchange defect. FEV1/FVC actual = predicted = 0.65. Per
pulmonary note: has severe COPD with superimposed restriction,
severe emphysema by CT scan, obesity, probably OSA. Now
presenting with worsening cough of 14 days productive of sputum.
No fever. Has leukocytosis to 12.5. Dif is pending. No clear
infiltrates on CXR except possible small infiltrate at left
heart border. Given her prolonged cough with increased sputum in
the setting of risk factors including chronic prednison, severe
underlyting lung disease, diabetes, CHF and her age would tend
to cover her with Abx for CAP organisms. She was started on PO
Levofloxacin for likely 5day treatment course. She was continued
on home Advair (500/50), ipratropium nebs as well as standing,
chronic prednisone 5mg
.
# Anemia: Has baseline macrocytic anemia, with Hct ~ 30-31. In
OSH noted to have PR bleeding per-rectal examination and was
guiaic positive. Hct was 26 and she received PRBC X2, now Hct
31. B12, Folate were normal in [**Month (only) 404**]. Patient continued on
Pantoprazole 40 mg PO Q24H in the setting of Plavix + Asprin.
HCT stable in house.
.
# Chronic Kidney Disease (Stage III). Creatinine in [**2107-1-1**]
was 2.1. Creatinine did uptrend in setting of diuresis as well
as contrast load during catheterization. Patient continued to
make urine thoughout hospitalization. Creatinine at time of
discharge was 2.2.
.
# Question of cirrhosis. Patient has history of fatty liver with
recent CT demonstrating nodular liver. Has chronic macrocytosis,
low albumin, borderline elevated INR and mild chronic
thrombocytopenia. All suggesting chronic liver disease. Of note
current elevated AST is likely of cardiac origin.
- Out-patient hepatlogy f/u.
.
# HTN: Converted to Metoprolol succinate from tartrate and
started on Lisinopril for her CHF instead of felodipine. Her
blood pressure was well controlled during her hospital stay.
Lisinopril should be uptitrated as creatinine allows.
.
# HLD. Patient was started on Atorvastatin 80mg daily for
treatment of CAD. Her lipid panel was normal.
.
OUTPATIENT ISSUES:
- Continue Atorvastatin 80mg daily
.
# DM. Her HbA1c was 5.2%. Her glypizide was held and she as put
on an insulin sliding scale and a low carbohydrate diet.
.
OUTPATIENT ISSUES:
- Restart glypizide
.
# Gout: She has some minor joint pain that was treated with
Tramadol prn, No evidence of acute flare.
- Continue Febuxostat 40 mg PO DAILY
.
# Rheumatoid Arthritis. Hydroxychloroquine was held in the
context of recent arrythmias as well as ABx treatment with
levofloxacin to avoid excess QT prolongation. This should be
restarted as an outpt.
.
#Urinary Tract Infection. A UA was positive on [**5-25**], but she was
asymptomatic. She was treated with PO levofloxacin for 5 days
for her pneumonia, course was finished at the time of the
postivie U/A. Urine cultures were sent. Rehab will be called if
the results are positive.
.
OUTPATIENT ISSUES:
- Urine culture results will need to be followed-up as an
outpatient
Medications on Admission:
HOME MEDICATIONS:
- Advair Diskus 500/50 mcg one inhalation [**Hospital1 **]
- Uloric one pill qd
- Aspirin 162mg qd
- Iron sulfate 325mg qd
- Folic acid 1mg qd
- Lasix 20mg qd
- Felodipine 5mg daily
- Glipizide 5mg qd
- Glucosamine and chondriotin [**Hospital1 **]
- Lopressor 50mg po bid
- Lovaza 2g [**Hospital1 **]
- Plavix 75mg qd
- Pravastatin 10mg po at bedtime
- ReQuip 1mg po at bedtime
- Prednisone 5mg qd
- Plaquenil 200mg po qd
- Spiriva 18mcg inhalation qd
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
11. 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*
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lovaza 1 gram Capsule Sig: Two (2) Capsule PO twice a day.
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation: hold for diarrhea.
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
18. ferrous sulfate 324 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsulr Inhalation once a day.
20. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Non ST elevation myocardial infarction
Acute on Chronic Systolic congestive heart failure
Ventricular tachycardia
Acute on chronic kidney disease
Community aquired pneumonia
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 Mrs [**Known lastname 40800**],
.
you were transferred to our hospital after suffering a
myocardial infarction ("heart attack") which was complicated by
heart failure and heart rythm disturbances. You underwent
coronary catheterization which did not show any lesions that
require intervention. Your kidneys worsened temporarily because
of the catheterization dye, they are improving today.
.
The following changes were made to your medications:
.
- Felodipine was stopped
- Plaquenil was stopped
- Pravastatin was stopped
- Lopressor 50mg tablet was changed to a long acting formulation
at 100 mg daily
- Omeprazole was changed to pantoprazole to protect your stomach
from the medicines.
Please do not resume these medications without consulting your
doctor.
.
- Aspirin tablet was increased to Aspirin 325mg tablet: please
take one tablet once daily.
.
- Lisinopril 2.5mg tablet was started for blood pressure. Please
take one tablet once daily.
.
- metoprolol succinate 100 mg Tablet Extended Release 24 hr
was started to help your heart beat more efficiently. Please
take one tablet once daily.
.
- Atorvastatin 80mg was started. Please take one tablet once
daily.
.
- Laxtulose was started as needed for constipation
.
- STart Tramadol to treat the pain in your knee and chest wall
area.
.
Daily weights every morning, please notify Dr. [**Last Name (STitle) 5017**] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Street Address(2) **], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 39854**]
Phone: [**Telephone/Fax (1) 5424**]
Appointment: Monday [**2107-6-6**] 2:15pm
Completed by:[**2107-5-26**]
|
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"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56"
] |
icd9pcs
|
[
[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,174
| 170,472
|
38897
|
Discharge summary
|
report
|
Admission Date: [**2152-4-30**] Discharge Date: [**2152-5-21**]
Date of Birth: [**2117-2-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Pancreatitis, DKA
Major Surgical or Invasive Procedure:
EGD
Intubation
Angiography
History of Present Illness:
35 year old male with history of alcohol abuse and pancreatitis
transferred from OSH with pancreatitis and concern for bowel
ischemia.
He presented to the OSH on the evening of [**4-28**] after a week of
nausea, vomiting and abdominal pain. Wife called 911 because
patient did not want to see a doctor, SBPs in 80s per report.
Per OSH last drink was [**4-26**]. At OSH he was noted to be in DKA
with no prior history of DM with BG of >1200, gap 37. He was
started on insulin drip. He was also noted to have pancreatitis
with a lipase 167 and amylase 425. While at the OSH, he was
intermittently febrile to max of 103, hypotensive requiring
phenylephrine transiently, and broad-spectrum antibiotics
(imipenem). Additional issues during his hospital course
included the following: 1) non-oliguric renal failure (Cr 4.0),
likely due to hypotension and volume depletion. 2) respiratory
distress in the setting of renal failure requiring intubation. A
repeat abdominal CT was performed which revealed possible
mesenteric ischemia, and he was then transferred to [**Hospital1 18**] for
further evaluation.
Past Medical History:
1. Alcohol Abuse w/ prior DTs in setting of pancreatitis in [**2145**]
2. h/o Pancreatitis with pseudocyst in [**2145**]
Social History:
Home: Lives with his wife.
[**Name (NI) 1139**]: + tobacco
EtOH: endorses alcohol use.
Family History:
Could not assess
Physical Exam:
General: intubate sedated
HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachy rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present *4,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
trace edema
Pertinent Results:
ADMISSION LABS:
[**2152-4-30**]
WBC 4.6 / hct 29.6 / Plt 41
INR 1.1 / PTT 25
Na 145 / K 4 / Cl 112 / CO2 18 / BUN 55 / Cr 4.3 / BG 146
ALT 87 / AST 112 / LDH 417 / Alk Phos 145 / TB .8
Alb 2.6 / Ca 7 / Mg 1.7 / Phos 2.4
[**2152-5-1**]
TIBC 135 / Vitamin B12 1783 / Folate 11.9 / Haptoglobin 271 /
TRF 104
[**2152-5-2**] HBsAg negative / HBsAb negative / HBcab negative / HAV Ab
negative / HCV Ab negative
[**2152-5-2**] AMA negative / Anti smooth muscle antibody negative / [**Doctor First Name **]
negative
[**2152-5-2**] Ferritin 1245
[**2152-5-3**] Ammonia 56
DISCHARGE LABS:
[**2152-5-21**]
Na 140 / K 4.2 / Cl 103 / CO2 31 / BUN 9 / Cr .6 / BG 75
Ca 9.1 / Mg 1.8 / Phos 5
WBC 4.3 / Hct 28.4 / Plt 158
INR 1.4 / PTT 28.4
MICROBIOLOGY:
5/2/210 Blood cx negative
[**2152-4-30**] Urine Cx negative
[**2152-5-1**] Blood cx negative
[**2152-5-1**] Cdiff negative
[**2152-5-2**] Sputum Cx MSSA, Yeast
[**2152-5-2**] Cdiff negative
[**2152-5-3**] Urine Cx negative
[**2152-5-11**] Blood Cx x 2 negative
[**2152-5-12**] Blood Cx x 2 negative
[**2152-5-15**] Cdiff negative
STUDIES:
[**2152-5-3**] RUQ US -
1. Non-occlusive thrombus in the left portal vein.
2. Hepatomegaly.
3. Moderate amount of ascites. A spot was marked for
paracentesis to be
performed by the clinical team in the lower pelvis in the
midline.
[**2152-5-5**] MRI Abdomen -
1. Findings consistent with extensive hemorrhagic pancreatitis
involving head and body of the pancreas and almost complete
devascularization, consistent with necrotic pancreas..
2. Fluid collection adjacent to the pancreas in the lesser sac
measuring 4.6 x 7.7 cm with a suspicion of connection to the
main pancreatic duct.
3. Moderate amount of ascites with mild enhancement of
peritoneal leafs on
the right.
4. Small amount of bilateral pleural effusions with atelectasis.
5. Mild splenomegaly.
6. SMV, splenic and portal vein thrombosis. Partial left portal
vein
thrombosis.
7. Mild dilatation of the intrahepatic biliary tree, left more
than right,
without evidence of CBD dilatation.
[**2152-5-11**] CTA Pelvis
1. No significant change in the necrotizing pancreatitis with
minimal to no residual enhancing pancreas. There may be a small
amount of enhancing head and uncinate process.
2. No significant change in the multiloculated fluid collections
within the pancreatic bed. No gas is seen within these fluid
collections at this time.
3. No significant change in thrombosis of the SMV extending into
the main
portal vein and distalmost splenic vein. The left portal vein is
also likely thrombosed, though does fill distally perhaps via
collaterals.
4. Numerous abdominal collaterals and mild splenomegaly
consistent with
portal hypertension due to the thrombosis.
5. Small amount of ascites, decreased from prior.
6. Possible mild hypoenhancement of the upper pole of the right
kidney. This may not be a clinically significant finding,
however, could possibly be seen in pyelonephritis and therefore
correlation with urinalysis recommended.
7. Nodular opacities in the right middle lobe, incompletely
evaluated, but
likely infectious or inflammatory in nature.
[**2152-5-14**] CT Abd/Pelvis
1. Findings concerning for pseudoaneurysm formation arising from
a
branch of the inferior pancreatic artery. No evidence for
rupture.
2. Stable appearance of multiloculated fluid collections
replacing most of
the pancreas, consistent with necrotizing pancreatitis. Stable
SMV and
proximal left portal vein thrombosis.
3. Stable mild splenomegaly with perisplenic varices, consistent
with portal hypertension.
4. Likely reactive inflammation in the duodenum and ascending
colon.
5. New small pleural effusions with atelectasis. Lateral segment
right
middle lobe pneumonia versus aspiration
Brief Hospital Course:
35 year old man with past history of alcohol abuse was
transferred from OSH for further management of severe
complicated alcoholic acute pancreatitis.
1. Acute pancreatitis
Etiology thought to be secondary to alcohol. Abdominal CT showed
hemorrhage and near-complete de-vascularization of the pancreas
with necrosis. Two repeat abdominal CT's obtained throughout his
hospital stay showed no evidence of further hemorrhage or
abscess formation. ICU course was also complicated by
respiratory failure, which quickly resolved, as well as acute
renal failure attributable to severe pancreatitis which resolved
with hydration. His pancreatitis gradually improved and upon
discharge, he was tolerating a regular diet with pancrease.
Pancrease was given before meals for presumed pancreatic
insufficiency resulting from necrosis of the pancreas.
2. New-onset Diabetes Mellitus
Etiology was thought secondary to extensive necrosis of the
pancreas, complicated by DKA. Patient was seen in consultation
by [**Last Name (un) **] and started on Lantus with a sliding scale with
resultant good control of his blood sugars. He received
extensive teaching regarding his diabetes and insulin.
3. Fevers
Patient was febrile on presentation to the ICU and was
empirically treated with Meropenem for five days. All cultures
remained negative and Meropenem was stopped. Several days after
cessation of Meropenem the patient again spiked fevers to 104.8.
He received an empiric course of Vanc/Ceftriaxone/Flagyl for 48
hours, which was also stopped when repeat cultures were again
negative. Repeat abdominal CT at that time showed no evidence of
pancreatic abscess. He was afebrile for at least the last 7 days
of his hospitalization.
4. Anemia
Patient had a marked decrease in his hematocrit and was found to
have guaiac positive stools. He underwent an upper endoscopy
significant only for portal gastropathy attributed to extensive
portal vein thrombosis; no varices or active bleeding noted.
Colonoscopy was deferred given his complex hospital course but
should be completed as an outpatient. He was started on iron
supplementation.
5. Portal vein/superior mesenteric vein thrombosis
Patient seen in consultation by general surgery and hepatology,
who recommended anticoagulation given the risk of mesenteric
ischemia with SMV thrombosis. The patient was started initially
on a Heparin to Coumadin bridge with 5mg of Coumadin daily, but
quickly became supratherapeutic with an INR to 4.0 after only
two doses of Coumadin. After his INR decreased he was re-started
on heparin bridge with coumadin 2.5mg daily. His INR was rising
very slowly, and his coumadin was again increased to 5mg daily.
He received 5mg coumadin for the last 2 days prior to discharge,
and his INR increased only from 1.1 to 1.4. He was discharged
with lovenox and coumadin with plans to have his INR rechecked
48 hours after discharge. He was continued on coumadin 5mg daily
upon discharge.
6. Thrombocytopenia
His platelets were in the 40's upon presentation, attributed to
severe pancreatitis and alcohol abuse. His platelets rose to a
high of 140, then decreased to the 90-100 range in the setting
of high fevers. No evidence of primary liver disease or
cirrhosis noted on imaging or endoscopy; very low suspicion for
HIT given one negative HIT antibody and the steady rise in his
platelet count early in his hospital course while on Heparin.
7. ? Pseudoaneursym
During his admission, he underwent a CT Abd/Pelvis which
revealed a pseudoaneurysm in the inferior pancreatic artery. Due
to concern for bleeding from this aneurysm, he was recommended
to undergo a coiling procedure with IR. He underwent angiography
with IR, but no pseudoaneurysm was seen.
Medications on Admission:
none per records
Discharge Medications:
1. One Touch Ultra Glucometer, Dispense One, No Refills
2. One Touch Ultra Test Strips, Dispense One Month's Supply, no
refills
3. Please dispense one month's supply of lancets, no refills
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours).
Disp:*40 doses* Refills:*0*
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*200 Cap(s)* Refills:*0*
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Coumadin 2 mg Tablet Sig: 2.5 Tablets PO once a day: You
should have your INR checked on Tuesday [**2152-5-23**] and faxed to
your PCP's office. After this, they will tell you what dose to
take.
Disp:*90 Tablet(s)* Refills:*0*
12. Lantus 100 unit/mL Solution Sig: As directed units
Subcutaneous twice a day: Take 30 units with breakfast and 5
units at bedtime.
Disp:*10 mL* Refills:*0*
13. Humalog 100 unit/mL Solution Sig: As directed units
Subcutaneous four times a day: Please take your insulin
according to the attached sliding scale. .
Disp:*30 mL* Refills:*0*
14. Lancets Misc Sig: One (1) Miscellaneous four times a
day: Please dispense Lancets for the Accu Check Aviva
Glucometer. .
Disp:*160 lancets* Refills:*0*
15. Outpatient Lab Work
Please have your INR checked on Tuesday [**2152-5-23**]. The results
should be faxed to your primary care physician's office at
[**Telephone/Fax (1) 86312**]. They will instruct you what dose of coumadin to
take after that and what to do about your lovenox.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. severe complicated alcoholic acute pancreatitis
2. respiratory failure
3. Type 2 Diabetes Mellitus
4. Cholestatic hepatitis
5. Non-occlusive portal vein and SMV thrombosis
6. Acute renal failure
7. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had severe complicated alcoholic acute pancreatitis with
respiratory failure, new onset diabetes, cholestatic hepatitis,
non-occlusive portal vein thrombosis, acute renal failure, and
progressive anemia from GI bleeding requiring transfusion. You
have recovered, but you will need Insulin and Coumadin to treat
the above conditions. Please follow up with your liver doctors,
PCP, [**Name10 (NameIs) **] Endocrinologist.
For your coumadin monitoring, please have your labs checked at
your local Quest Lab. They may fax the results to your primary
care physician's office at [**Telephone/Fax (1) 86312**]. They will then instruct
you what dose of coumadin to take after that and also whether or
not to continue your lovenox.
We have made the following changes to your medication regimen:
- Omeprazole - This is a medication to treat acid reflux.
- Folate and multivitamin - We would encourage you to continue
taking these to maintain adequate nutrition.
- Iron - We recommend that you take this to help treat your low
blood count (anemia).
- Creon - These are supplemental medications to help you digest
food since your pancreas was damaged.
- Lidocaine - This is a pain patch.
- Coumadin - This is a medication to help prevent further blood
clots.
- Lovenox (Enoxaparin) - This is a medication to help prevent
further blood clots. You should take this medication until your
INR (coumadin level) is high enough.
Followup Instructions:
1. PRIMARY CARE APPOINTMENT
Please follow-up with your primary care physician [**Name9 (PRE) 7217**],[**Name9 (PRE) **]
[**Name Initial (PRE) **]. on Thursday [**2152-6-1**] at 2:30pm. If you need to reschedule,
please call his office at [**Telephone/Fax (1) 70071**].
2. SURGERY APPOINTMENT
You have a CT scan on [**2152-6-19**], and you should arrive at
08:00AM. It is located at [**Hospital Ward Name 23**] 4, [**Hospital Ward Name 516**], [**Hospital1 18**] [**Location (un) 86**].
If you need to reschedule, please call their office at
[**Telephone/Fax (1) 327**]. Please do not have anything to eat/drink 3 hours
before the CT scan. After the CT scan, please go to your
scheduled appointment with Dr. [**First Name8 (NamePattern2) 251**] [**Name (STitle) **] on [**2152-6-19**] at 9:15
am. His office is located at [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**], [**Hospital1 18**]
[**Location (un) 86**]. If you need to reschedule, please call his office at
[**Telephone/Fax (1) 2835**].
3. GASTROENTEROLOGY APPOINTMENT
You should also follow-up with a gastroenterologist to continue
evaluation of your pancreas and liver problems. [**Name (NI) **] should
follow-up with Dr. [**First Name8 (NamePattern2) 1255**] [**Name (STitle) 1256**] within 1 month. Please call his
office at [**Telephone/Fax (1) 463**] to schedule an appointment.
|
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icd9cm
|
[
[
[]
]
] |
[
"45.16",
"88.47",
"99.15",
"38.93",
"94.62",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11881, 11887
|
6018, 9738
|
341, 369
|
12157, 12157
|
2261, 2261
|
13747, 15108
|
1764, 1782
|
9805, 11858
|
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|
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|
12307, 13724
|
2843, 5995
|
1797, 2242
|
284, 303
|
397, 1499
|
2277, 2827
|
11927, 12136
|
12172, 12283
|
1521, 1644
|
1660, 1748
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,461
| 118,569
|
46410
|
Discharge summary
|
report
|
Admission Date: [**2165-4-5**] Discharge Date: [**2165-4-7**]
Date of Birth: [**2098-3-15**] Sex: F
Service: MEDICINE
Allergies:
Prilosec / Bactrim Ds / Percocet / Sulfonamides / Vitamin D /
Nifedipine / Atrovent Hfa / Maxair Autohaler
Attending:[**First Name3 (LF) 98592**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 67 yo F with past medical history of breast cancer,
hypertension, cardiomyopathy now resolved and atrial
fibrillation who is admitted with a segmental RLL PE.
.
The patient presented to the ED on the day of admission after
feeling weak and nauseated after a blood draw for an INR check.
She had approximately 24 hours of diffuse malaise, abdominal
discomfort and bloating as well as dizziness. She took
pepto-bismol at home which relieved her abdominal discomfort.
In the ED, the patient had one episode of bilious vomiting.
Lactate was within normal limits. There was concern given her
leukocytosis, malaise and abdominal discomfort for a GI pathogen
so she was covered with levofloxacin 750 mg IV x1 and flagyl 500
mg IV x1. She was sent for a CTA of her chest as well as a CT
abd/pelvis after she became hypoxic, satting 80s on RA, up to
98% on 4L. She additionally became tachypneic to the 30s and
tachycardic to 120s per report (though not documented in ED
paperwork).
ECG showing change in p waves, sinus tach. No clinical evidence
of LE DVTs. Cr is up to 1.5, on her second L of fluid. Lactate
1.5. Blood cultures and urine cultures sent.
.
In the ED, initial vs were: T 97.9 P 107 BP 108/78 R 18 O2 sat
100% on RA. Patient was given levo/flagyl as above as well as 4
mg Zofran.
On the floor, the patient continues to have some nausea, but no
further episodes of vomiting. She denies any lightheadedness,
chest pain, pleuritic pain or palpitations.
Past Medical History:
1. Atrial fibrillation on disopyramide
2. Asthma/COPD, with last FEV 1 0.81L (47%) on [**2164-11-27**]
3. Hypertension
4. H/o CHF/cardiomyopathy with EF 20%, spontaneously resolved,
now EF 50% in [**12-1**]
5. Possible amiodarone-induced lung toxicity
6. H/o breast cancer, s/p lumpectomy, chemo and XRT in [**2146**]
7. Osteopenia
8. H/o lung nodules
9. H/o trigeminal neuralgia
10. H/o migraine headaches, usually right-sided, retroorbital.
11. History of TAH/BSO for post-menopausal bleeding
12. S/p laprascopic cholecystectomy
Social History:
Patient lives alone. Denies tobacco (never used). No ETOH. No
illicits. She is retired from multiple jobs in the past.
Family History:
Per OMR records, sister with MI in 20s. Family history of CAD
and valvular disease. She reports her father had lung cancer.
She reports she has 2 brothers with prostate cancer.
Physical Exam:
Vitals: T: 98.9 BP: 137/88 P: 112 R: 26 O2: 99% on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at 6 cm
Lungs: Decreased breath sounds bilaterally, slight rales at R
base, no wheezes
CV: Regular rhythm, tachycardic, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, distended, hypoactive bowel sounds,
no rebound tenderness or guarding, no organomegaly, well-healed
midline scar
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2165-4-5**] 11:30AM PT-25.5* INR(PT)-2.5*
[**2165-4-5**] 06:10PM PLT COUNT-348
[**2165-4-5**] 06:10PM NEUTS-76.2* LYMPHS-18.3 MONOS-4.3 EOS-0.7
BASOS-0.5
[**2165-4-5**] 06:10PM WBC-12.4* RBC-5.19# HGB-14.3# HCT-40.9#
MCV-79*# MCH-27.6 MCHC-35.0 RDW-14.1
[**2165-4-5**] 06:10PM estGFR-Using this
[**2165-4-5**] 06:10PM GLUCOSE-96 UREA N-27* CREAT-1.5* SODIUM-133
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-25 ANION GAP-18
[**2165-4-5**] 06:16PM HGB-15.1 calcHCT-45
[**2165-4-5**] 06:16PM COMMENTS-GREEN TOP
[**2165-4-5**] 07:10PM LACTATE-1.5
[**2165-4-5**] 07:10PM COMMENTS-GREEN TOP
[**2165-4-5**] 09:50PM URINE RBC-0-2 WBC-[**3-28**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2165-4-5**] 09:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2165-4-5**] 09:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2165-4-5**] 10:05PM PTT-27.1
Imaging:
[**2165-4-5**]:
CXR: Low lung volumes with no acute cardiopulmonary process
[**2165-4-7**]:
CT chest/pelvis:
IMPRESSION:
1. The addendum concurs with the results in the final report
issued
previously on the chest CT. A suboptimal contrast bolus rendered
evaluation
of the distal subsegmental branches incomplete and therefore a
pulmonary
embolism could not be excluded. The patient has had subsequent
chest CTA on
[**2165-4-6**], which demonstrates no pulmonary embolism with a better
contrast
bolus.
2. In addition to the change in the initial wet regarding a
pulmonary
embolism, the pulmonary nodules noted in the CT are stable
relative to a prior
in [**2159**] and therefore there is no suspected metastatic
involvement of the
lungs.
3. Findings are consistent with a high-grade small-bowel
obstruction likely
due to adhesion at the midline of a presumed prior hysterectomy
incision. The
preliminary results to this effect were provided by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at 1:30 p.m.
on [**2165-4-7**]. At that point, Dr. [**First Name (STitle) **], of the clinical team,
inform Dr. [**First Name (STitle) **]
that she had subsequently advanced her diet and was passing
flatus and
therefore likely spontaneously reduced. Nonetheless, the imaging
findings are
striking. There are no features of intestinal ischemia on the
current study.
A surgical consultation nonetheless is likely advised, now on a
more nonurgent
outpatient basis unless symptoms again arise.
As the patient had already been discharged at the time of
addendum, the
patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was
informed of these
results at 8:45 pm on [**2165-4-7**].
[**2165-4-6**] CTA chest
1. No evidence of pulmonary emboli.
2. Similar patchy ground-glass opacities and many sub-5-mm
nodules which are not significantly changed.
Brief Hospital Course:
# ?Pulmonary embolism: Patient presented intially with nausea
and lightheadedness. Due to transient hypoxia on room air in
the emergency department, a Chest CTA was obtained. Although
the bolus was inappropriately timed, there was concern for PE.
This was concerning given that she has breast cancer, had a
recent TAH-BSO and was therapeutic on coumadin for Atrial
Fibrillation. She was admitted to the ICU and started on heparin
drip. A repeat CTA was performed and there was no evidence of
PE. Therefore, the decision was made that the patient should
remain on coumadin and did not need an IVC filter. An echo was
performed and did not show RV dysfuction. she was transferred to
the medicine floor where she remained on telemetry and was
hemodynamically stable. Her coumadin dose was continued per home
regimen.
.
# Nausea/vomiting. She developed nausea in the ED which
improved with zofran. She was given IVF and a CT abd/pelvis was
performed initially read as negative for concerning findings.
The patients was continued on IV fluids until she was able to
tolerated po. She continued to have intermittent episodes of
nausea, but no vomiting or diarrhea. She was passing flatus.
Once she was able to tolerate food, she was discharged home with
outpatient follow-up. The day post-discharge, her provider was
informed by radiology that the CT A/P did show a small bowel
obstruction on admission, that appeared to have resolved during
her stay. Her PCP was informed, and the patient was contact[**Name (NI) **] to
ensure proper follow-up and further treatment if needed.
# ARF. Patient presented with pre-renal acute renal failure and
lightheadedness. This responded to IVF. ARF was likely
secondary to dehydration, though patient did not report a clear
history of poor PO intake. She did have an episode of vomiting
in the ED. Her electrolytes and creatinine returned to baseline
prior to discharge.
.
# Atrial fibrillation. Patient been therapeutic with her INR
for the last several months and remained therapeutic during her
hospital stay. On diltiazem and disopyramide for rate/rhythm
control.
.
# Hypertension. Patient was hypertensive during hospital stay.
SHe was continued on home BP medication regimen. No changes were
made prior to discharge.
Medications on Admission:
Albuterol 90 mcg 2 puffs po four times a day as needed
Albuterol Sulfate 0.63 mg/3 mL QID prn wheeze/cough
Clonazepam 0.25 mg [**Hospital1 **]
Diltiazem HCl 360 mg Sustained Release daily
Disopyramide 150 mg [**Hospital1 **]
FIORINAL [**Medical Record Number 3668**] Q6H prn headache
Lisinopril 5 mg [**Hospital1 **]
Pantoprazole 40 mg daily
Potassium Chloride 10 mEq TID
Triamcinolone Acetonide 75 mcg 4 puffs TID
Warfarin 7.5 mg x 6 days, Tuesday takes 5 mg only
.
Discharge Medications:
1. Disopyramide 150 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO Q12H (every 12 hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Triamcinolone Acetonide 75 mcg/Actuation Aerosol Sig: One (1)
Inhalation TID (3 times a day).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM as needed for M,W, Th, F, Sat, Sun.
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO three times a day.
8. Clonazepam 0.5 mg Tablet Sig: [**1-25**] Tablet PO BID (2 times a
day).
9. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
10. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) Inhalation once a day as needed for shortness of
breath or wheezing.
11. Fiorinal 50-325-40 mg Capsule Sig: One (1) Capsule PO once a
day: per outpt regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
viral gastroenteritis
small bowel obstruction
Discharge Condition:
hemodynamically stable
Discharge Instructions:
You were admitted to the hospital for nausea, diarrhea and an
acute episode of shortness of breath in the emergency room,
concerning for a blood clot in the lungs. You were started on
heparin therapy however CT imaging showed there was no concern
for clot. You were also given one dose of antibiotics and IV
fluids for hydration and to treat any underlying infections.
For your nausea and abdominal discomfort you were treated with
nausea medications, and your abdominal CT showed an obstruction
in your small bowel. When you were discharged you were feeling
better, eating and passing gas.
***If you have a return of abdominal pain, not have bowel
movements or having trouble eating please return to the ED.
Please make sure to follow up with your primary care doctor,
Dr.[**Last Name (STitle) **], at your earliest convenience.
If you experience any chest pain, shortness of breath,
presistent palpitations, fevers, chills, worsening abdominal
pain or nausea and vomiting please call your doctor
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2165-6-12**] 9:50
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2165-7-8**]
10:15
|
[
"008.8",
"V45.89",
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"346.90",
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"V10.3",
"786.05",
"V87.41",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10183, 10189
|
6257, 8526
|
376, 383
|
10279, 10304
|
3345, 6234
|
11474, 11755
|
2595, 2773
|
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|
2788, 3326
|
327, 338
|
411, 1885
|
1907, 2440
|
2456, 2578
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,558
| 152,799
|
12164+12165
|
Discharge summary
|
report+report
|
Admission Date: [**2102-4-27**] Discharge Date: [**2102-4-27**]
Service: MICU
The patient was transferred to MICU on [**2102-3-25**]. The patient
was transferred to the Medical Floor on [**2102-4-27**].
Below is a summary of the hospital course from [**2102-4-25**] to
[**2102-4-27**].
HISTORY OF THE PRESENT ILLNESS: The patient is a 79-year-old
male with no significant past medical history, who presented
to his primary care physician approximately one month ago
with the complaint of a nine to ten month history of fatigue.
The EKG obtained, showed a left bundle branch block and the
patient was transferred for stress test with nuclear imaging
on [**2102-2-21**] which revealed an ejection fraction of 50% with
hypokinesis of the septal and inferior walls and reversible
ischemia of the apical wall. The patient denies history of
chest pain or shortness of breath. The patient underwent an
elective cardiac catheterization at [**Hospital **] Hospital on
[**2102-4-21**], which showed LAD disease. The patient was
referred to [**Hospital1 69**]. Of note,
the patient's hematocrit prior to cardiac catheterization was
41.9. On admission to [**Hospital1 69**],
the patient's hematocrit was 36.8.
The patient underwent cardiac catheterization on hospital day
#1, which showed an 80% to 90% LAD lesion and the patient is
status post PCA to the LAD. Post procedure, the patient was
placed on aspirin, Integrilin, and Plavix.
Integrilin was discontinued approximately 16 hours post
procedure. Around that time, the patient had a sudden onset
of diaphoresis, dizziness, and nausea. Blood pressure, at
the time, was 80/40 with the pulse of 60. The patient denied
any chest pain or shortness of breath. The patient was given
a 500 cc normal saline bolus with increase in the systolic
blood pressure to 92. That morning, the patient was noted to
be orthostatic on examination and a.m. labs revealed the
hematocrit of 25.8 (down to 36.6 on admission). In addition,
the patient had a witnessed syncopal episode with brief loss
of consciousness arising from supine to standing. The
patient was noted to be in bigeminy on telemetry during the
syncopal episode.
PHYSICAL EXAMINATION: On physical examination, the patient's
right groin (from the first cardiac catheterization, showed a
moderate ecchymoses around the groin site with no appreciable
bruit. Left groin showed small hematoma, but again no
appreciable bruit. CT of the abdomen was done, which showed
no evidence of retroperitoneal bleed. The patient
subsequently had two bowel movements with bright red blood
per rectum and stool mixed with blood clots.
Of note, following bloody bowel movements, the patient's
blood pressure and pulse remained stable. NG lavage was
done, which was negative. The patient was subsequently
transfused.
The patient was evaluated by the GI Service. Following their
evaluation, the patient had a third bowel movement with no
bright red blood per rectum. It was decided to follow serial
hematocrits as the patient will require anticoagulation for
Plavix for one month following PCA of the LAD.
REVIEW OF SYSTEMS: On review of systems, the patient denied
any history of bright red blood per rectum or melena. The
patient reports history of intermittent abdominal pain for
the past one year, described as a diffuse, sharp pain reduced
by passing flatus. The patient had a barium enema
approximately six months ago, which the patient reports was
negative. The patient's pain was attributed to constipation
and the patient was placed on high-fiber diet with the use of
Dulcolax suppositories p.r.n.
On admission, the patient reported worsening abdominal pain
on the four to five days prior to admission. which was
relieved with the first bowel movement. The patient denies
any history of chest pain, shortness of breath, or orthopnea.
The patient had no nausea or vomiting. On transfer to the
MICU, the patient denied any dizziness or light headedness.
PAST MEDICAL HISTORY:
1. Vertigo.
2. Benign prostatic hypertrophy.
CARDIAC RISK FACTORS: The patient has no history of
hypertension or tobacco use. Lipid panel on [**2102-4-6**] showed
a total cholesterol of 169, HDL 38, and LDL of 102. The
patient was started on Lipitor 5 mg p.o.q.h.s. at that time.
Of note, the patient's precatheterization chest x-ray on
[**2102-4-6**] showed large lingular cavity containing air-fluid
with CT of the chest recommended as followup.
MEDICATIONS ON ADMISSION:
1. Lipitor 5 mg p.o.q.h.s.
2. Vitamin B12 200 mg p.o.q.d.
3. Vitamin B6 100 mg p.o.q.d.
4. Folic acid 1 mg p.o.q.d.
5. Multivitamin one tablet p.o.q.d.
6. Antivert 12.5 mg p.o.t.i.d.
7. Atenolol 25 mg p.o.q.d.
8. Aspirin 325 mg p.o.q.d.
9. Proscar 5 mg p.o.q.d.
10. Mavik 1 mg p.o.q.d. (started on [**2102-3-27**] for secondary
primary prevent of coronary artery disease).
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **]
is a retired federal employee (worked in Army and Air Force
Service). The patient quit tobacco 53 years ago. He reports
approximately two alcoholic drinks per week. The patient
walks two miles a day with no shortness of breath.
LABORATORY DATA: Laboratory data on admission revealed the
following: WBC 5.7, hematocrit 36.9, platelet count 160,000,
INR 1.2, CPK 33, albumin 3.1.
Radiographic imaging: CT of abdomen and chest revealed no
evidence of retroperitoneal hemorrhage.
Chest x-ray: No evidence of cavity lesion. The rounded
opacity in the region of the aortic knob likely corresponds
with ectatic aneurysmal dilation of the arch of the aorta.
However, given the relative paucity of adjacent vessels and
the presence of linear atelectasis in this region, partial
obstructing mass cannot be entirety excluded.
HOSPITAL COURSE: Hospital course during the MICU: The
patient is a 79-year-old male with no history of coronary
artery disease, who presented to his physician with the
complaint of fatigue. The EKG was abnormal leading to stress
test with nuclear imaging and subsequent cardiac
catheterization. Cardiac catheterization revealed the
following: One vessel coronary artery disease with a 99% mid
LAD stenosis, status post PTCA and stenting of LAD. The
patient subsequently developed lower GI bleed and was
transferred to the MICU.
CARDIOVASCULAR: The patient is status post cardiac
catheterization revealing one vessel coronary artery disease
status post PTCA and stenting of the LAD. Of note, the
patient has no history of chest pain or shortness of breath.
The patient was started on Plavix 75 mg p.o.q.d. post
procedure for a 30 day course. In addition, aspirin was
continued. Given episode of hypotension during acute bleed,
the patient's Mavik and Atenolol were held during the MICU
course. The patient remained hemodynamically stable
throughout his MICU course.
GASTROINTESTINAL: The patient transferred to the MICU after
an episode of bright red blood in the stool. NG lavage was
negative. The patient had no prior history of melena or
bright red blood per rectum and reports normal barium enema
approximately six months ago. The patient was made NPO,
started on IV fluids and given Protonix 40 mg IV b.i.d.
Serial hematocrits were drawn and the patient was transfused
three units of packed red blood cells. Following the second
unit of packed red blood cells, the patient's hematocrit
increased from 24.3 to 28.1. The patient was transfused a
third unit of packed red blood cells. Post transfusion
hematocrit was 32.2. The patient had no recurrent bright red
blood per rectum during his MICU stay. The patient's
hematocrit remained relatively stable over twenty-four hours.
The patient was transferred to the floor team.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2102-4-27**] 13:41
T: [**2102-4-27**] 12:32
JOB#: [**Job Number 38100**]
Admission Date: [**2102-4-25**] Discharge Date: [**2102-5-1**]
Date of Birth: Sex:
Service: MEDICINE
ADDENDUM: Note: The following is a discharge summary
addendum to the one done by Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 1250**]. This addendum
has been late because the chart has not been located until
now.
HOSPITAL COURSE: This ends the dictation of Dr. [**First Name8 (NamePattern2) 402**]
[**Last Name (NamePattern1) 1250**]. The patient's course has included a GI bleed with
bright red blood per rectum. His hematocrit went from the
high 30s to 26. He was transfused and subsequently his
hematocrit stabilized. He was started on Protonix 40 mg p.o.
b.i.d. per GI recommendations. He was hemodynamically stable
for the remainder of the hospitalization. Given his recent
cardiac intervention, GI felt that although he needs
colonoscopy, this could wait until his Plavix course has been
completed. Therefore, Mr. [**Name13 (STitle) 1194**] was discharged with follow-up
in the [**Hospital **] clinic in four to six weeks for colonoscopy.
At the time of discharge, Mr. [**Name13 (STitle) 1194**] was clinically stable and
appropriate for discharge.
DISCHARGE CONDITION: Markedly improved.
DISCHARGE STATUS: Discharged home with follow-up and
services.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post stent.
2. Acute gastrointestinal bleed.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. for 30 days.
4. Lipitor 5 mg p.o. q.d.
5. Atenolol 25 mg p.o. q.d.
6. Mavik 1 mg p.o. q.d.
7. Proscar 5 mg p.o. q.d.
FOLLOW-UP: Mr. [**Name13 (STitle) 1194**] was scheduled to follow-up with his
primary physician, [**Last Name (NamePattern4) **]. ..................... He will see his
cardiologist, Dr. .................... on [**2102-5-15**] at
1:15 p.m. where his potassium and hematocrit will be checked.
He will also follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] on [**2102-5-29**] at
2:00 p.m. in the [**Hospital Ward Name 23**] Clinical Center. The telephone
number is [**Telephone/Fax (1) 1954**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
ATTENDING IN MEDICINE
Dictated By:[**Last Name (NamePattern4) 38101**]
MEDQUIST36
D: [**2103-2-1**] 06:51
T: [**2103-2-1**] 19:07
JOB#: [**Job Number 38102**]
|
[
"V15.82",
"414.01",
"272.0",
"998.12",
"E885.9",
"424.1",
"293.0",
"578.9",
"607.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"99.20",
"36.06",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9298, 9383
|
9510, 10547
|
9404, 9487
|
4483, 4920
|
8442, 9276
|
2206, 3115
|
3136, 3979
|
4001, 4457
|
4937, 5823
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,958
| 162,910
|
45004
|
Discharge summary
|
report
|
Admission Date: [**2126-12-24**] Discharge Date: [**2126-12-30**]
Service: [**Hospital Unit Name 196**]
DISCHARGE DATE IS PENDING AT THE TIME OF THIS DICTATION
HISTORY OF PRESENT ILLNESS: Mrs. [**Last Name (STitle) 96211**] s a 77 year old
female with a known medical history of three-vessel coronary
artery disease, insulin dependent diabetes mellitus, and
peripheral vascular disease, who presented with acute
shortness of breath on the evening of [**2126-12-23**], to
the Emergency Department. She reported the sudden onset of
shortness of breath at approximately 6 p.m. on [**12-23**],
not associated with chest pain, nausea, vomiting or
diaphoresis. She had been medically managed for her coronary
disease. When EMS personnel arrived, she was noted to be in
respiratory distress and was given Lasix and Nitroglycerin
spray with slight improvement. She was thought to be in
congestive heart failure on arrival to the Emergency
Department, and was admitted for the same.
In the Emergency Department, a rule out myocardial infarction
sequence was started. On [**12-24**], the patient ruled in
for a myocardial infarction with a CK of 798, CK MB 58, and
MB index 7.3 with troponin listed as greater than 2.0. She
was started on intravenous heparin. She was evaluated by the
Cardiology Consult Service who recommended evaluation by
Cardiac Surgery prior to any catheterization procedure.
On the morning of [**12-25**], the patient became nauseated
and diaphoretic. EKG done at that time showed ST segment
elevation in leads V2, V3, V4, compared to baseline. There
were also inferior lead ST segment depressions. The
Cardiology Service was made aware of this development and the
patient was prepared for urgent cardiac catheterization in
the setting of a likely ST segment elevation myocardial
infarction.
While being transferred to the gurney, the patient developed
bradycardic arrest, was intubated, resuscitated and
emergently taken to the Catheterization Laboratory where she
was found to have a 95% proximal left anterior descending
occlusion. She underwent successful percutaneous
transluminal coronary angioplasty with stenting and an
intra-aortic balloon pump was placed. The patient was
transferred to the Coronary Care Unit. The intra-aortic
balloon pump was weaned and discontinued on [**12-26**]; the
patient was extubated on [**12-26**] successfully. Coronary
Care Unit course was complicated by one episode of coffee
ground emesis on [**12-25**], but cleared, and the patient's
hematocrit remained stable.
A repeat echocardiogram performed in the Coronary Care Unit
showed an ejection fraction of less than 20%, a mildly
dilated left ventricle, severe hypokinesis, some
contractility in the basal inferior segment, and a distal
half of the left ventricle which was akinetic. The patient
was started on Lovenox for apical akinesis. She was
evaluated by Cardiac Surgery and declined as a surgical
candidate. The patient was transferred to the [**Hospital Unit Name 196**] Service
on [**12-27**], in stable condition.
PAST MEDICAL HISTORY:
1. Three vessel coronary artery disease medically managed
until the present admission; declined as a surgical
candidate; ejection fraction less than 20% with apical
akinesis.
2. Insulin dependent diabetes mellitus times 30 years.
3. Peripheral vascular disease.
4. History of lower gastrointestinal bleeding.
5. History of bilateral hip fracture.
6. Status post total abdominal hysterectomy.
7. Status post cholecystectomy.
ALLERGIES: Penicillin, Azithromycin, Tetracycline,
Terbutaline, Nifedipine, eggs.
MEDICATIONS: On admission:
1. Atenolol 75 mg p.o. q. day.
2. Imdur 30 mg p.o. q. day.
3. Zestril 40 mg p.o. q. day.
4. Aspirin 325 mg p.o. q. day.
5. Calcium carbonate.
6. NPH insulin 19 units subcutaneously q. a.m., 12 units
subcutaneously q. p.m.
7. Lasix 60 mg p.o. q. day.
SOCIAL HISTORY: The patient is widowed and lives with her
two sisters. During the admission, one of these sisters died
of cancer. The patient denies tobacco, alcohol or drug
history.
PHYSICAL EXAMINATION: On admission, pulse 100; blood
pressure 140/80; respirations 20; 97% oxygen saturation on
six liters. Generally, pleasant, elderly female in mild
respiratory distress who is alert and oriented times three.
HEENT: Pupils are equal, round and reactive to light.
Extraocular movements intact. Sclerae anicteric. Neck:
Supple. Jugular venous pressure at approximately 8
centimeters. Chest: Bibasilar rales present.
Cardiovascular: Regular with normal S1 and S2. No murmurs,
rubs or gallops. Abdomen: Soft, nondistended, nontender.
Normoactive bowel sounds. Extremities: No pedal edema.
Neurologic: Alert and oriented times three. Cranial nerves
II through XII intact. Strength five out of five upper and
lower extremities bilaterally. Sensation intact to light
touch.
LABORATORY: On admission, CBC with white blood cell count of
12.8, hematocrit 44.9, platelets 228, 69% neutrophils, 23%
lymphocytes, 3.6% monocytes, 2.8% eosinophils. Sodium 141,
potassium 4.8, chloride 102, bicarbonate 28, BUN 22,
creatinine 1.0, glucose 301. PT 12.2, PTT 21.7, INR 1.0.
CK 85, troponin 1.3. Urinalysis, specific gravity of 1.025,
with trace protein, glucose 100, negative ketones. No white
or red cells present.
EKG rate of 108, in sinus rhythm; poor R wave progression,
0.5 millimeter ST segment elevations in V2 and V3.
Pseudo-normalization of T waves V4 through V6.
Chest x-ray: Consistent with pulmonary edema.
Echocardiogram from [**2126-3-19**]: Ejection fraction of greater
than 55%. Aortic valve leaflets mildly thickened.
HOSPITAL COURSE: Please refer to the HPI for the bulk of the
hospital course. The patient remained stable on the [**Hospital Unit Name 196**]
Service after transfer from the Coronary Care Unit. As she
was a medical management patient, her medications continued
to be optimized prior to discharge. She was evaluated by
Physical Therapy on [**12-28**], and found to be unsafe for
discharge to home. It was felt that she would benefit from
acute rehabilitation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is being discharged to a
rehabilitation facility when a bed becomes available (pending
at the time of this dictation).
DISCHARGE INSTRUCTIONS:
1. Diet is cardiac and diabetic.
2. Activity with assistance.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post myocardial
infarction.
2. Cardiac arrest.
3. Congestive heart failure.
4. Ischemic cardiomyopathy.
5. Type 2 diabetes mellitus.
6. Peripheral vascular disease.
DISCHARGE MEDICATIONS (subject to change at the actual time
of discharge):
1. Aspirin 325 mg p.o. q. day.
2. Plavix 75 mg p.o. q. day times 30 days.
3. Lopressor 25 mg p.o. twice a day.
4. Lipitor 10 mg p.o. q. h.s.
5. Protonix 40 mg p.o. q. day.
6. Lasix 80 mg p.o. q. day.
7. Captopril 12.5 mg p.o. three times a day.
8. NPH insulin, 8 units at breakfast and 6 units at bedtime.
9. Coumadin 2.5 mg p.o. q. h.s.
10. Lovenox 60 mg p.o. twice a day.
11. Colace 100 mg p.o. twice a day.
12. Senokot two tablets p.o. q. h.s. and p.r.n.
DISCHARGE INSTRUCTIONS:
1. Follow-up to be with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within two weeks
after discharge.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**MD Number(1) 5381**]
Dictated By:[**Last Name (NamePattern1) 737**]
MEDQUIST36
D: [**2126-12-28**] 15:53
T: [**2126-12-28**] 16:18
JOB#: [**Job Number 96212**]
|
[
"427.5",
"V49.72",
"424.0",
"414.01",
"428.0",
"410.71",
"443.9",
"414.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.01",
"99.20",
"97.44",
"36.06",
"37.23",
"88.53",
"96.04",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
6403, 7152
|
5661, 6118
|
7176, 7587
|
4098, 5643
|
6133, 6293
|
202, 3064
|
3630, 3888
|
3086, 3616
|
3905, 4075
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,124
| 103,629
|
20346
|
Discharge summary
|
report
|
Admission Date: [**2201-3-6**] Discharge Date: [**2201-3-11**]
Date of Birth: [**2131-12-8**] Sex: M
Service: [**Hospital1 **]
HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old
male with a history of CAD, hypertension, cervical diskectomy
on [**2201-2-16**], hospital course complicated by a left lower lobe
pneumonia treated with Azithromycin and Levaquin. He was
noted by the VNA to be tachycardiac on [**2201-3-5**] to the 120s
and referred to PCPs office where the PCPs EKG documented
sinus tachycardia at 130s and referred the patient to [**Hospital3 9683**] ED where a V/Q scan reportedly showed a pulmonary
embolus, questionable saddle-like on films but films were
unavailable upon transfer to [**Hospital6 2018**] Emergency Department for consideration of thrombectomy
given recent C spine surgery and contraindication [**First Name8 (NamePattern2) **] [**Hospital1 **]
surgeons by report to anticoagulation.
Upon admission, the patient had dyspnea on exertion but no
chest pain. The patient had a dry cough but no fevers or
chills and had some left leg swelling. The patient developed
a sharp burning left back pain and right back pain for the
past week also, pleuritic, sudden onset dyspnea as with
pneumonia and since in the ED, was transferred to the MICU
Service. The following was the MICU HPI.
PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. Hypertension.
3. CAD, status post angioplasty with stent two years ago.
4. Cervical diskectomy on [**2201-2-16**] at [**Hospital3 **].
5. Varicose veins.
6. DM2.
7. Seizure disorder four years ago.
8. No prior history of DVTs or PEs.
ADMISSION MEDICATIONS:
1. Lipitor.
2. Dilantin.
3. Lisinopril.
4. Timolol.
5. Amaryl.
SOCIAL HISTORY: No tobacco use.
FAMILY HISTORY: No DVT or PE in the family history.
PHYSICAL EXAMINATION ON ADMISSION TO MEDICAL INTENSIVE CARE
UNIT: Vital signs: Temperature 99, pulse 115, blood
pressure 121/77, respiratory rate 24, 02 saturation 97% on 2
liters nasal cannula. General: The patient was a pleasant
male with 30 inch soft cervical collar in place, nasal
cannula 02, speaking in full sentences, no major acute
distress. HEENT: PERRLA. Moist membrane mucosa. Neck:
Right anterior surgical site. No oozing. Steri-Stripped.
Prominent external jugular venous pulsations. Heart:
Tachycardiac, regular rhythm, S1 and S2 normal. No S3 or S4.
No rub. Lungs: Decreased breath sounds on the left, basilar
and also some crackles on the right basilar. Abdomen: Bowel
sounds present, scaphoid, nontender, nondistended, no
hepatosplenomegaly. Extremities: Increased edema in the
left leg. Trace pitting edema to the knee. No cords. No
calf tenderness. Pulses bilaterally present. Right leg
unremarkable. Neurologic: Alert and oriented times three.
Left upper extremity weakness, grossly intact sensation
throughout.
LABORATORY/RADIOLOGIC DATA: On admission, sodium 137,
potassium 4.5, chloride 103, bicarbonate 28, BUN 13,
creatinine 0.8, glucose 110, calcium 9.3, troponin 0.07, INR
1.2, PTT 23.6. White blood cell count 7.3, hematocrit 40.9,
platelets 427,000.
EKG at [**Hospital1 18**] showed sinus tachycardia at 106, normal axis,
normal intervals, and no RV strain, no S1, T3, had a positive
small Q in III but no ST changes or T wave inversions.
HOSPITAL COURSE: Since admitted, he was admitted to the MICU
and it was decided that instead of the thrombectomy to
actually go through anticoagulation with heparin. He
tolerated the heparin drip well and has become
hemodynamically stable and has been off the oxygen since and
the goal was once stable transfer to the floor. Her was
transferred to the floor without any new acute findings.
Homans sign negative. No calf tenderness since and has
become therapeutic on Coumadin after the third day on
admission to the [**Hospital1 139**] firm. The patient has done well
since on [**Hospital1 139**] firm and bridged to Coumadin to keep INR
level between 2 and 3. Have already discussed follow-up INRs
with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], over the phone. The patient will
follow-up with her tomorrow for INR checks and further
follow-up.
In terms of CAD, given that there is a possibility of
intervention, his aspirin was held to be restarted at the
PCPs office tomorrow. Already discussed with the PCP. [**Name10 (NameIs) **]
was continued on lisinopril, Lipitor meanwhile. Also, his
beta blockers were restarted on the day of discharge.
In terms of his diabetes, continue his Amaryl and he was
getting fingersticks while in the hospital and doing well,
and was well-controlled.
In terms of seizure disorder, he is asymptomatic. He had
Dilantin levels which were slightly subtherapeutic. To be
continued to be checked by PCP but continue with the Dilantin
while in the hospital.
The patient tolerated p.o. intake well and was doing well,
stable, and in very good condition, good spirits upon
leaving.
The only other added note is that since he has been here he
had emphasized that he had mood changes which were consistent
with some depressive episodes. He was started on Celexa
given that it will have less of an interaction in terms of
drug interactions with other drugs he has on board. The
start of Celexa was discussed with his PCP and is to be
continued at her discretion.
DISPOSITION: The patient was discharged to home. The
patient was noted to seek medical care if his symptoms worsen
or any new symptoms arise or any sign of bleeding from
anywhere.
FINAL DIAGNOSIS: Pulmonary embolus.
RECOMMENDED FOLLOW-UP: The patient has an appointment
tomorrow with Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 14214**], on [**2201-3-12**] at 2:45
p.m. He will have his INR followed-up over there. The goal
INR is [**12-30**] and consider also starting aspirin per PCPs input
and discretion.
MAJOR SURGICAL INVASIVE PROCEDURES: There were no procedures
done while the patient was in-house.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Docusate.
2. Phenytoin 200 mg b.i.d.
3. Atorvastatin 10 mg p.o. q.d.
4. Lisinopril 10 mg p.o. q.d.
5. Timolol maleate eyedrops 0.25% b.i.d.
6. Pantoprazole 40 mg q.d.
7. Citalopram 20 mg one-half tablet p.o. q.d.
8. Warfarin 6 mg p.o. q.h.s. with a goal INR of [**12-30**], to be
adjusted by PCP at her discretion.
9. Metoprolol 12.5 mg p.o. b.i.d. to be adjusted by PCP at
her discretion.
FOLLOW-UP: As discussed above.
The patient is to have liver function tests checked regularly
by PCP since on Citalopram.
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D. [**MD Number(1) 19814**]
Dictated By:[**Name8 (MD) 6112**]
MEDQUIST36
D: [**2201-3-11**] 10:29
T: [**2201-3-12**] 19:49
JOB#: [**Job Number 54571**]
|
[
"272.4",
"780.39",
"427.89",
"E878.8",
"415.11",
"250.00",
"401.9",
"414.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1773, 3309
|
6021, 6800
|
3327, 5523
|
5541, 5966
|
1653, 1722
|
1365, 1630
|
1739, 1756
|
5991, 5998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,714
| 192,665
|
15068
|
Discharge summary
|
report
|
Admission Date: [**2153-4-30**] Discharge Date: [**2153-5-7**]
Date of Birth: [**2091-4-6**] Sex: M
Service: SURGERY
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Juxta and suprarenal aneurysm.
Major Surgical or Invasive Procedure:
[**4-30**]: Retroperitoneal repair of juxta and suprarenal
aneurysm with 20 mm Dacron Tube graft
[**4-30**]: Left femoral cutdown with abdominal and pelvic
angiography and bilateral Endograft limb (Iliac
artery)angioplasty.
History of Present Illness:
This is a 62-year-old gentleman
who had previously undergone infrarenal tube graft aneurysm
repair with subsequent Endograft repair of a left common
iliac artery aneurysm. He now presents with new aneurysmal
formation around his visceral vessels extending to just above
the celiac artery.
Past Medical History:
hyperlipdemia
history of renal lithasis
hypertension, controlled
Social History:
married lives with spouse
current [**Name2 (NI) 1818**] pack per day x years
alcohol use occasional
Family History:
unknown
Physical Exam:
a/ox3
nad
cta
rrr
benign abd
all pulses palp distally
inc c/d/i
Pertinent Results:
[**2153-5-5**] 06:18AM BLOOD
WBC-9.9 RBC-3.16* Hgb-10.0* Hct-27.9* MCV-88 MCH-31.6 MCHC-35.8*
RDW-16.5* Plt Ct-172#
[**2153-5-4**] 04:58AM
BLOOD PT-11.1 PTT-27.7 INR(PT)-0.9
[**2153-5-5**] 06:18AM BLOOD
Glucose-119* UreaN-24* Creat-1.2 Na-141 K-3.7 Cl-104 HCO3-26
AnGap-15
[**2153-5-6**] 05:00AM BLOOD
Calcium-7.7* Phos-4.0 Mg-2.4
[**2153-5-2**] 01:42PM URINE
Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
RBC-[**1-29**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2152-5-7**] for an elective Juxta and
suprarenal aneurysm repair. Pre-operatively,he was consented,
prepped, and brought down to the operating room for surgery.
Intra-operatively, he was closely monitored and remained
hemodynamically stable. He tolerated the procedure well without
any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
He was then transferred to the [**Date Range **] for further recovery.
In the [**Name (NI) **], pt was stable, He was delined in the usual manner,
a PT consult was obtained / Rehab screening initiated
Pt did have diarrhea. C-Diff negative
He was then transfered to the floor.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve his
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]: ASA 81', folate 1', lasix 40', lisinopril 30', lipitor 80',
Plavix 75', trazadone 25', ultram 50', verapamil 240'
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Verapamil 120 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q24H (every 24 hours).
3. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): [**Month (only) 116**] resume home dose of 40mg daily.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
over the counter.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Juxta and suprarenal aneurysm
PMH: nl PMIBI [**4-2**], dyslipidemia, CVA w L arm weakness '[**47**],
kidney stones, quit smoking 2 months ago
PSH: EVAR, appy, B shoulder surgery, R fem-BKpop for aneurysm,
cervical disc repair, hamstring repair
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-4**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? 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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-30**]
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
?????? You should get up every day, get dressed and walk, gradually
increasing 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 (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 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Call Dr.[**Name (NI) 1720**] office to schedule post op visit to be seen in
[**12-30**] weeks [**Telephone/Fax (1) 1241**]
Completed by:[**2153-5-13**]
|
[
"V12.59",
"996.79",
"V13.01",
"V70.7",
"272.4",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.46",
"38.93",
"39.50",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
4031, 4037
|
1779, 2802
|
302, 529
|
4325, 4332
|
1177, 1756
|
7072, 7226
|
1069, 1078
|
2993, 4008
|
4058, 4304
|
2828, 2970
|
4356, 6619
|
6645, 7049
|
1093, 1158
|
232, 264
|
557, 847
|
869, 935
|
951, 1053
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,849
| 113,883
|
44217
|
Discharge summary
|
report
|
Admission Date: [**2193-1-30**] Discharge Date: [**2193-2-21**]
Date of Birth: [**2106-8-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
somnolence
Major Surgical or Invasive Procedure:
[**2193-2-5**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], surgeon
1. T8 to L1 fusion.
2. Laminectomy of T11.
3. Multiple thoracic laminotomies.
4. Instrumentation T8 to L1.
5. Autograft and allograft.
6. Vertebroplasty L1
[**2193-1-30**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], surgeon:
1. Partial vertebrectomy of T11 and T12.
2. Fusion, T10 to T12.
3. Instrumentation, T10 to T12.
4. Cage placement.
5. Vertebroplasties T10 and T12.
6. Autograft.
a line
Right internal jugular central line placement
intubation and extubation
History of Present Illness:
86 yo man with diet controlled DM2, recently diagnosed benign
pharyngeal mass associated with aspiration, spinal stenosis, s/p
a fall in late [**Month (only) 1096**], admission [**Date range (1) 94858**]/12, readmitted on
[**2193-1-29**] for LE weakness and s/p spinal fusion surgeries on [**1-30**]
and [**2-5**] for T11 fracture, with VAP post-op and now with
increasing hypercarbia and somnolence. Pt initially presented 3
days after a fall; on his first admission no evidence of
fracture was found, although he had new onset atrial
fibrillation and discovery of a L pharyngeal mass and associated
aspiration during that visit. The atrial fibrillation
self-resolved after pt received a calcium channel blocker, and
pathology from the pharyngeal mass was benign. He was
discharged to rehab on [**2193-1-18**] with a Dobhoff tube in place.
Repeat swallow eval on this admission recommended he continue
NPO.
He was readmitted on [**1-29**] after another fall (?) and found to
have a T11 fracture with a significant lower extremity
paraparesis and was admitted to ortho spine. On [**1-30**] he had a
partial vertebrectomy of T11 and T12 with T10 to T12 fusion. He
was extubated a day after surgery; at that time he had CXR
evidence of VAP and he was started on vanc/Zosyn and
reintubated. Sputum grew MSSA and pt was switched to nafcillin
on [**2-6**]; he finished his course of nafcillin on [**2-10**]. He
returned to the OR on [**2-5**] for a planned T8-L1 fusion and was
extubated on [**2-6**]. Pt developed afib with RVR in the TSICU; he
was cardioverted and started on an amiodarone drip which was
then stopped for prolonged QTc. Pt devoloped rapid afib again
but spontaneously converted. He was rate controlled on
metoprolol. He triggered on [**2-11**] for afib with RVR that was
difficult to control with IV metoprolol and diltiazem; pt
received a dilt gtt overnight and had increasing O2 requirements
from 2-4L NC to facemask with oxygen. Per pt's daughter, pt was
last at his baseline mental status prior to his second
operation, but was conversant and articulating thoughts clearly
on the night of [**2-11**]. On [**2-12**], pt became increasingly somnolent
with blood gas 7.26/72/85 and was transferred to the MICU.
Past Medical History:
ANEMIA, chronic, unknown baseline
BENIGN PROSTATIC HYPERTROPHY, hx turp, hx incontinence
CONSTIPATION
DEPRESSION
DIABETES TYPE II - diet controlled
GAIT DISORDER, falls d/t spinal stenosis
MELANOMA leg [**2187**] no records
SPINAL STENOSIS
S/P HIP REPLACEMENT, KNEE REPLACEMENT
Social History:
Admitted from rehab in [**Location (un) **] where he has been since
discharge. Prior to admission [**1-13**], was living in [**Hospital 4382**] at [**Doctor Last Name **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] where he has been living for the
past one year, active in many activities, walks with walker. He
is retired from sales, whole-selling men's clothes about 20
years ago. He is a widower for one year after over 50 years of
marriage. Has two daughters.
Family History:
No premature CAD, no diabetes. The patient has
personal history of diet-controlled diabetes.
Physical Exam:
(on MICU TRANSFER)
HR 56, BP 100/70, temp 99, O2 92% on NRB, RR 16
Gen: Caucasian male, non-responsive to sternal rub, not
withdrawing to pain
Cardiac: Nl s1/s2 irregular rhythm
Pulm: crackles at bases bilaterally
Abd: soft, NT, ND normoactive bowel sounds
Ext: 1+ LE edema present bilaterally
Pertinent Results:
ADMISSION LABS
[**2193-1-29**] 07:00PM BLOOD WBC-10.3 RBC-4.17* Hgb-12.6* Hct-36.3*
MCV-87 MCH-30.2 MCHC-34.7 RDW-14.3 Plt Ct-224
[**2193-1-29**] 07:00PM BLOOD Neuts-88.8* Lymphs-6.7* Monos-3.4 Eos-0.8
Baso-0.3
[**2193-1-29**] 07:00PM BLOOD PT-11.6 PTT-28.7 INR(PT)-1.1
[**2193-1-29**] 07:00PM BLOOD ESR-15
[**2193-1-29**] 07:00PM BLOOD Glucose-128* UreaN-26* Creat-0.6 Na-137
K-4.0 Cl-99 HCO3-28 AnGap-14
[**2193-1-29**] 07:00PM BLOOD ALT-22 AST-16 AlkPhos-172*
[**2193-1-29**] 07:00PM BLOOD Lipase-10
[**2193-1-30**] 09:04PM BLOOD Calcium-7.1* Phos-3.7 Mg-1.5*
[**2193-1-29**] 07:00PM BLOOD CRP-39.5*
[**2193-2-2**] 06:15PM BLOOD Vanco-13.1
[**2193-1-30**] 05:13PM BLOOD Type-ART pO2-155* pCO2-43 pH-7.43
calTCO2-29 Base XS-4 Intubat-INTUBATED
[**2193-1-30**] 05:13PM BLOOD Glucose-110* Lactate-1.1 Na-135 K-3.6
Cl-102
[**2193-1-30**] 05:13PM BLOOD Hgb-11.9* calcHCT-36 O2 Sat-98
[**2193-1-30**] 05:13PM BLOOD freeCa-1.12
Brief Hospital Course:
86 yo man with diet controlled DM2, recently diagnosed benign
pharyngeal mass associated with aspiration, spinal stenosis, s/p
a fall in late [**Month (only) 1096**], admission [**Date range (1) 94858**]/12, readmitted on
[**2193-1-29**] for LE weakness and s/p spinal fusion surgeries on [**1-30**]
and [**2-5**] for T11 fracture, with VAP post-op and now with
increasing hypercarbia and somnolence. Pt initially presented 3
days after a fall; on his first admission no evidence of
fracture was found, although he had new onset atrial
fibrillation and discovery of a L pharyngeal mass and associated
aspiration during that visit. The atrial fibrillation
self-resolved after pt received a calcium channel blocker, and
pathology from the pharyngeal mass was benign. He was
discharged to rehab on [**2193-1-18**] with a Dobhoff tube in place.
Repeat swallow eval on this admission recommended he continue
NPO.
He was readmitted on [**1-29**] after another fall (?) and found to
have a T11 fracture with a significant lower extremity
paraparesis and was admitted to ortho spine. On [**1-30**] he had a
partial vertebrectomy of T11 and T12 with T10 to T12 fusion. He
was extubated a day after surgery; at that time he had CXR
evidence of VAP and he was started on vanc/Zosyn and
reintubated. Sputum grew MSSA and pt was switched to nafcillin
on [**2-6**]; he finished his course of nafcillin on [**2-10**]. He
returned to the OR on [**2-5**] for a planned T8-L1 fusion and was
extubated on [**2-6**]. Pt developed afib with RVR in the TSICU; he
was cardioverted and started on an amiodarone drip which was
then stopped for prolonged QTc. Pt devoloped rapid afib again
but spontaneously converted. He was rate controlled on
metoprolol. He triggered on [**2-11**] for afib with RVR that was
difficult to control with IV metoprolol and diltiazem; pt
received a dilt gtt overnight and had increasing O2 requirements
from 2-4L NC to facemask with oxygen. Per pt's daughter, pt was
last at his baseline mental status prior to his second
operation, but was conversant and articulating thoughts clearly
on the night of [**2-11**]. On [**2-12**], pt became increasingly somnolent
with blood gas 7.26/72/85 and was transferred to the MICU.
In the MICU, the patient was intubated. His hypercarbic
respiratory failure was felt to be secondary to post-op
deconditioning and weakness, possible aspiration pneumonia. CTA
chest did not show PE but did show pneumonia. He was initially
hypothermic with T 94 and bairhugger was placed. He had
bradycardia to the 40s. He underwent bronchoscopy, and BAL grew
pan-sensitive klebsiella and staph aureus, resistant to
erythromycin and clindamycin. The patient did have hypotension
requiring neosynephrine, which was weaned off the day after
admission to the MICU. He was treated with vancomycin and zosyn.
In speaking to the family, the patient was going to need to be
transitioned to trach, which the family did not want. The
patient actually bit his ETT and required extubation, and the
family opted to not re-intubate, as he would need a trach the
following day. The patient did maintain his saturations,
however, his mental status did not improve. Throughout his MICU
admission, he has been minimially responsive to pain, opening
his eyes but not verbalizing or following commands. The
vertebroplasty was likely limiting his respiratory effort, and
in this setting, we were holding warfarin, although treating
with aspirin. The patient's acidosis worsened and his family
opted to transition to [**Month/Day (4) 3225**].
The patient did have afib and required diltiazem drip prior to
admission to the MICU; he had no further episodes of afib. The
patient has a pharyngeal mass, which is benign, but does
increase risk for aspriation. He does have T2DM, which was
controlled with insulin sliding scale. He had acute kidney
injury, with creatinine elevated to 2.7, from baseline of 0.7
prior to his MICU admission. This was thought to be related to
ATN related to initial hypotension episode.
The patient's code status was changed multiple times throughout
his admission, according to the wishes of his HCP, his daughter,
talk to [**Name (NI) 94859**] ([**Telephone/Fax (1) 94860**], cell [**Telephone/Fax (1) 94861**]. Finally, in
discussion with his HCP, he was transitioned to [**Name (NI) 3225**].
The patient was started on a dilaudid drip for comfort and
expired on [**2193-2-21**]. His daughter, [**Name (NI) 94859**], was at the bedside and
declined autopsy.
Medications on Admission:
Discharge meds [**1-18**]: ASA 81, citalopram 20 daily, enablex 15 mg,
collace, bisacodyl, lidocaine patch, lansoprazole 30 mg [**Hospital1 **],
psyllium
.
Meds on transfer:
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Ondansetron 4 mg IV Q4H:PRN nausea/vomiting
Milk of Magnesia 30 mL PO/NG Q6H:PRN constipation
Insulin SC (per Insulin Flowsheet)
Heparin 5000 UNIT SC BID
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
FoLIC Acid 1 mg PO/NG DAILY
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Calcium Carbonate 500 mg PO/NG QID:PRN osteopenia
Bisacodyl 10 mg PR HS:PRN constipation
CefePIME 2 g IV Q8H
Vancomycin 1000 mg IV Q 12H
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired on [**2193-2-21**] at 1505.
Discharge Condition:
expired
Completed by:[**2193-2-21**]
|
[
"806.25",
"348.31",
"852.41",
"263.9",
"276.0",
"V43.64",
"250.00",
"E888.9",
"997.1",
"427.31",
"584.5",
"041.11",
"285.1",
"997.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"96.04",
"38.93",
"81.04",
"81.05",
"77.89",
"33.24",
"81.63",
"84.52",
"03.53",
"96.72",
"96.6",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
10644, 10653
|
5381, 9892
|
314, 910
|
10740, 10778
|
4432, 5358
|
4006, 4102
|
10674, 10719
|
9918, 10074
|
4117, 4413
|
264, 276
|
938, 3180
|
3202, 3481
|
3497, 3990
|
10092, 10621
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,437
| 163,151
|
3642+55490
|
Discharge summary
|
report+addendum
|
Admission Date: [**2163-9-6**] Discharge Date: [**2163-9-10**]
Date of Birth: [**2102-3-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Atrial fibrillation
Major Surgical or Invasive Procedure:
[**2163-9-7**] - Bil. Thoracotomies - Mini MAZE Procedure with left
atrial appendage ligation
History of Present Illness:
61 year old male with long standing history of paroxysmal atrial
fibrillation,treated medically as well as DCCV(done
approximately 15 times per pt.) Now presents for surgical
intervention
Past Medical History:
Hemophilia B (factor IX deficiency)
IVC filter s/p DVT & PE
s/p right knee arthroscopy in [**2156**]
s/p cardioversion for PAFib
GERD
Right total knee arthroplasty [**2159**]
s/p right THR [**8-24**]
HTN
hemorrhoids
BPH
Social History:
Race: Caucasian
Last Dental Exam:[**May 2163**]
Lives with:Wife
Occupation:Semi-retired
Tobacco:no hx
ETOH:2 glasses wine/night
Family History:
Brother:+ MI/AFib, Father +CVA/?heart dz.
Physical Exam:
Pulse:SR 48-52 Resp:11 O2 sat: 100% RA
B/P Right:146/90 Left:
Height: 71" Weight: 205#
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] Sinus brady 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 [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:none Left:none
Pertinent Results:
Conclusions
The left atrium is moderately dilated. The left atrium is
elongated. Mild spontaneous echo contrast is seen in the body of
the left atrium. No mass/thrombus is seen in the left atrium or
left atrial appendage. Mild spontaneous echo contrast is present
in the left atrial appendage. The right atrium is dilated. 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. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
There does not appear to be any significant remnant of the left
atrial appendage after its resection.
Dr. [**Last Name (STitle) 914**] was notified in person of the results in the
operating room at the time of the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2163-9-7**] 16:06
[**2163-9-10**] 06:30AM BLOOD WBC-8.4 RBC-3.54* Hgb-10.0* Hct-30.7*
MCV-87 MCH-28.2 MCHC-32.6 RDW-14.2 Plt Ct-275
[**2163-9-8**] 02:56AM BLOOD PT-12.7 PTT-33.5 INR(PT)-1.1
[**2163-9-10**] 06:30AM BLOOD Glucose-85 UreaN-30* Creat-1.5* Na-136
K-4.7 Cl-100 HCO3-32 AnGap-9
Brief Hospital Course:
Mr. [**Name13 (STitle) 3827**] was admitted to the [**Hospital1 18**] on [**2163-9-6**] for surgical
management of his atrial fibrillation. Despite his atrial
fibrillation, COUMADIN is CONTRAINDICATED in this patient due to
his factor IX deficiency. Heparin was started in anticipation of
surgery. He was worked-up in the usual preoperative manner.
Hematology ( Dr. [**Last Name (STitle) 3060**]was consulted for Factor IX replacement
therapy for the periop period. On [**2163-9-7**], he was taken to the
operating room where he underwent a mini maze procedure. Please
see operative note for details. Postoperatively he was taken to
the intensive care unit for monitoring. Over the next several
hours, he awoke neurologically intact and was extubated. On
postoperative day one he was transferred to the step down unit
for further recovery. The physical therapy service was consulted
for assistance with his post operative strength and mobility. He
was cleared for discharge to home on POD four. A daily Benefix
infusion was scheduled until (and including) 9/30 per Dr. [**Name (NI) 16544**] service. He is to receive aspirin until his Benefix
doses are complete. Per the CV surgery miniMAZE protocol he was
placed on colchicine for one month. Although Hematology felt he
could receive indocin until his Benefix doses were complete,
indocin was not prescribed due to a slightly elevated creatine
of 1.5, which has been improving. He is to make all followup
appointments as per discharge instructions.
Medications on Admission:
Multaq 400 mg [**Hospital1 **] (recently added with amiodarone discontinued)
Celebrex 200 mg daily (increases to 400 mg daily PRN pain,
hydrochlorothiazide 12.5 mg daily
levothyroxine 175 mcg M W F, 200 mcg T, Thurs, Sat, Sun,
omeprazole 40 mg daily
B-12 [**2153**] daily
Amoxicillin 4/50 mg tabs with dental procedures
Fluticasone propionate nasal spray 50 mg daily (recently added)
Zyrtec
tylenol and gaviscon PRN
Coumadin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): stop when
Benefix doses complete.
Disp:*8 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
Disp:*30 Tablet(s)* Refills:*2*
5. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO
QTU,TH,[**Last Name (LF) **],[**First Name3 (LF) **] ().
Disp:*60 Tablet(s)* Refills:*2*
6. Multaq 400 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Coagulation Factor IX (Recomb) 1,000 unit Kit Sig: 5050
(5050) units Intravenous once a day for 4 days: until and
including [**2163-9-14**].
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Atrial fibrillation s/p MAZE
Factor IX deficiency with a CONTRAINDICATION to Warfarin
Pulmonary embolism x2- s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter placement in the
inf. vena cava '[**50**],
Hyperthyroidism s/p thyroidectomy'[**55**]
Hypertension
Hemmorhoids
hiatal hernia
Benign Prostatic hypertrophy
Discharge Condition:
Good
Discharge Instructions:
1) monitor wounds for signs of infection. These include redness,
drainage or increased pain. Report any or all wound issues to
your surgeon. ([**Telephone/Fax (1) 1504**]
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) Shower daily. Wash incisions with soap and water. No lotions,
creams or powders to incisions.
5) No driving for one month AND off all narcotics.
6) No lifting greater than 10 pounds for 2-3 weeks
7) Hip restrictions per Dr.[**Name (NI) 14478**] instructions.
8) Post discharge Benefix infusions x2 as per Dr.[**Name (NI) 16545**]
orders.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] in 2 weeks for follow-up
appointment.
Please follow-up with Dr. [**Last Name (STitle) **] as instructed.
Please follow-up with Dr. [**Last Name (STitle) 3060**] as instructed.
Please call for all appts.
Take Benefix 5050 units daily until (and including) [**2163-9-14**] per
Dr. [**Last Name (STitle) 3060**]. Can take aspirin while taking Benefix only,
discontinue aspirin after Benefix doses completed.
Completed by:[**2163-9-10**] Name: [**Known lastname 2581**],[**Known firstname **] D Unit No: [**Numeric Identifier 2582**]
Admission Date: [**2163-9-6**] Discharge Date: [**2163-9-10**]
Date of Birth: [**2102-3-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Aspirin was discontinued on the day of discharge per Dr.
[**Last Name (STitle) **].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1082**] VNA
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2163-9-10**]
|
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icd9cm
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76,008
| 193,040
|
42079
|
Discharge summary
|
report
|
Admission Date: [**2123-10-11**] Discharge Date: [**2123-10-15**]
Date of Birth: [**2054-2-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Claudication
Major Surgical or Invasive Procedure:
1. PTA/stenting of the left external iliac artery
History of Present Illness:
69 year old man has a history of hypertension, hyperlipidemia,
chronic renal insuffiency, heavy former tobacco abuse and COPD.
Over the past year he has been bothered by left upper thigh, hip
and buttocks discomfort after walking about 100 feet. This
resolves with rest. He denies any non healing ulcers. The right
leg becomes fatigued with walking. Recent MRI has revealed a
high grade left external iliac artery stenosis and he is now
being referred for angiography and revascularization.
.
Of note, the patient has a fair amount of dyspnea with limited
exertion. Non invasive cardiac testing has been unremarkable.
It
is felt that his dyspnea is due to COPD.
.
left external iliac stent placed by Dow yesterday with right
groin access. hematoma after procedure - stable, but had
ultrasound this morning, found femoral pseudoaneurysm. 1 hour
later, popping sensation, swelling of right groin and scrotal
hematoma, systolics 60's, back to bed, volume resuscitation 1L,
1unit of blood. presyncopal per patient, no LOC. vascular
called and transferred to CCU. will watch for repair: vascular
recs: pulse checks - all palpable, systolic checks
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- PAD
- CRI
- GERD
- Gout
- COPD
- BPH
- Recovering alcoholic
- Anemia
- Ptosis s/p surgery
Social History:
Patient is married with two adult children. Retired construction
worker. Tobacco: 2ppd x 50+ years ago but quit one year ago.
ETOH: prior heavy ETOH use but quit 4 years ago.
Family History:
Brother passed away from an MI at age 48.
.
Physical Exam:
ADMISSION EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Limited exam as patient can not bend at waist or roll.
Anterior exam CTAB.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Some RLQ
abdomen ecchymosis
GU: prominent Scrotal/groin swelling and eccyhmoses, groin clamp
in place
EXTREMITIES: 1+ edema R>L.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT trace
Left: Femoral 2+ 2+ DP 2+ PT trace
.
DISCHARGE EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Wheezing but otherwise CTAB
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Some RLQ
abdomen ecchymosis
GU: Scrotal/groin swelling and eccyhmoses reduced but still
present. Skin with some blistering from clamp placement
EXTREMITIES: 1+ edema R>L, improved from admission
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT trace
Left: DP 2+ PT trace
Pertinent Results:
ADMISSION LABS:
[**2123-10-12**] 01:20PM BLOOD Glucose-138* UreaN-35* Creat-2.0* Na-138
K-4.1 Cl-106 HCO3-23 AnGap-13
[**2123-10-12**] 01:20PM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7
[**2123-10-13**] 05:09AM BLOOD ALT-31 AST-22 AlkPhos-61 TotBili-1.0
[**2123-10-12**] 06:35AM BLOOD Hct-27.5* Plt Ct-203
.
DISCHARGE LABS:
[**2123-10-15**] 05:53AM BLOOD WBC-7.3 RBC-3.05* Hgb-9.7* Hct-28.2*
MCV-92 MCH-31.9 MCHC-34.5 RDW-15.1 Plt Ct-211
[**2123-10-15**] 05:53AM BLOOD calTIBC-320 Ferritn-141 TRF-246
[**2123-10-15**] 05:53AM BLOOD Mg-2.1 Iron-39*
.
Peripheral Catheterization:
COMMENTS:
1. Limited peripheral angiography demonstrated a no plaquing in
the
abdominal aorta. The right lower extremity had a 40% stenosis in
the
right external iliac with no flow limiting disease downstream.
The left
lower extremity had a 90% stenosis in the external iliac artery
with no
flow limiting disease downstream and preserved three vessl
runoff.
2. Successful stenting of the left EIA with an 8x40mm ZILVER
self
expanding stent which was postdilated with a 7mm SUBMARINE
balloon at 4
ATMs.
3. Limited resting hemodynamics revealed a central aortic
pressure of
158/78 mmHg.
FINAL DIAGNOSIS:
1. Peripheral arterial disease.
2. Successful stenting of the left EIA.
3. Moderately elevated systolic hypertension.
.
US [**2123-10-13**]
IMPRESSION:
1. No evidence of pseudoaneurysm in the right inguinal region. A
2.8 cm
hematoma is noted in the high right inguinal region and might
represent the thrombosed remnant of the previously seen
pseudoaneurysm.
2. Deep venous thrombosis of the right common femoral and deep
femoral veins.
3. No deep venous thrombosis in left lower extremity.
Brief Hospital Course:
69 year old man with a left external iliac artery stenosis and
claudication s/p stenting [**2123-10-11**] c/b R groin/scrotal
hematoma
.
ACTIVE ISSUES:
#Hematoma: A psuedoanuerysm in the right groin was noted the day
after his procedure on US. He later coughed, felt a popping
sensation, and became hypotensive and presyncopal. He was given
IVF and 2uPRBC and a FemStop clamp was placed. He he was then
remained hemodynamically stable. The following day an ultrasound
showed no pseudoaneurysm but did show a DVT.
.
#DVT: Provoked in the setting of FemStop clamp decreasing venous
return. He was given lovenox to bridge him to therapeutic
anticoagulation with warfarin. The plan is to continue his
anticoagulation for THREE months and then repeat an ultrasound.
He was discharged on 5mg warfarin. This will likely need to be
adjusted as an outpatient.
.
#PAD: He underwent succesful stenting of his left external iliac
artery through right femoral artery access complicated by R
Groin hematoma as above. He was discharged on aspirin, plavix,
atorvastatin, as well as lovenox and warfgarin as above.
.
#Hypertension: Home HTN regmen was Dilt (also for A-FIB) and
clonidine. During this admission we started Carvedilol 25 mg PO
BID, lisinopril 20 mg, Torsemide 10mg daily and started tapering
off clonidine. Torsemide was chosen instead of a thiazide
diuretic because of his low GFR. His blood pressures were well
controlled with this regimen. He was discharged on clonidine 0.1
mg [**Hospital1 **] with the plan to stop this 2 days after discharge. He may
need further uptitration of his lisinopril if his blood pressure
increases after clonidine is discontinued.
.
#COPD: Not on inhalers or oxygen at home. He did have some mild
shortness of breath so ipratropium inhaler was started. He did
not endorse much benefit from the inhaler. Further management
can be considered as an outpatient.
.
CHRONIC ISSUES:
.
#CKD: Creatinie was at his baseline throughout admission and did
not increase after starting lisinopril and torsemide.
.
#GERD: Continue home omeprazole
.
#Gout: Reduced allopurinol dose to 150 mg because of lower
creatinine clearance
.
#BPH: Continued doxazosin
.
#Anemia: Unclear etiology. [**Month (only) 116**] be related to CKD or prior ETOH
use. Does not appear to be iron deficient.
.
TRANSITIONAL ISSUES:
#Anemia: Perhaps chronic but of unclear etiology. Would suggest
further work-up of this issue as an outpatient.
Medications on Admission:
1. ALLOPURINOL 300 mg PO daily
2. CLONIDINE 0.3 mg PO BID
3. DILTIAZEM HCL ER 360 mg PO daily
5. DOXAZOSIN 4 mg PO daily
6. OMEPRAZOLE 20 mg PO daily
7. ASPIRIN 81 mg PO daily
8. MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] PO 2X/Week
9. Fenofibrate 120 mg daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 4 days: Please stop this medication completely after
four days.
7. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
once a day for 5 days.
Disp:*5 * Refills:*0*
8. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day.
9. multivitamin Capsule Sig: One (1) Capsule PO once a day.
10. fenofibrate 120 mg Tablet Sig: One (1) Tablet PO once a day.
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*20 Tablet(s)* Refills:*0*
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis: peripheral arterial disease, hypertension,
right femoral artery pseudoaneurysm, scrotal hematoma, deep vein
thrombosis
Secondary Diagnosis: hyperlipidemia, stage 3 chronic renal
insufficiencey, gout, benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS 130-150/70 HR 70
Lungs CTA
Heart RRR-MRG
PV R fem access + bruit as per pre exam DPs 2+ PTs 1+
L fem + buit though less than RFA DPs 2+ PTs 1+
Discharge Instructions:
Dear Mr. [**Known lastname **],
You had an angiogram to evauluate symptoms of left leg
discomfort when walking. There was a blockage in the artery
above the groin in the left leg. Dr [**Last Name (STitle) 7047**] used a balloon and
stent to reopen this area.
A pseudoaneurysm was found at the puncture site in your right
groin. This aneurysm burst and you bled into your thigh. A
clamp was placed to hold pressure over the femoral artery. The
pseudoaneurysm resolved upon ultrasound done 24 hours later.
Activity restrictions and groin site care as per discharge
instructions.
A clot formed in your right leg. As a result, you will need to
take blood thinners to prevent the clot from moving and to help
it resolve.
The following changes have been made to your medication regimen:
-INCREASE Aspirin is 325mg once a day - you will need to buy
this at the pharmacy
-START Plavix is 75 mg once a day and will be taken for one
month. Do NOT stop these medications unless your cardiologist
tells you to.
-CONTINUE lipitor 40mg to help prevent the buildup of plaque in
arteries in not only the legs, but the heart, kidneys, and to
the brain. Dr [**Last Name (un) **] will repeat your cholesterol levels
in [**5-19**] weeks.
-DECREASE allopurinol to 150mg once a day as this is appropriate
for your kidney function.
-START lovenox for 5 days and then stop
-START warfarin daily for one month. A repeat ultrasound will
then need to be done to evaluate for clot.
Your blood pressure regimen was changed in order to use
medications that protect your heart and kidneys. The following
changes were made:
-START lisinopril 20mg once daily
-START carvedilol 25mg twice daily
-START torsemide 10mg once daily
-DECREASE clonidine to 0.1mg twice daily for the next four days,
and then STOP this medication
-STOP diltiazem
Followup Instructions:
Please attend the following appointments:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (un) 91309**], MD
Specialty: Internal Medicine
When: Wednesday [**10-20**] at 3:30p
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
Specialty: Cardiology
When: Monday [**10-25**] at 12pm
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 18655**]
Phone: [**Telephone/Fax (1) 8725**]
|
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6,146
| 183,602
|
8904+8905
|
Discharge summary
|
report+report
|
Admission Date: [**2188-9-7**] Discharge Date: [**2188-9-18**]
Date of Birth: [**2115-4-6**] Sex: M
Service: BONE MARROW TRANSPLANT
HISTORY OF PRESENT ILLNESS: Patient is a 73-year-old male
with angioimmunoblastic lymphoma disease diagnosed three
years ago status post fludarabine x2 cycles, CHOP x6 cycles,
Campath x6 doses ([**5-30**]) with retreatment of Campath ([**5-31**]),
who presents to the Emergency Room complaining of cramping
abdominal pain for the last four days with underlying dull
pain. Of note, the patient was constipated and took Colace
yesterday with four soft loose bowel movements this morning
with relief of abdominal pain. However, in Emergency
Department, the patient required Dilaudid for recurrent
colicky pain, which was diffuse.
Patient also complains of a chronic persistent cough (patient
has history of recent Pseudomonal pneumonia) with associated
shortness of breath. Patient also complains of cough with
yellow sputum and his oxygen requirement has also increased.
He denies any fever or chills, melena, bright red blood per
rectum, dysuria, chest pain, or palpitations. Patient had
vomiting after drinking CT contrast today. The patient also
reports a decreased appetite for the last several days. Of
note, the patient recently completed an extended
ciprofloxacin course on [**2188-9-3**]. He also recently
discontinued valganciclovir for history of CMV viremia given
a recent negative viral load and associated thrombocytopenia.
On admission, the patient denied any other symptoms other
than those noted above. He denied any orthopnea or
paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY:
1. AILD status post Campath in [**2188-5-29**], Campath in [**2187-5-30**], CHOP in [**2185-11-30**], and fludarabine x2 cycles.
2. Chronic recurrent DIC: Recently previously treated with
Heparin drip and responded well.
3. History of CMV viremia and pneumonitis.
4. History of gram-negative bacteremia.
5. History of alpha Strep bacteremia.
6. ARDS.
7. Coronary artery disease status post CABG x2 in [**2175**] and
[**2183**].
8. Congestive heart failure with an ejection fraction of
greater than 55% in [**2188-3-29**].
9. Lumbar compression fractures secondary to steroids.
10. Paroxysmal atrial fibrillation status post cardioversion.
11. Oral candidiasis.
12. Gastroesophageal reflux disease.
13. Gout.
14. Hypercholesterolemia.
15. History of Pseudomonal pneumonia.
16. Status post cholecystectomy.
MEDICATIONS:
1. Amiodarone 200 mg q am po.
2. Allopurinol 150 mg po q am.
3. Prednisone 10 mg po q am.
4. Ritalin 5 mg po q am.
5. Celexa 20 mg po q am.
6. Lasix 20 mg po q am.
7. Spironolactone 25 mg po q am.
8. Losartan 25 mg po q am.
9. Potassium 10 mEq po q day.
10. Bactrim double strength Monday, Wednesday, Friday.
11. Protonix 40 mg po q day.
12. Vicodin prn.
13. Colace 100 mg po q day.
14. Lipitor 20 mg po q day.
15. Albuterol/Atrovent inhaler.
16. Tessalon Perles.
17. Nystatin/clotrimazole troches.
ALLERGIES:
1. Penicillin: Anaphylaxis.
2. Biaxin: Anaphylaxis.
3. ? Levaquin: The patient has questionable allergy to
Levaquin, however, he tolerates ciprofloxacin. He also
received a dose of Levaquin in the Emergency Department with
no reaction or symptoms.
PHYSICAL EXAMINATION: Temperature was 97.6, blood pressure
124/79, pulse 76, respirations 20, and sating 95% on room
air. In general: Patient was alert and oriented to person,
place, and time, appearing comfortable, able to complete full
sentences in no apparent distress. HEENT: Pupils are equal,
round, and reactive to light. Extraocular movements are
intact. Oropharynx with white exudate on tongue and blackish
telangiectasias on sides of tongue. Mucosa was moist. Neck:
Supple, nontender, jugular venous distention to the jawline.
Pulmonary: Diffuse rhonchi with mild expiratory wheezes.
Cardiovascular: Regular, rate, and rhythm, +2/6 systolic
ejection murmur. Abdomen: Soft, nontender, nondistended,
obese with normoactive bowel sounds. Patient was heme
positive with brown stool. Extremities: Warm and well
perfused, 1+ edema bilaterally lower extremities, 2+ dorsalis
pedis pulses. Left groin mass. Neurologic: Motor strength
5/5 in lower extremities bilaterally. Sensation intact
distally, no focal deficits.
LABORATORIES ON ADMISSION: White blood cell count 2.8,
hematocrit 37.7, platelets 42. Differential on white blood
cell count equals neutrophils 69%, bands 10%. PT 12.8, PTT
24.2, INR 1.1. Sodium 129, potassium 5.4, chloride 95,
bicarb 25, BUN 33, creatinine 1.4, and glucose 90. Calcium
8.8, magnesium 1.9, and phosphorus 3.9. Of note, Chem-7 was
known to be hemolyzed sample. AST: 277, ALT 325, albumin
3.0, alkaline phosphatase 708, total bilirubin 0.9, lipase
70, fibrinogen 56. CMV viral load on [**8-31**] was
negative. First set of cardiac enzymes: CPK 17, troponin
0.07. Urinalysis showed 0-2 white blood cells, 0-2 epi
cells, otherwise negative.
Chest x-ray showed bilateral basal atelectasis with no
effusions and no infiltrate, no pneumonia.
Electrocardiogram: Normal sinus rhythm, consistent with
07/03, questionable new prominent Q waves in V2 and V3,
questionable ST depressions in V4, V5, V6, I and aVL.
KUB: No obstruction.
CT of the abdomen/chest/pelvis: A 15 mm node seen along the
right paratracheal region. No enlarged hilar lymph nodes.
No pericardial effusion. Scattered small ill-defined nodules
throughout the lungs that were not present on the prior
study. No effusions. Interval development of several masses
within the spleen. With a history of lymphoma, this is
worrisome for splenic involvement. Interval development of
multiple nonspecific nodules within the lungs. This could be
infectious, neoplastic, or inflammatory. No masses in the
liver, no free fluid. No intraabdominal abscess or
obstruction. Normal pancreas, no ascites.
HOSPITAL COURSE:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], M.D. [**MD Number(1) 7775**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2188-9-17**] 21:42
T: [**2188-9-18**] 06:31
JOB#: [**Job Number 30957**]
Admission Date: [**2188-9-7**] Discharge Date: [**2188-9-18**]
Date of Birth: [**2115-4-6**] Sex: M
Service: Bone Marrow Transplant
This is a continuation of the previous discharge summary
dictated up to the hospital course:
HOSPITAL COURSE: 1. Gastrointestinal: The patient was
initially admitted with a transaminitis with very elevated
alkaline phosphatase. Abdominal CT did not show any evidence
of ductal dilatation. It was initially thought that his
transaminitis was most likely due to infiltration of his
lymphoma in the patient's liver. GI was initially consulted
for the possibility of performing a liver biopsy, but since
the patient's other issues took precedence over his immediate
liver biopsy, the decision was made to put this off and watch
his liver function tests through the rest of his hospital
course. The patient's stool studies were checked for C.
difficile and ova and parasites. These studies were
negative. The patient was continued on Protonix q. day. He
was also started on Flagyl and Levaquin for empiric coverage
of any possible abdominal infection. It was also thought
that possibly the patient's increased transaminitis could be
secondary to a reinfection with CMV. A CMV viral load was
checked which returned on [**2188-9-12**] as not detectable.
Infectious disease was consulted and the details of this
consultation are in the next section. The patient's liver
function tests remained elevated until the patient received
his first pentostatin dose on [**2188-9-10**]. Because the patient
had not spiked a temperature and his renal and liver function
tests continued to be elevated, the decision was made to
discontinue his antibiotics, Levaquin and Flagyl, on
[**2188-9-10**]. After the patient received his first dose of
pentostatin on [**2188-9-10**], the patient's liver function tests
continued to improve throughout his hospital course. At the
time of this dictation the patient's liver function tests are
considerably decreased from his admission tests. It is now
thought that his transaminitis was most likely due to
infiltration of lymphoma in his liver and may have been
improved with therapy with pentostatin. The patient
currently has no real complaints of abdominal pain and his
diarrhea has resolved. The patient also had new splenic
masses on CT initially. This was also thought to have been
due to infiltration of his lymphoma. The patient will have a
repeat CT in one week after discharge, currently scheduled
for Tuesday, [**2188-9-23**] at 2 PM, to evaluate the progression of
his disease.
2. Pulmonary: Upon admission the patient had complaints of a
chronic cough productive with yellow sputum, shortness of
breath, and increased oxygen requirement. He had recently
completed a ciprofloxacin course of Pseudomonal pneumonia.
The chest CT performed on admission showed scattered small
nodules throughout. It was unclear whether this may be due
to his lymphoma or a new infection. The patient had a sputum
culture sent but it did not yield any data. The patient's
Bactrim dose was temporarily held secondary to his decreased
counts, but was restarted the next day after admission for
PCP [**Name Initial (PRE) 1102**]. The pulmonary team was consulted to perform
a bronchoscopy if indicated to rule out whether the patient's
pulmonary status was most likely due to lymphoma or whether
his pulmonary issues could be secondary to an opportunistic
infection. Initially when pulmonary was consulted, they felt
that bronchoscopy was not indicated since the patient's
pulmonary issues were most likely secondary to the advance of
his lymphoma. However, status post patient's pentostatin
dose on [**2188-9-10**], the patient's pulmonary status continued to
decrease. Overnight on [**2188-9-10**] the patient had desaturated
to the 80s and had an increased oxygen requirement from 1.5
liters of oxygen to 2-3 liters. He improved with Lasix 20 to
40 mg IV in one-time doses somewhat, however his pulmonary
status still remained poor. In addition his lung examination
was worsened with more diffuse rhonchi and expiratory
wheezes. Pulmonary evaluated the patient again and the
decision was made to perform a bronchoscopy on [**2188-9-12**] to
rule out any possible source of infection. On [**2188-9-12**]
bronchoscopy was completed which showed inflamed airways with
thin white/clear secretions throughout. The right middle
lobe and lingula were lavaged. Specimens were sent for micro
and cytology. However, post procedure, the patient had
decreased saturation, hypoventilating, and was dyspneic with
diffuse rhonchi. He was given Lasix 20 mg IV and put out 300
cc. He received albuterol nebulizers and was suctioned
nasally, with only partial improvement in his respiratory
status. His saturations remained 92-96% on 40-100% oxygen.
Since required [**Hospital 30958**] nursing care, he was transferred to
the intensive care unit. The patient was diuresed further in
the intensive care unit with 40 mg of Lasix one-time dose,
and his respiratory status improved from saturating on a
nonrebreather, to saturating 94-95% on four liters. On the
next day, [**2188-9-13**], the patient was stable and was
transferred back to the bone marrow transplant service for
further management. His pulmonary status continued to
improve throughout the rest of his hospital course. He
currently is saturating 95-96% on four liters and this has
been stable for him. He still has diffuse rhonchi through
his lung examination, predominantly at his bases, however
this is improved from prebronchoscopy. The patient is to be
continued on a total 14-day course of Levaquin. He should
continue with his Combivent inhaler every four to six hours.
The patient often refused nebulizer treatments.
On [**2188-9-16**] the patient's bronchoalveolar lavage results
returned showing positive Aspergillus infection in his
respiratory and fungal cultures. The patient was started on
AmBisome 5 mg per kg dose q. day, and at the time of this
dictation has received two doses. The patient will likely
continue with this therapy for at least one to two weeks if
not longer, since it will take some time for him to clear
this fungal infection. Per pulmonary, the patient should
have a repeat CT scan which is currently scheduled for
[**2188-9-23**] at 2 PM to evaluate the effectiveness of the
treatment on his disease and the size of the nodules on CT.
The patient has been doing well with his AmBisome therapy.
He continues to have a productive cough with yellow sputum.
3. Recurrent DIC: The patient had a significantly decreased
fibrinogen and platelet count on admission. He was given
cryoprecipitate one-time dose. He was also placed on a
heparin drip at 600 units per hour, which was increased to
800 units per hour several days later. His fibrinogen began
to improve on this heparin drip and the patient was also
given [**1-31**] bags of cryoprecipitate prior to his pentostatin
infusion. The reason for the heparin drip was because his
primary oncologist, Dr. [**First Name (STitle) **], stated that he had improved on
this in prior hospitalizations. The patient received
fibrinogen and coagulation laboratory studies twice a day and
was closely monitored through his hospital course. After his
pentostatin dose, the patient's fibrinogen levels continued
to improve. At the time of this dictation, they have
remained above 100 for four to five days. He has not
required any cryoprecipitate and he has not been on his
heparin drip since [**2188-9-12**]. The patient should continue to
be monitored for recurrence of his DIC, however it appears
that possibly the pentostatin has improved this issue.
4. Infectious disease: Infectious disease was consulted with
regard to whether the patient may have a reinfection with
CMV. They suggested performing liver and colon biopsies to
truly rule out whether this is a recurrence of the CMV and
also suggested starting valganciclovir for CMV prophylaxis.
In light of the patient's negative CMV viral load on [**2188-9-12**]
and the patient's increased liver function tests, the
decision was made by the primary team to hold off on CMV
prophylaxis. An ophthalmologist was consulted to perform a
CMV retinal examination to rule out CMV retinitis and this
was negative for CMV retinitis. Another CMV viral load has
been sent off at the time of this dictation, and is still
pending. There are no other therapies for CMV that would be
less nephrotoxic and hepatotoxic than valganciclovir. In
addition, the patient should be continued on Levaquin for a
14-day course for proper antibiotic coverage for his
pulmonary infection. The patient should also be continued on
AmBisome 5 mg per kg per day for treatment of his Aspergillus
infection.
5. History of coronary artery disease: The patient had new Q
waves on EKG suggestive of a new infarct, and was cycles for
cardiac enzymes x 3. His troponins remained flat at 0.07.
An echocardiogram was performed that showed an ejection
fraction of greater than 55% but evidence of mild diastolic
dysfunction. The patient remained asymptomatic and free of
chest pain throughout his hospital course. He remained in
sinus rhythm even though he had this history of paroxysmal
atrial fibrillation. When the patient was transferred to the
intensive care unit, the thought was that maybe the patient
had suffered a mild cardiac event as well, and he was watched
closely on telemetry and was put on a low-dose beta blocker
as well as diuresed with Lasix to help with his diastolic
dysfunction. The patient improved with the Lasix but the
metoprolol was subsequently discontinued secondary to his
poor pulmonary status. Subsequent EKGs have not shown any
changes but still do demonstrate the Q waves in V2 and V3.
His troponins have remained flat and a repeat set drawn in
the intensive care unit showed a troponin even lower of 0.04.
His cardiac issues have remained stable and it is
questionable whether the patient did have a new infarct upon
admission, however this has not changed through his hospital
course.
6. Code Status: The patient is DNR/DNI.
7. Depression: The patient was continued on his Celexa.
8. Poor appetite: The patient remained with a poor appetite
throughout his hospital course. He was started on Megace 800
mg p.o. q.d. for appetite stimulation near the end of his
hospital stay. The patient had also complained of dysphagia
in the first week of his hospital stay and with an
oropharyngeal examination that was not very highly suggestive
of thrush, but with patient's complaints of dysphagia, the
patient was started on IV Diflucan. He seemed to improve
with this since he had less complaints of painful swallowing.
However the Diflucan was discontinued when the AmBisome was
started since this would be better fungal coverage. The
patient now has improved swallowing so it might be possible
that the patient had some level of thrush in his esophagus.
He should be continued on his current regimen. Liver
function tests should be closely monitored.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
1. Immunoblastic lymphoma disease.
2. Recurrent DIC.
3. History of CMV viremia.
4. Aspergillus infection.
5. Coronary artery disease.
6. Diastolic congestive heart failure.
DISCHARGE MEDICATIONS:
1. Celexa 20 mg p.o. q.d.
2. Amiodarone 200 mg p.o. q.d.
3. Allopurinol 150 mg p.o. q.d.
4. Prednisone 10 mg p.o. q.d.
5. Ritalin 5 mg p.o. q.d.
6. Spironolactone 25 mg p.o. q.d.
7. Losartan.
8. Bactrim 1 double-strength tablet q. Monday, Wednesday, and
Friday.
9. Protonix 40 mg p.o. q.d.
10. Fentanyl patch 25 mcg per hour transdermal q. 72 hours.
11. Dilaudid 1-2 mg p.o. q. 4-6 hours p.r.n. pain.
12. Colace 100 mg p.o. b.i.d.
13. Lipitor 40 mg p.o. q.d.
14. Nystatin swish and swallow.
15. Tessalon Perles.
16. Levaquin 500 mg p.o. q.d. for a total of 14 days.
17. AmBisome 5 mg per kg per day IV.
18. Megace 800 mg p.o. q.d.
FOLLOW-UP PLANS: The patient should follow up with Dr.
[**Last Name (STitle) 30959**] on [**2188-9-24**]. The patient should have a follow-up CT
scan, scheduled currently for [**2188-9-23**] at 2 PM. The patient
should remain n.p.o. three hours prior to examination.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], M.D. [**MD Number(1) 7775**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2188-9-18**] 05:54
T: [**2188-9-18**] 08:01
JOB#: [**Job Number 30960**]
cc:[**Hospital1 30961**]
|
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49,453
| 171,148
|
2271
|
Discharge summary
|
report
|
Admission Date: [**2105-4-13**] Discharge Date: [**2105-4-17**]
Date of Birth: [**2033-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 71 [**Last Name (un) **] with history of Perianal Mucinous
Adenocarcinoma currently receiving radiation therapy with
concurrent 5-Fu for 3 days (2-26-2/28) who presented to his
radiation appointment today with shortness of breath and was
referred to the ED out of concern for PE. The patient reports
gradually worsening SOB since friday with SOB now occuring at
rest. He denies any assoicated chest pain, N/V palpitations,
PND, orthopnea, pedal edema or calf pain. He denies any recent
cough, nasal congestion, sore throat. He denies any recent
fevers but does report +chills x 4 days. Patient reports no
other symptoms aside from his SOB.
.
In the ED: Temp 98.4, BP 97/70, HR 103, RR 20, 100% 3LNC. Labs
notable for K 6.3. EKG with peaked T waves. He was given
Kayexalate 30gm PO x 1, Insulin 10u IV x 1 and D50 1 amp IV x 1.
Given CKD, CTA was not performed. LENIS were done and were
negative. V/Q scan was ordered but not performed prior to
patient leaving the ED. Patient was admitted to the medical
floor for further management.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias. Denies rashes or skin breakdown.
No numbness/tingling in extremities. No feelings of depression
or anxiety. All other review of systems negative.
Past Medical History:
Past Oncologic History:
Perianal mucinous adenocarcinoma currently receiving radiation
therapy, s/p concurrent 5-Fu for 3 days (2-26-2/28)
.
Other Past Medical History:
CKD IV- s/p transplant [**2102**] with course c/b membranous GN
[**1-/2105**] and possible acute rejection due to med non-compliance
ESRD s/p renal transplant secondary to HTN, glomerulonephritis
in [**2102**]
Hypertension
Hyperlipidemia
Genital HSV-2 (penile) in [**3-/2105**] s/p acyclovir
Gout
GI bleed secondary to gastric ulcer in [**1-14**]
Recent enterococcal bacteremia treated with [**Date Range 11958**]
Social History:
Denies tobacco, EtOH or illicit drug use. From [**Location (un) **], married
but separated from his wife, lives with his son.
Family History:
Mother has [**Name (NI) 2481**]. Brother has diabetes and gout. There is
no family history of any renal failure, diabetes, or any
coronary artery disease.
Physical Exam:
GEN: NAD, tachpneic but answering question in complete
sentences, no accessory muscle use
VS: Temp 95.3, BP 144/70, HR 106, RR 24 100% 2LNC
HEENT: NCAT, EOMI, PERRLA, OP clear, MMM
CV: +S1/S2, II/VI SEM heard best in LUSB, no R/G
PULM: CTAB, no wheezes crackles or ronchi
ABD: +BS, NT/ND
LIMBS: no c/c/e, + 2 distal pulses
SKIN: no rashes
.
on discharge
Vitals: 98.4 119/62 72 18 100%RA
Pain: denies
Access: PICC, RUE
Gen: nad
HEENT: o/p clear, mmm
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, nonfocal, mild baseline tremor
Skin: improving swelling and bruising of RUE, LUE old fistula
w/o thrill
psych: appropriate
Pertinent Results:
wbc 3.8 (baseline)-->1.6 with 63%N
hgb 11 (baseline)-->[**9-14**] stable (s/p 1U prbc)
Plt 174->102 (b/l wnl)
INR 1.3
Chem: K 6.2->4.7
Bicarb 8->32 after bicarb drip-->19 off gtt
BUN/Creat 38/2.5 (baseline creat 3s)
tacro [**4-15**] 5.6
albumin 4.3
AST/ALT 77/206-->54/158, alkphos and t.bili wnl
.
UA [**4-13**] negative
Blood Cx [**4-13**] X2 NTD
.
.
.
.
Imaging/results:
CXR: R base calcified granuloma, old
.
LE dopplers [**4-13**]: no DVT b/l LE
Brief Hospital Course:
71year old male with h/o ESRD [**3-10**] HTN vs chronic GN, s/p kidney
transplant in [**2102-9-6**], [**Last Name (un) **] in [**1-14**] found to have membranous GN
(unclear [**Name2 (NI) **] [**Last Name (un) 11083**] or recurrent) in the background of acute
cellular rejection with new baseline Cr 3's, PUD, recently
diagnosed anal adenocarcinoma [**1-14**] currenlty receiving
radiation therapy with concurrent 5-Fu for 3 days (2-26-2/28)
who presented to his radiation appointment on [**4-13**] and reported
progressive shortness of breath x4days. He denied any assoicated
chest pain, palpitations, PND, orthopnea, pedal edema or calf
pain. He denies any recent cough, nasal congestion, sore throat.
No obvious bleeding.
.
Initially admitted to Onc service. Concern was for PE and pt
awaiting V/Q scan. On labs, noted to have bicarb of 8, nongap
met acidosis, so resp distress likely tachypnea from
compensation. So V/Q scan defered, LENIs negative. Access was
difficult so pt t/f to MICU given severe acidosis. In MICU on
[**4-15**], bicarb gtt X12hours with correction of acidosis (bicarb
8->32) as well as resp distress. Taken off bicarb gtt on [**4-15**]
prior to transfer to floor. Seen by renal who felt that the
metabolic acidosis and hyperK is [**3-10**] RTA IV on top of CKD IV. He
was followed over next two days off gtt just on home Nabicarb
1300mg TID. His bicarb slowly downtrended from 32 to 19. His
previous baseline bicarb was around 20s so it is unclear why he
dropped so much this time and whether this will reccur. Only new
med from last admission was acyclovir for genital herpes, but
there are no reports of this causing metabolic acidosis so renal
felt okay to resume on d/c so pt could complete course. Renal
reccommended increasing NaBicarb to 3tabs TID. They will follow
up bicarb levels. Pt did very well ever since his bicarb was
initially corrected with drip. Other issues: Also had severe
hyper K to 6.2 with peaked Twaves on admission, which improved
with kayexalate, insulin/D50. Bactrim resumed, K was stable.
ACE-I not resumed. For access issues RUE midline placed on [**4-15**]
and was d/c'd prior to d/c. Was noted to have R arm swelling but
no DVT noted by IR at time of midline placement, and this was
improving at time of discharge. He continued to get his XRT per
schedule while here. He developed pancytopenia, with lowest WBC
1.6 (63%N) and hgb [**9-14**]. We gave him 1U prbc while here. However,
we did not give him neupogen but the oncology service was
notified of dropping counts. his plt count was around 100s. he
was discharged in good condition with onc/transplant f/u on [**5-4**]
and PCP f/u on [**5-5**]. he has home VNA for PT and nursing but he
is fairly independent.
.
see progress note below for details:
.
71year old male with h/o ESRD [**3-10**] HTN vs chronic GN, s/p kidney
transplant in [**2102-9-6**], [**Last Name (un) **] in [**1-14**] found to have membranous GN
(unclear [**Name2 (NI) **] [**Last Name (un) 11083**] or recurrent) in the background of acute
cellular rejection with new baseline Cr 3's, PUD, recently
diagnosed anal adenocarcinoma [**1-14**] currenlty receiving
radiation therapy with concurrent 5-Fu for 3 days (2-26-2/28)
who presented to his radiation appointment on [**4-13**] and reported
progressive shortness of breath x4days. Found to have severe
metabolic acidosis, which has been corrected, with improvement
in his symptoms. Short ICU stay for access issues.
.
Severe nongap metabolic acidosis: possbile type IV RTA/hypoaldo
on top of CKD. Unclear why he had acute drop given his baseline
bicarb is 20s while on NaBicarb tabs. Bicarb 8->32 with bicarb
gtt with improvement in symptoms of SOB-->19 today
-continue to monitor bicarb trend off gtt
-increase NaBicarb 650mg to 3tabs TID
-only new med since last admission is acyclovir. pt has new LFT
elevation as well as acidosis. however, renal does not feel this
is the cause and are okay with resuming acyclovir to complete
course
-f/u renal/transplant on [**5-4**]
-okay with them to cont tacro/bactrim
.
Pancytopenia: likely [**3-10**] 5-FU. WBC 1.6, ANC barely 1000
-follow closely
-may need neutropenic precautions if ANC<1000, have notified onc
of this
.
Anemia: current drop hct [**3-10**] BM suppression from chemo. no
obvious bleeding. s/p 1U prbc [**4-16**], hgb stable today (all counts
dropping)
-Fe supp
-epo MWF
.
Dyspnea: no hypoxia. likley hypervent as compensation for MA.
has chronic mild dyspnea, stable, good O2 sats.
-defer V/Q scan. LE dopplers neg.
.
CKD IV s/p renal transplant: baseline creat 3s [**3-10**] chronic GN vs
allograft nephropathy
-cont tacro (follow levels) and MMF at home doses
-have set up appt with Dr. [**Last Name (STitle) **] on [**5-4**]
-bactrim SS
.
HSV-2 genital infection:
-recently started on acyclovir on [**4-7**], completed on 6/14days
before admission
-renal okay with resuming this and completing course.
.
HyperK: may be part of RTA/hypoaldo. improved with medical
management.
-cont holding ACE-i. bactrim okay per renal.
.
RUE swelling: started 2days ago. went to IR for PICC this am and
they did not mention thrombus (wouldnt have placed line if this
was the case).
-improving
.
HTN:
-lopressor, norvasc at home doses
.
BPH: tamsulosin 0.8mg qd
.
Perianal mucionus adenoCa s/p chemo with 5FU/XRT: no acute
issues, monitor pancytopenia
-getting XRT per schedule
-cont megestrol
-cont zofran
-has f/u with Dr. [**Last Name (STitle) **] on [**5-4**]
.
PUD: PPI [**Hospital1 **] and sucralafate. GIB [**1-14**]. current anemia likely
[**3-10**] chemo.
.
Dispo/Code: full code. wife [**Name (NI) 5627**] [**Telephone/Fax (1) 11961**] .
Medications on Admission:
Tamsulosin 0.8 mg PO HS
Tacrolimus 2 mg PO twice a day.
MMF 500mg [**Hospital1 **]
Metoprolol Tartrate 25 mg PO once
Ferrous Sulfate 300 mg PO BID
Megestrol 400 mg/10 mL (625) ML PO daily
Pantoprazole 40 mg PO Q12H
Sucralfate 1 gram PO QID
Sodium Bicarbonate 1300 mg PO three times a day.
Amlodipine 10 mg PO once a day.
Sulfamethoxazole-Trimethoprim 400-80 mg PO DAILY
Epoetin Alfa 4,000 unit/mL One (1) mL Injection QMOWEFR
ZOFRAN ODT 8 mg PO every eight (8) hours as needed for nausea.
Compazine 10 mg PO every six (6) hours as needed for nausea.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
11. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: 625mg
PO once a day: resume your previous dose.
12. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO twice
a day: resume your previus dose.
14. Sodium Bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO
three times a day: higher dose.
15. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
16. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO three times a
day for 7 days: complete your previous 14day course.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
severe nongap metabolic acidosis leading to resp distress/sob
from compensation
CKD IV after renal transplant, stable
hyperkalemia, resolved
Genital herpes infection
Anemia, s/p 1U prbc
Anal adenoCa s/p 5FU, undergoing XRT
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with respiratory distress/shortness of breath.
This was due to your blood being very acidic. This is caused by
your kidney failure. We gave you some medicine to fix this and
your symptoms improved. You will go home on a higher dose of
your sodium bicarb tablets,take 3tabs three times a day instead
of two. you will have follow up with nephrology to follow these
levels.
.
Also while here, you continued to get your radiation therapy.
.
Also, your anemia level was low again and we gave you a unit of
blood as reccommended by your oncologist.
.
Your medications are otherwise kept the same. Your acyclovir was
held while you were here. please complete the remaining 8 or so
days of therapy for your herpes infection.
Followup Instructions:
Department: TRANSPLANT
When: MONDAY [**2105-5-4**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
When: Tuesday, [**5-5**], 2:40PM
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 11962**]
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2105-5-4**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2105-5-4**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8950**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2105-5-4**] at 12:00 PM
With: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"E933.1",
"276.7",
"274.9",
"V42.0",
"255.42",
"585.4",
"403.90",
"154.3",
"276.2",
"284.89",
"054.10",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11842, 11900
|
4037, 9677
|
322, 328
|
12167, 12167
|
3558, 4014
|
13073, 14562
|
2687, 2843
|
10279, 11819
|
11921, 12146
|
9703, 10254
|
12314, 13050
|
2858, 3539
|
1421, 1919
|
275, 284
|
356, 1402
|
12182, 12290
|
2110, 2528
|
2544, 2671
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,748
| 155,541
|
2907+55422
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-9-24**] Discharge Date: [**2161-10-16**]
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
woman transferred from [**Hospital **] Hospital with bilateral acute
subdural hematomas. The patient apparently was seated on the
side of her bed at home the night before admission and leaned
forward to remove her shoes and fell forward off the bed and
onto the floor. Unclear if there was any loss of
consciousness. The patient refused to seek medical attention
at that time but subsequently at the urging of the patient's
daughter she ambulated into [**Name (NI) **] Emergency Department for
medical attention. Head CT there showed the above bilateral
acute subdural hematomas with no evidence of skull fracture
and the patient was transferred to [**Hospital1 190**] in stable condition for further management.
PAST MEDICAL HISTORY: Hypertension
Coronary artery disease.
PAST SURGICAL HISTORY: Coronary angioplasty and stent.
MEDICATIONS ON ADMISSION:
1. Potassium.
2. Norvasc.
3. Lasix.
4. Iron.
5. Aspirin.
ALLERGIES: The patient has an allergy to Sulfa.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Her temperature was 98.8, heart rate
65, blood pressure 182/76, respiratory rate 20, oxygen
saturation 100 percent in room air. The patient was awake,
alert and oriented times three and in no acute distress,
neurologically moving all four extremities, no focal
deficits. GCS was 15. Head, eyes, ears, nose and throat -
The pupils are equal, round and reactive to light and
accommodation, four down to three millimeters. She had
bilateral raccoon eyes. She had oromaxillofacial injuries.
She had no hemotympanum. Neck - Cervical collar was intact.
No spinous tenderness. Back - No step-off. No tenderness in
the thoracolumbosacral spine.
HOSPITAL COURSE: The patient was seen by neurosurgery,
recommended admitting the patient to the Intensive Care Unit
for close neurologic observation and repeating a head CT the
following day. The patient was assessed by Dr. [**First Name (STitle) **] the
following day and Dr. [**First Name (STitle) **] recommended close neurologic
monitoring and no surgical intervention at that time. Repeat
head CT remained stable with no midline shift or mass effect
from the subdural hematomas and the patient's cervical spine
was cleared.
DICTATION ENDED
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2161-10-15**] 16:24:26
T: [**2161-10-15**] 16:43:39
Job#: [**Job Number 14045**]
Name: [**Known lastname **], [**Known firstname 460**] Unit No: [**Numeric Identifier 2184**]
Admission Date: [**2161-9-24**] Discharge Date: [**2161-10-22**]
Date of Birth: [**2078-7-20**] Sex: F
Service: NSU
Repeat head CT remains stable with no midline shift or mass
effect from the subdural hematomas and the cervical spine was
cleared. The patient had a repeat head CT on [**2161-9-26**] which
again was stable. She had a PICC line placed for IV access
and the patient was transferred to the Regular Floor on
[**2161-9-26**]. On transfer, she responded when her name was
called, but did not follow commands. She was not oriented.
Her pupils were equal, round and reacted to light. She moved
all four extremities spontaneously. She had a nonfocal exam.
She had a repeat head CT again on the 4th which again showed
no change. She remained on the Trauma Service. On [**9-29**], she
was more somnolent, but was alert and oriented times three
when awake. She had a repeat head CT which again was stable.
She had a bedside swallow that was done which they
recommended advancing to ground solids and nectar-thick
liquids. However, on [**2161-9-30**], she became minimally
responsive to painful stimulation only. She had a head CT
which was unchanged. She also had a chest x-ray which showed
left lower lobe pneumonia and a Dilantin level came back at
22. She had a sodium of 151 and enlarged pupil. On [**10-1**],
the patient became acutely worse with a nonreactive pupil on
the right side. The left pupil was sluggish to react. The
patient was taken emergently to the OR on [**10-1**] for
evacuation of the subdural hematoma. Essentially, the patient
herniated just prior to surgery. Postop, the patient was in
the Recovery Room. On physical examination postop, the
patient's pupils were equal and reacted. The right was
slightly more sluggish than the left. The right was 4 down to
3.3 mm. The left was 4 down to 2. The patient had a positive
gag and cough. Her chest was clear on auscultation. Her
abdomen was soft and nontender. Extremities - she had some
bruising noted. She withdraw to noxious stimulation in all
extremities. On [**10-2**], on exam, she was awake, alert and
localizing but not following commands. Her pupils were equal
and reacted to light. She had a repeat head CT which showed
pneumocephalus and she was put on 100 percent oxygen. On
[**2161-10-3**], on exam, she was following commands in both lower
extremities. Her pupils were 3.5 down to 3. She was more
sluggish to react on the right than the left. Her sensation
was intact. She localized in all extremities. She was
transfused with one unit of packed red blood cells for some
anemia. She was started on Lopressor 50 [**Hospital1 **] and subcutaneous
heparin for DVT prophylaxis. She remained stable. The patient
was started on Levaquin for the left lower lobe pneumonia. ID
was following the patient and recommended to discontinue the
levofloxacin and start her on Zosyn for empiric coverage of
aspiration and nosocomial pneumonia. Her condition remained
stable. A family meeting was held on [**10-9**] and the patient
was made a DNR. However, she may be reintubated and trach and
PEG if she fails extubation. She was extubated and did
tolerate that. She had a PEG placed and was transferred to
the regular floor on [**2161-10-14**]. She has remained
neurologically stable, moving all extremities, intermittently
following commands and has had episodes of congestive heart
failure, receiving IV Lasix. She also had a filter placed. On
[**10-16**], the patient had an episode of respiratory distress.
The family was consulted and they did not want the patient
intubated. She was therefore transferred to the MICU
overnight and was put on BiPAP. This episode did resolve and
the patient was transferred back to the regular floor the
following day. She has remained neurologically stable and
respiratory-wise has been stable, receiving daily doses of
Lasix. She has also had difficulty with hypertension and has
been treated with hydralazine, Lopressor and lisinopril for
blood pressure control. She was afebrile up until the 25th
when she did spike a temperature. Her UA came back positive
for Enterococcus which was sensitive to ampicillin and she
was started on ampicillin for that. She is also currently on
levofloxacin for her left lower lobe pneumonia. Her condition
remained stable.
Her medications at the time of discharge include Dilantin 100
mg po tid, metoprolol 75 mg po bid, hold for heart rate less
than 60 and SBP less than 120, lisinopril 10 mg po daily,
hydralazine 10 mg IV q4 prn, hold for SBP less than 120,
ampicillin 500 mg po q6 for three days which was started on
the 27th, levofloxacin 250 mg po q24h which was started on
the 24th for a total of seven days for pneumonia,
multivitamins 5 ml po daily, isosorbide 30 mg po tid, insulin
sliding scale, ferrous sulfate 300 mg po bid, folic acid 1 mg
po daily, heparin 5000 subcutaneous q12h, lansoprazole 30 mg
per NG daily.
Her condition was stable at the time of discharge. She will
follow up with Dr. [**First Name (STitle) 24**] in one month with repeat head CT.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 2185**]
Dictated By:[**Last Name (NamePattern1) 2186**]
MEDQUIST36
D: [**2161-10-22**] 11:14:26
T: [**2161-10-22**] 12:07:59
Job#: [**Job Number 2187**]
|
[
"518.81",
"486",
"E888.9",
"V45.82",
"428.0",
"401.9",
"414.00",
"852.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"99.04",
"38.7",
"96.04",
"01.31",
"96.72",
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
1139, 1157
|
1013, 1122
|
1844, 8070
|
954, 987
|
1180, 1826
|
119, 867
|
890, 930
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,129
| 151,614
|
43364+58614
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-7-31**] Discharge Date: [**2112-8-6**]
Date of Birth: [**2027-5-16**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Right upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic, converted to open cholecystectomy
Umbilical hernia repair
History of Present Illness:
The patient is an 85-year-old woman with a massive gallstone in
her gallbladder. She is 2 months status post right upper
quadrant pain with a diagnosis of the large stone and acute
cholecystitis. At that time due to a
transient troponin increased to 0.8 she was considered not to be
a candidate for surgery and she underwent a percutaneous
cholecystostomy. Ultimately she did not rule in for myocardial
infarction.
One month prior to this admission the tube was clamped. She had
a drain study
which showed that there was flow of contrast injected through
the cholecystostomy tube into the cystic duct and common duct.
Three days PTA the drain was removed. 1 day PTA she experienced
right upper quadrant pain getting worse throughout the day. She
presented to the emergency room with a white blood cell count of
11.6, alkaline phosphatase of 100, total bilirubin of 0.9.
Ultrasound showed less inflammation than was previously seen on
her ultrasound with a 4 cm stone in the gallbladder. There was
no pericholecystic fluid or edema, but there was slight
stranding.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Diastolic heart failure - likely NYHA II
-Atrial Fibrillation s/p AVJ ablation
- s/p Biotronik biventricular pacemaker placement at CSEMC [**8-13**]
- not on warfarin because of life-threatening LGIB
3. OTHER PAST MEDICAL HISTORY:
-GERD
-Anxiety
-Anemia
Social History:
She lives alone with some assistance from nurses who come to her
home. She does not speak fluent English, her daughter has served
as a translator in past interactions.
Patient was a former technician doing mechanical drawings.
Lives alone. Patient walks with cane and also has walker.
-Tobacco history: Never smoked
-ETOH: None
-Illicit drugs: None
-Herbal Medications: None
Family History:
Mother - died 79 ? cause
Father - died of old age
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: 98.8 69 107/77 18 97% 4L NC
GEN: A&O, NAD, Russian speaking only
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no r/m/g
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender in RUQ/epigastrum. no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: 1+ LE edema, LE warm and well perfused
Pertinent Results:
CBC - 11.6 > 37.2 < 185
N:85.6 L:9.8 M:4.2 E:0.3 Bas:0.1
134 | 95 | 12
---------------< 188
3.3 | 27 | 1.0
AST: 36 ALT: 19 AP: 100 Tbili: 0.9 Lip: 16
PT: 14.0 PTT: 25.5 INR: 1.2
EKG: biventricular pacing, unchanged from prior. Recent
interrogation of her Biotronik device shows 13 months of battery
life left. She is [**Age over 90 **]% V-paced with underlying AF with slow VR.
RUQ U/S: Large gallstone (3-4 cm) partially impacted at GB neck.
GB distended w/ wall edema, + [**Doctor Last Name **]. No free fluid. Shadowing
limits eval of CBD.
Brief Hospital Course:
Ms. [**Known lastname 28613**] was taken the operating room on [**2112-7-31**] for a lap
converted to open cholecystectomy, largely due to the size of
stone and difficulties associated with body habitus. Please
refer to Dr.[**Name (NI) 6218**] operative note for additional details.
Post-operatively, she was admitted to the ICU for further care
due to severe pain and low urine output requiring heavy fluid
resuscitation in the setting of her multiple comorbidities and
pulmonary hypertension. Overall, her neuro status wasw normal.
She had some post-op agitation into POD [**1-10**] which was treated
with haloperidol and ultimately resolved. She remained with
normal mental status throughout the rest of her course. Her
pain was managed with an epidural placed by the acute pain
service team and was subsequently removed on POD 4 without
incident; she tolerated a dilaudid PCA then oral pain when
appropriate.
She required pressors intermittently into POD 2 and remained HD
stable thereafter. From a pulmonary perspective, CXRs were
routinely monitored for fluid overload and she was dosed with IV
lasix a couple times in order to manage her fluid balance.
Urine output improved gradually. From a renal perspective, her
Cr did increase immediately post-operatively, peaking on [**8-3**] to
1.8 before trending downwards. This was attributed to fluid
resuscitation issues post-op as well as lasix therapy.
From a GI perspective she was NPO initially and advanced to a
regular diet over the course of her hospitalization. She
tolerated regular diet without incident.
She was kept on ciprofloxacin/flagyl for antibiotic coverage
until POD #3.
Of note, patient was noted to have decreased movement in her
left side during an episode of hypotension in the post-operative
period while in the ICU. A carotid ultrasound was performed and
did not show plaque at the bifurcation but did show some flow
abnormalities including reversal of flow indicative of a
proximal lesion. This is to be followed up as an outpatient
with further imaging potentially required. Due to the symptoms
resolving and its overall lack of acuity this was not
readdressed during this hospitalization.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#6, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
aspirin 325', atorvastatin 80', omeprazole 40', metoprolol
25", losartan 25', tramadol 50 prn, torsemide 10', metformin
500''', lorazepam 0.5", glipizide 5", cyclobenzaprine 5',
meclizine 12.5', ferrous sulfate 325', vit B-12
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 14 days.
Disp:*120 Tablet(s)* Refills:*0*
2. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cyclobenzaprine 10 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
5. ciclopirox 0.77 % Suspension Sig: Two (2) Topical once a
day: to right thumb nail and between fingers.
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
8. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for dizziness.
9. metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO at bedtime.
12. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
CityWide Home Care Inc
Discharge Diagnosis:
Cholecystitis and umbilical hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the general surgery service for a hernia
repair and cholecystectomy.
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
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience 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 concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*You have staples. Please have them removed at your follow up
appointment at the general surgery clinic.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or ??????washed out?????? for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All these feelings and reactions are normal and should go away
in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that, it??????s OK.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as Milk
of Magnesia, 1 tablespoon) twice a day. You can get both of
these medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
[**Male First Name (un) **]??????t take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] upon discharge to
arrange a follow up appointment in [**1-10**] weeks. Office is located
at [**Hospital1 18**], [**Hospital 2577**] Medical Office Building, [**Location (un) **].
Please follow up with your PCP regarding your carotid artery
study and the need for an MRA or CTA of the arch, neck and
intracranial vessels.
Please follow up with a physical therapist in your area.
Completed by:[**2112-8-6**] Name: [**Known lastname 14733**], [**First Name3 (LF) 6371**]
Unit No: [**Unit Number 14734**]
Admission Date: [**2112-7-31**]
Discharge Date: [**2112-8-6**]
Date of Birth: [**2027-5-16**]
Sex: F
Service: SURGERY
ADDENDUM: The pulmonary edema that she has experienced
during this admission was acute and indeed was diastolic CHF
or cardiogenic in etiology.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 846**]
Dictated By:[**Last Name (NamePattern4) 6631**]
MEDQUIST36
D: [**2112-9-16**] 13:36:13
T: [**2112-9-16**] 14:10:53
Job#: [**Job Number 14735**]
|
[
"416.8",
"V45.01",
"574.00",
"553.1",
"435.9",
"E878.6",
"293.9",
"V64.41",
"997.5",
"250.00",
"428.0",
"530.81",
"428.33",
"401.9",
"458.29",
"788.5",
"285.9",
"575.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"03.90",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
7200, 7253
|
3415, 5936
|
337, 410
|
7332, 7332
|
2835, 3392
|
11754, 12854
|
2284, 2449
|
6213, 7177
|
7274, 7311
|
5962, 6190
|
7483, 8462
|
9251, 11731
|
2464, 2816
|
1616, 1819
|
8494, 9236
|
262, 299
|
438, 1512
|
7347, 7459
|
1850, 1875
|
1534, 1596
|
1891, 2268
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,411
| 175,346
|
29138
|
Discharge summary
|
report
|
Admission Date: [**2122-12-31**] Discharge Date: [**2123-1-1**]
Date of Birth: [**2081-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
EtOH intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 41 year-old man with a history of ETOH abuse who was
brought to [**Hospital1 18**] ER by police after being found wandering in the
street.
.
Patient alert when seen in [**Hospital Unit Name 153**]. Reports he was drinking beer
and vodka from store yesterday and yesterday evening with his
girlfriend and also took percocet for his knee arthritis and
then does not remember events of last night.
.
He says he had been abstinent of alcohol for the past 6months
with prior abuse in past. He has been drinking in the past week
and doesn't want his family to know.
.
Denies chest pain, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, constipation. Says he is doing ok without
complaint.
.
In the emergency room, frankly intoxicated, aggressive, concern
given osmolar gap but tox screen positive only for opiates and
ETOH of 392. (Acetaminophen level of 5.1)-both consistent with
his history. Trauma work-up inlcuidng CT head, CT abdomen, CT
C-spine, CXR negative. CK 1025 with normal trop and creatinine
of 1.2 (non known baseline). Given 5 liters NS with improvement
of osmolar gap, tachycardia. Tox called and felt osm gap likely
secondary to etoh intoxication alone. Levoquin and flagyl given
for unclear reason.
.
Tachycardic on admission, sinus at 155. BP elevated to 160s.
Past Medical History:
1. H/o ETOH abuse
2. s/p gunshot wound (years ago while in Guatemalan army)
3. Arthritis of left knee--takes percocet from girlfriend.
Social History:
Occasional smoking with drinking. Drinking as above. Denies
other medications or drugs. Originally from [**Country 7192**], lives
with girlfriend. Cocaine in remote past. Works as a roofer.
Family History:
No h/o heart disease
Physical Exam:
VS: Temp:97.9 BP: 140/90 HR:97 RR:14 97%room air O2sat
.
general: smells of alcohol
HEENT: PERLLA, EOMI, anicteric, small laceration on bridge of
nose, no sinus tenderness, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema
skin/nails: no rashes/no jaundice
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
EKG: on presentation:Sinus tachycardia at 155
In ED at 8:26AM--sinus, TWI in V2-V3(new)
In ICU: Sinus at 80, TWI in v1-V4.
.
[**11-2**]: STRESS: EKG: SINUS HEART RATE: 61 BLOOD PRESSURE:
150/90
PROTOCOL [**Doctor First Name 569**] - TREADMILL
41yo male with history of tobacco use who is referred to the
stress lab for evaluation of chest pain. The patient was able to
do 11min of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol stopping for fatigue. He denied any
chest, arm, back, or neck discomfort. This represents a good
functional capacity for his age (13 METS). There were no
significant ST segment changes. The rhythm was sinus with no
ectopy. The hemodynamic response to exercise was appropriate.
IMPRESSION: No anginal type symptoms and no ischemic EKG changes
at a high workload.
.
Radiologic: [**2122-12-31**] CT abd/pelvis:
1. Distended gallbladder with mild wall enhancement. No edema
or
pericholecystic fluid. Right upper quadrant ultrasound is
recommended for further evaluation.
.
[**2122-12-31**] CT head:
No intracranial hemorrhage or mass effect.
.
[**2122-12-31**] CT C-Spine:
No fracture or abnormal alignment. No change from prior study.
.
[**2122-12-31**] CXR
1. No focal consolidations.
2. Radiopaque foreign body--seen previously.
.
[**2122-12-31**] RUQ U/S: No evidence for cholelithiasis or
cholecystitis. Adjacent fatty liver is seen, but not completely
imaged. Please note that other forms of liver disease such as
significant hepatic fibrosis and cirrhosis cannot be excluded on
the basis of this examination.
.
[**2122-12-31**] 03:14PM BLOOD CK(CPK)-8545*
[**2123-1-1**] 05:14AM BLOOD ALT-78* AST-181* LD(LDH)-373*
CK(CPK)-6941* AlkPhos-101 TotBili-1.3
.
[**2123-1-1**] 05:14AM BLOOD Glucose-129* UreaN-2* Creat-0.6 Na-137
K-4.0 Cl-106 HCO3-22 AnGap-13
.
[**2122-12-31**] 12:41AM BLOOD CK-MB-13* MB Indx-1.3 cTropnT-<0.01
[**2122-12-31**] 06:33AM BLOOD cTropnT-<0.01
[**2122-12-31**] 03:14PM BLOOD CK-MB-50* MB Indx-0.6 cTropnT-<0.01
.
[**2123-1-1**] 05:14AM BLOOD WBC-6.5 RBC-4.36* Hgb-13.2* Hct-36.3*
MCV-83 MCH-30.2 MCHC-36.3* RDW-13.1 Plt Ct-176
[**2123-1-1**] 05:14AM BLOOD calTIBC-261 Ferritn-454* TRF-201
Brief Hospital Course:
41 year-old man with history of ETOH abuse presenting with
alcohol intoxication.
.
# ETOH intoxication: He was placed on IVFs, thimaine, folate,
mvi and was monitored on CIWA protocol. There was no evidence
of withdrawal while inpatient. He will follow up with his PCP
and for referral to substance abuse counseling.
.
# Tachycardia/TWI: Noted to have sinus tachycardia to the 150s
in the ED. He received aggressive IVFs and repeat EKG revealed
sinus rhythm at a rate of 90s. Additionally, EKG revealed TWI
in V2-V3. He had no chest pain, shortness of breath, nor
hypoxia to have suggested PE. Furthermore, cardiac enzymes were
negative x 3 to r/o ischemia as a cause of TWI.
.
# CK elevation/rhabdo: CK peaked at 8545 and then began trending
downward with continued aggressive IV fluids. His creatinine
improved from 1.2 on admission to 0.6 on day of discharge.
.
# Distended gallbladder: Radiologic finding on CT abdomen
without evidence of pathology on physical exam. RUQ U/S was
obtained and showed no evidence of cholecystitis nor
cholelithiasis.
.
# Anemia: MCV normal. Guaiac negative. Likely element of
hemodilution given IVFs for rhabdomyolysis. This should be
followed as an outpatient.
.
# Transaminitis: Likely secondary to his EtOH consumption given
history and ratio of AST:ALT. RUQ U/S revealed evidence of
fatty liver. Coags were normal as was his albumin. This, too,
should be followed as an outpatient.
Medications on Admission:
Percocet prn from his girlfriend (for his knee pain)
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication
Rhabdomyolysis (peak CK 8600)
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed.
You should follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 4656**]
your kidneys and liver within the next week.
You had an ultrasound that may show fatty liver, this is likely
from drinking too much alcohol. You should refrain from drinking
alcohol
Followup Instructions:
Follow up with your PCP within one week as above.
|
[
"305.00",
"728.88",
"276.51",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6860, 6866
|
5010, 6446
|
334, 341
|
6961, 6968
|
2803, 3852
|
7342, 7395
|
2068, 2090
|
6549, 6837
|
6887, 6940
|
6472, 6526
|
6992, 7319
|
2105, 2784
|
277, 296
|
369, 1681
|
3861, 4987
|
1703, 1839
|
1855, 2052
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,353
| 152,385
|
52577
|
Discharge summary
|
report
|
Admission Date: [**2165-9-2**] Discharge Date: [**2165-9-28**]
Date of Birth: [**2101-6-19**] Sex: M
Service: SURGERY
Allergies:
Benadryl / Morphine
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Infected femoral-femoral bypass graft
Major Surgical or Invasive Procedure:
Placement of right axillary to right profunda to below-knee
popliteal vein graft bypass, excision of left-to-right
femoral-femoral polytetrafluoroethylene graft, patch angioplasty
of right common femoral artery using bovine patch, placement of
vacuum-assisted closure dressing in right groin wound.
History of Present Illness:
64 yo male w/ significant history of PVD, s/p axillary bifemoral
bypass, R PFA to BK popliteal bypass, and L SFA to AK bypass,
who presented to [**Hospital1 18**] on [**9-2**] with fever and non-healing right
groin wound, with exposed fem-fem PTFE graft.
Past Medical History:
1. Coronary artery disease: Myocardial infarction in [**2155**],
MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous
RCA stent patent at that time.
2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**]
to 25%
3. Diabetes greater than 20 years; with triopathy.
4. Hypertension.
5. End stage renal disease on hemodialysis, q. Monday,
Wednesday and Friday via right arteriovenous fistula.
6. Hypothyroidism.
7. Chronic obstructive pulmonary disease.
8. Hepatitis C.
9. Chronic pancreatitis.
10. Peptic ulcer disease.
11. Right perinephric hematoma; status post embolization.
12. Obstructive sleep apnea on CPAP.
13. Ruptured right groin abscess; recurrent right groin
abscess in [**2162-12-4**].
14. Peripheral vascular disease.
15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein
16. Status post 2nd and 3rd toe amps
17. Status post left CFA to AK [**Doctor Last Name **] with PTFE
18. Status post L inguinal hernia repair
19. Status post umbilical hernia repair
20. Ischemic left foot
21. A - Fib
Social History:
Social: [**Location (un) 686**], lives with wife, has older children, tob: 1
ppd x 60 yrs. quit 3 months ago, no EtOH
Family History:
Non contributary
Physical Exam:
alert, oriented, comfortable, well-nourished appearing
chest clear bilaterally
RRR
Abdomen soft, nontender
R groin w/ open wound, exposed graft, no purulence or discharge
Brief Hospital Course:
As above, Mr. [**Known lastname 91245**] presented to [**Hospital1 18**] on [**9-2**] with exposed
PTFE graft from his femoral-femoral bypass on [**9-2**] in stable
condition. He began to spike high fevers. Cultures were
obtained which grew out Pseudomonas sensitive only to tobramycin
and Klebsiella sensitive to meropenem from his right groin
wound. He was also found to have klebsiella and pseudomonas in
his blood. The infectious disease team was consulted and he was
started on Tobramycin, Meropenem, and Vancomycin. He would
remain on this antibiotic regimen for most of his hospital stay,
and he would remain in stable condition. He continued with
dialysis three times weekly. On [**9-19**], Mr. [**Known lastname 91245**] [**Last Name (Titles) 1834**] a
Placement of right axillary to right profunda to below-knee
popliteal vein graft bypass, excision of left-to-right
femoral-femoral polytetrafluoroethylene graft, patch angioplasty
of right common femoral artery using bovine patch, placement of
vacuum-assisted closure dressing in right
groin wound. He tolerated the procedure well. Post-operatively
he would remain in stable condition on the same antibiotic
regimen. His wound vac was changed every three days and his
surgical wound sites were changed daily. Culture of his graft
from the operating room grew out three different kinds of
pseudomonas- two of which were susceptible to tobramycin, and
one of which sensitive to zosyn, but resistant to tobramycin.
His antibiotic regimen was then adjusted to tobramycin, zosyn,
and vancomycin. He will continue that antibiotic regimen for
six weeks from [**9-25**]. He was discharged to rehab on [**9-28**] in
stable condition.
Discharge Medications:
1. Zosyn 2.25 g Recon Soln Sig: One (1) Intravenous twice a
day for 6 weeks: Please continue six weeks from [**9-25**].
2. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO BID (2 times 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. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp < 100.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for SOB.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
19. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday): hold for sbp < 100.
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp < 100 or hr < 60. Tablet(s)
21. Tobramycin 180 mg IV QHD
please draw peak level 1 hr after next dosing
22. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
23. Dilaudid 1 mg/mL Solution Sig: 0.5-1 Injection q 2-4 hrs
prn as needed for pain: hold for sedation or RR < 10.
24. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Infected femoral-femoral polytetrafluoroethylene graft.
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed
Please take all medications as prescribed. Seek medical
attention if you experience fever, chills, nausea, vomiting,
increased pain, significant bleeding, or shortness of breath.
Please take all medications as prescribed. Seek medical
attention if you experience fever, chills, nausea, vomiting,
increased pain, swelling, or bleeding.
Please seek medical attention if you experience hearing loss or
disturbances, as the tobramycin you are taking could lead to
this problem.
Please take all medications as prescribed. Seek medical
attention if you experience fever, chills, nausea, vomiting,
increased pain, significant bleeding, or shortness of breath.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2165-10-22**]
10:30
Please call Dr.[**Name (NI) 7257**] office at [**Telephone/Fax (1) 2395**] within the
first few days following discharge to schedule a follow-up
appointment
Please contact medical attention if you experience hearing loss
(tobramycin may lead to hearing disturbance), fever, chills,
nausea, vomiting, increased pain, or significant bleeding
|
[
"E849.7",
"250.60",
"E849.8",
"428.0",
"425.4",
"070.70",
"414.01",
"362.01",
"996.62",
"E878.2",
"309.0",
"250.50",
"041.3",
"496",
"250.40",
"998.83",
"041.85",
"427.31",
"403.91",
"041.19",
"585.6",
"583.81",
"440.20",
"790.7",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.29",
"38.93",
"93.59",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
6435, 6507
|
2375, 4077
|
316, 617
|
6607, 6614
|
7365, 7875
|
2147, 2165
|
4100, 6412
|
6528, 6586
|
6638, 7342
|
2180, 2352
|
239, 278
|
645, 901
|
923, 1995
|
2011, 2131
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,123
| 114,383
|
3582
|
Discharge summary
|
report
|
Admission Date: [**2199-7-4**] Discharge Date: [**2199-7-24**]
Date of Birth: [**2125-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
Intubation
PICC line placed on [**7-8**]
History of Present Illness:
This is a 74 y.o. female with diabetic neuropathy and chronic
lower extremity edema who was evaluated and treated in the ER on
[**6-26**] for lower extremity cellulitis. At that time she was
discharged on 2 week regimen of PO Augmentin. She was readmitted
today since her symptoms did not improve on this regimen. She
denies any fevers or chills. She reports ulceration and purulent
drainage from ulcers. She denies any pain but reports that her
sensation is markedly decreased in her lower extremities due to
neuropathy. She denies any nausea, vomitting, diarrhea,
abdominal pain, chest pain or shortness of breath.
Past Medical History:
Chronic atrial fibrillation.
Colon cancer [**2187**] s/p colectomy, treatment with 5-FU, in
remission since.
DM-II x 10 years, has peripheral neuropathy,
microalbuminuria. Most recent Hgb A1c 6.2 in [**10-6**].
HTN
Hyperlipidemia
PVD s/p bilateral fem [**Doctor Last Name **] bypasses
Bilateral cataracts
Obstructive sleep apnea
Urge incontinence
Social History:
Patient is retired and formerly worked at [**Location (un) 8599**]Hospital
in
computers. She has never married and currently lives alone in
senior housing in [**Location (un) 686**]. She has several close friends
that help her with her shopping and getting to appointments.
She has a remote smoking and alcohol history (puffed an
occasional cigarette in social gatherings 50 years ago) denies
any illict drug use.
Family History:
Brother - liver cancer.
Sister - colon cancer.
Physical Exam:
Vitals:BP:160/64 HR:86 RR:20 Tc:98.8 O2Sat:98.8
General:A&O x3, NAD
HEENT:EOMI, Sclera anicteric, MMM, no rhinorrhea or epistaxis,
clear oropharynx.
Neck:Supple, no JVD
Chest: Lungs CTAB, no wheezes, rales or rhonchi
Cardiovascular: RRR, nl S1 and S2, no M/G/R
Abdomen: Soft, NT, ND, +BS, no HSM
Extremities: +1 pitting edema bilaterally. Sensation decreased
bilaterally. Bilateral lower extremity stasis changes and
erythema/warmth overlying anterior legs bilaterally. Ulcerations
present between 1st and 2nd interdigital spaces and on anterior
shin.
Pertinent Results:
[**2199-7-8**] 05:35AM BLOOD WBC-12.8* RBC-3.12* Hgb-8.1* Hct-24.0*
MCV-77* MCH-25.8* MCHC-33.5 RDW-15.4 Plt Ct-276
[**2199-7-9**] 01:00AM BLOOD PT-14.1* PTT-117.7* INR(PT)-1.3*
[**2199-7-8**] 05:35AM BLOOD Glucose-83 UreaN-36* Creat-1.5* Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
[**2199-7-8**] 05:35AM BLOOD Calcium-8.8 Phos-5.2* Mg-2.3
[**2199-7-7**] 05:35AM BLOOD TSH-2.5
[**2199-7-7**] 05:35AM BLOOD Free T4-1.2
[**2199-7-8**] 05:35AM BLOOD Digoxin-1.2
.
Echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The right ventricular cavity is dilated. Right
ventricular systolic function is normal. [Intrinsic right
ventricular systolic function is likely more depressed given
the severity of tricuspid regurgitation.] The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) 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.
Compared with the prior study (images reviewed) of [**2198-1-4**]
estimated
pulmonary artery systolic pressure is now higher.
.
CXR [**7-19**]:
1. Increased interstitial markings, nonspecific in appearance.
Differential diagnosis includes CHF or other interstitial
processes. The appearance is likely accentuated by low
inspiratory volumes.
2. Bibasilar atelectasis and small effusions. An early
infiltrate would be difficult to exclude in this setting.
3. There has been some interval clearing of the left base
compared with [**2199-7-17**]. Otherwise, no significant change is
identified.
4. PICC line tip difficult to visualize.
3. ET tube and NG tube removed compared with [**2199-7-17**].
Brief Hospital Course:
74 yo F with DM, HTN, AFib presents with LLE cellulitis,
refractory to oral Abx.
.
#. Respiratory distress/decreased oxygen saturation: Pt noted to
have decreased oxygendation saturations on HD #[**1-5**], dropping
into the 70s while on RA with improvement to the 90s on oxygen.
On HD #6, pt was sent to the ICU for hypoxia and for initiation
of BiPAP with the thought that OSA was contributing to the
hypoxia. During her ICU stay, pt developed worsening hypoxia.
She was initially treated empirically for a PE with a heparin
drip but this was stopped after a VQ scan was low probability.
Due to increasing hypoxia and resp distress, she was intubated.
due to CHF, aspiration pneumonia and OSA. She was diuresed with
a lasix drip, treated with cipro and vancomycin for possible
aspiration pneumonia and she was successfully extubated on HD#14
after eight days. She did well and was sent to the floor. On
the floor, she still required 6L of O2 to maintain sats in the
low 90s. She continued to be diuresed with 80mg of IV lasix [**Hospital1 **]
but when her urine output dropped, Diuril was added to the
lasix, 30 minutes before. Her BP was controlled as below. She
diuresed 1-1.5L per day and her creatinine remained stable at
her baseline of 1.5-1.7. She should continue to be diuresed with
lasix and diuril to maintain goal of 1L negative per day. She
was treated with 14 days of vanc and 10 days of cipro for her
aspiration PNA.
.
# Obstructive Sleep apnea: Pt had been on CPAP 3 years ago but
discontinued due to repeatedly having to take the mask off at
night due to urinary incontinence and repeated trips to the
bathroom. As above, it was thought that OSA was contributing to
her hypoxia but she was not tried on BiPAP while in ICU. We
attempted to try mask on the floor but she did not tolerate. Pt
would benefit from additional sleep study testing as an
outpatient.
.
# Hypertension: Pt's BP was difficult to control in the
hospital. She cannot tolerate beta blockers due to bradycardia.
She was continued on diltiazem, norvasc, lisinopril and
hydralazine. Her hydralazine was discontinued due to poor
outpatient choice for BP control and clonidine patch was
started. Due to bradycardia, her diltiazem was decreased to
60mg qid and clonidine patch increased. She tolerated these
adjustments well and her BP was stable in the 130s/80s.
.
# Afib: Pt is chronically in afib but has refused
anticoagulation. She is very well rate controlled on calcium
channle blocker. Her digoxin was stopped as it was thought that
is was not needed for rate control and is not indicated for her
diastolic heart failure.
.
# Cellulitis: Cellulitis not resolving with outpatient PO
amoxicillin/clavulanate. Pt. is afebrile, hemodynamically
stable, with white count trending upwards. Wound Cx positive for
and treated for Pseudomonas sensitive to Ciprofloxacin.
Bilateral LE US to r/o DVT was negative. She was treated for 10
days with ciprofloxacin. Podiatry followed patient while in
house.
.
#. Acute on chronic renal failure: On admission, creatinine
increased to 1.5 from baseline of 1.3-1.4. This increased to
2.0 and her lasix was held due to thought of volume depletion.
With some fluids and holding renally cleared meds, creatinine
stabilized to 1.5-1.6. This remained stable even with
reinitiation of lasix and ACE. She likely requires a higher
creatinine to maintain euvolemic state.
.
# DM: Pt with some episodes of asymptomatic hypoglycemia while
in house. Her 70/30 was titrated to decrease hypoglycemia.
.
#. Urinary incontinence: Foley was kept in to watch I2 and Os
carefully. Oxybutynin was stopped due to foley and incidence of
orthostatic hypotension.
.
# Diarrhea: cdiff negative. Likely due to antibiotic associated
diarrhea.
.
#. Anemia: Stable at 27-28.
.
# Acccess: PICC placed on [**2199-7-8**]
.
Code status: Full Code
Medications on Admission:
ASPIRIN 81MG daily
COLACE 100MG daily
DIGOXIN 250MCG daily
DITROPAN XL 15MG daily
GLIPIZIDE 2.5 mg daily
LASIX 20 mg daily
LIPITOR 10 mg daily
LISINOPRIL 40MG daily
MULTIVITAMIN daily
NORVASC 10 mg
NOVOLIN 70/30 30u am, 24u pm
NOVOPEN 3
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clotrimazole 1 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H PRN ().
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Chlorothiazide 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): give 30 minutes prior to lasix.
11. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
12. Diltiazem HCl 240 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO once a day.
13. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge
Sig: as directed units Subcutaneous twice a day: 20U qam, 15U
qpm.
14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed units Subcutaneous four times a day: per sliding scale.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
16. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
[**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary Diagnosis:
1. diastolic heart failure
2. aspiration pneumonia
3. Pseudomonas cellulitis
4. Acute on chronic renal failure
5. Obstructive sleep apnea
6. Antibiotic associated diarrhea
7. Anemia of chronic disease
8. Hypertension
Discharge Condition:
Stable, afebrile, tolerating po, satting 100% on 6L
Discharge Instructions:
You were admitted with cellulitis and had several problems with
your breathing due to fluid in the lungs and pneumonia.
Please watch your salt intake and weight yourself every day.
Call your physician if your weight increased by more than 2lbs
in one day.
Please contact your physician or return to the Emergency
Department if you notice fevers > 101.5, chest pain, shortness
of breath, worsening of the leg rash, or any other worrisome
symptoms.
Followup Instructions:
Please follow up with your primary care provider [**Name Initial (PRE) 176**] 1 week.
Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**]
Completed by:[**2199-7-24**]
|
[
"443.9",
"327.23",
"507.0",
"V10.00",
"427.31",
"787.91",
"428.31",
"041.7",
"459.81",
"V58.67",
"357.2",
"518.81",
"403.91",
"682.6",
"285.29",
"707.15",
"V45.3",
"519.4",
"707.13",
"250.60",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.04",
"99.04",
"93.90",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10123, 10220
|
4496, 8355
|
324, 367
|
10500, 10554
|
2468, 4473
|
11051, 11288
|
1832, 1880
|
8642, 10100
|
10241, 10241
|
8381, 8619
|
10578, 11028
|
1895, 2449
|
274, 286
|
395, 1013
|
10260, 10479
|
1035, 1383
|
1399, 1816
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,025
| 161,338
|
6175
|
Discharge summary
|
report
|
Admission Date: [**2153-12-13**] Discharge Date: [**2153-12-19**]
Date of Birth: [**2077-11-3**] Sex: M
Service: O-MED
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
gentleman with a history of advanced pancreatic cancer with
known pancreatic head mass - status post stenting on [**2153-11-26**] with a metal stent in the major papilla and a
plastic stent in the biliary duct which has since been
removed and a metal stent in the common bile duct within
which a coated stent was placed on the day of admission. The
patient also with known liver metastasis. The patient was
admitted for the sudden onset of fever following stent
intervention associated with an acute-on-chronic band-like
pain across his abdomen and a new pain in his right upper
quadrant.
The patient denies nausea or vomiting. He reports that he
has been eating well. No diarrhea, but a lot of gas and
stool today. The patient received ampicillin, Levaquin, and
Flagyl in the Emergency Department and one liter of
intravenous fluids. The patient states that he feels better
and only has pain when palpated in the right upper quadrant.
Per the Emergency Department, the ERCP fellow had been
[**Name (NI) 653**], and the plan was for endoscopic retrograde
cholangiopancreatography in the morning.
PAST MEDICAL HISTORY:
1. Metastatic pancreatic cancer (on Xeloda); status post
gemcitabine. Known liver metastases. Admitted from [**11-23**] to [**2153-11-28**] for ascending cholangitis.
2. History of ascending cholangitis; status post endoscopic
retrograde cholangiopancreatography with stent on [**2153-11-26**].
3. Coronary artery disease; status post percutaneous
transluminal coronary angioplasty.
4. Hypercholesterolemia.
5. Status post hemorrhoidectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
FAMILY HISTORY: Positive family history of gastric cancer.
SOCIAL HISTORY: The patient is married with three daughters.
[**Name (NI) **] denies alcohol use. He smoked for one year [**80**] years. He
is retired from [**Company 22916**]. He immigrated from [**Location (un) 4708**] 40
years ago.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed his temperature was 103.3 degrees Fahrenheit, his
heart rate was 108 (ranging from 108 to 118), his blood
pressure was 104/64, his respiratory rate was 22, and his
oxygen saturation was 95% on 2 liters. In general, the
patient was in no apparent distress. He was cachectic.
Found up brushing his teeth and cleaning up prior to his
endoscopic retrograde cholangiopancreatography. Head, eyes,
ears, nose, and throat examination revealed the extraocular
movements were intact. The oropharynx was clear. The mucous
membranes were moist. Cardiovascular examination revealed
tachycardia with a regular rhythm. No murmurs, rubs, or
gallops. Pulmonary examination revealed the lungs were clear
to auscultation bilaterally. Abdominal examination revealed
normal active bowel sounds. The abdomen was soft. Very
tender focally to palpation of the epigastric region.
Extremity examination revealed no clubbing, cyanosis, or
edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission white
blood cell count was 19.5. His hematocrit was 27.6. His INR
was 1.4. Alanine-aminotransferase was 81, aspartate
aminotransferase was 96, alkaline phosphatase was 339, and
his total bilirubin was 0.7. Blood cultures revealed no
growth.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
abdomen and pelvis revealed increased liver metastases,
increased pancreatic head mass, old dilated pancreatic duct
with stent to pancreatic duct in place, left liver
pneumobilia (old). New splenic masses; question of
metastatic disease. No abscess.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is a 76-year-old gentleman with a history of advanced
pancreatic cancer with known liver metastases - on Xeloda
with known progression of disease. The patient was admitted
with fevers, chills, and increased abdominal pain following
stent intervention; likely ascending cholangitis.
1. CHOLANGITIS ISSUES: The patient admitted with fevers,
chills, and right upper quadrant pain with a recent history
of admission for ascending cholangitis; likely again an
infectious process within the liver as the patient
immediately started on ampicillin, levofloxacin, and Flagyl
with a plan for endoscopic retrograde
cholangiopancreatography in the morning.
An endoscopic retrograde cholangiopancreatography was
attempted with no epigastric output obstruction secondary to
the tumor. The scope was unable to be passed beyond the
tumor, and this intervention resulted in a significant amount
of bleeding.
The patient's course was thus complicated by an admission to
the Surgical Intensive Care Unit for a gastrointestinal
bleed. While in the Medical Intensive Care Unit, the
patient's antibiotics were changed to meropenem and
levofloxacin. The patient was ultimately discharged on by
mouth levofloxacin alone for a total of seven days with
instructions to fill his prescription for an additional 14
days if he again spiked a fever of greater than 101 degrees
Fahrenheit.
2. GASTROINTESTINAL BLEED ISSUES: The patient developed a
gastrointestinal bleed following endoscopic retrograde
cholangiopancreatography; during which endoscopic retrograde
cholangiopancreatography was prematurely held secondary to
gastric outlet obstruction and inability to pass the scope
with a notation made of oozing and bleeding at the
obstruction site. Upon return to the floor, the patient
received a nasogastric tube as requested by the ERCP fellow.
Nasogastric tube suctioning produced multiple clots. The
patient then passed multiple bloody bowel movements.
Discussions with family confirmed the patient remained a full
code despite his dismal prognosis. Thus, the Surgical
Intensive Care Unit team was consulted with a plan to
transfer to the Surgical Intensive Care Unit. The patient
was started on octreotide ad received a total of 3 units of
packed red blood cells while in the Intensive Care Unit. The
patient also received vitamin K for a supratherapeutic INR.
He subsequently stabilized and was weaned off octreotide. He
received a total of 4 units of packed red blood cells.
The patient was thus transferred back to the floor, and his
hematocrit remained stable prior to discharge.
3. PANCREATIC CANCER ISSUES: The patient previously on
Xeloda. This was held while in house. The patient was to
follow up with Dr. [**First Name (STitle) **] for continued care.
4. DUODENAL OBSTRUCTION ISSUES: The patient was noted to
have gastric outlet obstruction on endoscopic retrograde
cholangiopancreatography soon after admission. Thus, he was
kept nothing by mouth. His diet was subsequently advanced.
He tolerated clears and was advanced to full liquids. He was
discharged with instructions to restrict himself to a full
liquid diet as tolerated.
5. PAIN ISSUES: The patient was admitted on by mouth
morphine as needed. A Fentanyl transdermal patch was started
and titrated up to reduce his need for as needed medication.
The patient was also ultimately discharged on Fentanyl patch
100 mcg transdermally once per day with a prescription for
Dilaudid 2 mg to 4 mg by mouth q.4h. as needed.
6. CORONARY ARTERY DISEASE (STATUS POST PERCUTANEOUS
TRANSLUMINAL CORONARY ANGIOPLASTY) ISSUES: Initially, the
patient's Procardia was held secondary to a gastrointestinal
bleed. However, this medication was restarted at the time of
discharge.
DISCHARGE DIAGNOSES:
1. Cholangitis.
2. Metastatic pancreatic cancer.
3. Partial duodenal obstruction.
CONDITION AT DISCHARGE: Condition on discharge was fair.
Temperature maximum overnight was 100.2 degrees Fahrenheit.
Prior to discharge tolerating a full liquid diet and pain
well controlled.
DISCHARGE STATUS: The patient was to be discharged to home
with services.
MEDICATIONS ON DISCHARGE:
1. Colace 150 mg liquid by mouth twice per day as needed
(for constipation).
2. Dilaudid 2 mg to 4 mg by mouth q.4h. as needed (for
pain).
3. Bimatoprost 0.03% drops one ophthalmic drop at hour of
sleep.
4. Fentanyl patch 75-mcg per hour plus fentanyl 25 mcg per
hour transdermally q.72h.
5. Senna 17.2 mg by mouth twice per day as needed (for
constipation).
6. Protonix 40 mg by mouth once per day.
7. Procardia-XL 30 mg by mouth once per day.
8. Levofloxacin 500 mg by mouth once per day (times seven
days).
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name (STitle) **] for continued care.
[**First Name11 (Name Pattern1) 396**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9758**]
Dictated By:[**Name8 (MD) 14337**]
MEDQUIST36
D: [**2154-3-19**] 20:08
T: [**2154-3-21**] 19:19
JOB#: [**Job Number 24104**]
|
[
"197.7",
"276.5",
"287.5",
"998.11",
"157.0",
"537.0",
"286.7",
"576.1",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"99.04",
"44.13"
] |
icd9pcs
|
[
[
[]
]
] |
1852, 1896
|
7579, 7675
|
7961, 8480
|
1835, 1835
|
8514, 8907
|
3802, 7558
|
7690, 7935
|
165, 1299
|
1321, 1808
|
1913, 3767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,952
| 107,580
|
5059
|
Discharge summary
|
report
|
Admission Date: [**2126-7-10**] Discharge Date: [**2126-7-14**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
coma, glucose 22, seizure activity
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The pt is a 55-yo man, Type 1 Diabetic with frequent
hypoglycemic episodes, ERSD, and HTN, who was found unresponsive
in the waiting room at Josline Diabetes Center. He had a FSBS of
20 on the scene, and was given Glucagon and 1 amp of D50 without
effect on his mental status. He was brought to the [**Hospital1 18**] ED,
where his FSBS was 150s-170s, but he remained unresponsive (GCS
3). He proceeded to develop seizure-like activity including
tonic movements of his abdominal muscles and limbs. Head CT at
the time was normal, and he was intubated for airway protection.
Labs revealed renal failure with Cr 5.5, hyperkalemia (K 6.2),
and negative serum and urine tox screens. Studies were otherwise
normal, including ECG, CXR, and UA. VS in the ED - afeb
(normothermic), BP 107/66, HR 55, O2-sat 100% on CMV -
500x14/5/100% FiO2. He is admitted to the ICU for further care.
In the ICU: Pt was found to be hypothermic to 93 F, with
continued seizure-like activity of the extremities. He was
placed on a bear-hugger, but he remained unresponsive to any
stimulation. Given his fluctuating neurological exam, the pt was
sent for a repeat Head CT, which was unchanged.
Past Medical History:
1 DM1 X 37 yrs- frequent hypoglycemic episodes; high level of
anti-insulin Ab
- followed by Dr.[**Doctor Last Name 4849**] of [**Last Name (un) **]
- complicated by nephropathy, retinopathy (s/p right eye laser
surgery, repeated [**8-3**])
2 ESRD [**12-29**] DM1
3 Hypertension
4 Anemia, likely [**12-29**] CRI
5 Hyperuricemia
6 Graves' disease
7 Hyperlipidemia
8 Diastolic congestive heart failure with LVH
Social History:
Lives with parents. Works in construction. No alcohol, drugs, or
tobacco.
Family History:
Occupation: Lives with parents. Works in construction.
Drugs: None
Tobacco: None
Alcohol: None
Physical Exam:
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 37 ??????C (98.6 ??????F)
HR: 73 (54 - 73) bpm
BP: 147/83(98) {103/55(69) - 147/83(98)} mmHg
RR: 9 (9 - 15) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 75 kg (admission): 75 kg
Height: 68 Inch
General Appearance: intubated, sedated, unresponsive off
sedation
Eyes / Conjunctiva: pupils constricted, minimally responsive to
light, no nystagmus noted
Head, Ears, Nose, Throat: nec supple, no LAD
Cardiovascular: RRR, nl S1-S2, no MRG
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present), cool, no c/c/e
Respiratory / Chest: CTA bilat, no r/rh/wh
Abdominal: NABS, soft/NT/ND, no masses or HSM
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Responds to: Unresponsive, Movement: No spontaneous
movement, Sedated, Tone: Not assessed, hyper-reflexia
throughout, up-going toes bilaterally
Pertinent Results:
[**2126-7-13**] 05:30AM BLOOD WBC-5.7 RBC-3.08* Hgb-8.5* Hct-24.9*
MCV-81* MCH-27.4 MCHC-34.0 RDW-14.1 Plt Ct-191
[**2126-7-11**] 05:28AM BLOOD Neuts-78.9* Lymphs-14.6* Monos-4.7
Eos-1.3 Baso-0.4
[**2126-7-11**] 05:28AM BLOOD PT-12.7 PTT-28.0 INR(PT)-1.1
[**2126-7-10**] 07:25PM BLOOD Fibrino-501*
[**2126-7-13**] 05:30AM BLOOD Glucose-170* UreaN-72* Creat-5.3* Na-139
K-4.3 Cl-104 HCO3-25 AnGap-14
[**2126-7-11**] 05:28AM BLOOD ALT-34 AST-26 LD(LDH)-292* CK(CPK)-278*
AlkPhos-79 Amylase-105* TotBili-0.3
[**2126-7-13**] 05:30AM BLOOD Albumin-3.4 Calcium-8.6 Phos-4.5 Mg-2.2
[**2126-7-11**] 03:16PM BLOOD VitB12-1027*
[**2126-7-11**] 05:28AM BLOOD TSH-1.5
[**2126-7-11**] 05:28AM BLOOD TSH-1.5
[**2126-7-11**] 05:28AM BLOOD Cortsol-14.7
[**2126-7-12**] 06:24AM BLOOD Phenyto-9.3*
STUDIES:
Renal U/S: Mildly increased cortical echogenicity with no
hydronephrosis and no stones or solid masses
Noncon CTH: No evidence of swelling or infarction. If there is
concern for anoxic brain injury, MR is far more sensitive than
CT
EEG: Markedly abnormal portable EEG due to the very low voltage
background throughout the recording. This suggests a widespread
encephalopathy. Anoxia and medications are two of the most
common
explanations. There were no epileptiform features. The
persistent beta frequency activity suggests some influence of
medication.
CXR: ET tube positioned at/immediately above the carina.
Retraction by at least 3 cm is advised. NG tube in appropriate
position. No acute intrathoracic process.
Brief Hospital Course:
Mr. [**Known lastname **] is a 55 year old gentleman with a PMH significant for
type 1 diabetes, autoimmune antibodies to the insulin receptor,
ESRD, HTN, and CHF admitted for seizure secondary to
hypoglycemia with hospital course significant for MICU admission
with intubation for airway protection.
1. Diabetes Type 1 Uncontrolled with complications: Patient has
type 1 diabetes as well as insulin autoantibody that causes
frequent hypoglycemic episodes with multiple admissions for
similar presenting symptoms. The patient had stable blood
glucose levels on his home regimen of lantus 3 units [**Hospital1 **] and
HISS ([**First Name8 (NamePattern2) **] [**Last Name (un) **]). During the patient's hospitalization,
endocrinology and rheumatology were consulted regarding the
patient's condition. [**First Name8 (NamePattern2) **] [**Last Name (un) **] consultation recommendations,
insulin antibodies, as well as a SPEP and UPEP were sent off
during this admission and will be followed by the patient's
diabetologist. On discharge, the patient was instructed to
continue his home regimen and a prescription for an emergency
glucagon kit was provided. He was instructed to follow-up with
his endocrinologist at the [**Hospital **] Clinic as well as rheumatology
with Dr. [**Last Name (STitle) 20861**].
2. Seizures/Altered mental status: The inciting event most
likely hypoglycemia, as the patient has multiple admissions with
similar presentations. His altered mental status during his
initial presentation was likely multifactorial including post
ictal state, hypothermia, hypoglycemia, and uremia. The patient
did have a CT head that was unchanged and an EEG that
demonstrated encephalopathy. Neurology was consulted during the
patient's admission. On transfer to the general medicine floor,
the patient was mentating well without significant neurologic
abnormalities. On discharge, he continued to mentate well
without signs of altered mental status.
3. Renal failure: The patient has baseline ESRD. He has been
followed by Dr.[**Name (NI) 4849**] at the [**Hospital **] Clinic, and also evaluated
by renal transplant. During the patient's hospitalization, he
was started on nephrocaps, and renal was consulted with regard
to continuity on an outpatient basis. On discharge, the patient
was instructed to follow-up with Dr.[**Name (NI) 4849**] as well as renal
transplant clinic (Dr. [**Last Name (STitle) 816**]
4. SPEP: On the day after discharge, the patient had a IgM
monoclonal spike on SPEP to 368. The patient will require
referral to heme/onc for further evaluation and monitoring.
5. Prophylaxis: Patient was treated with heparin SQ during his
hospital admission for DVT prophylaxis.
6. Follow-up: The day after discharge, the patient was scheduled
with numerous follow-ups as stated below:
[**7-17**] at 11:30 AM: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Hospital **] Clinic
(Endocrinology).
[**7-18**] at 8:30 AM: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Hospital **] Medical
Building, [**Location (un) 436**] (Renal [**Hospital 1326**] Clinic).
[**7-24**] at 1:30 PM: Dr.[**Name (NI) 4849**] at the [**Hospital **] Clinic
(Nephrology).
[**8-2**] at 11:20 AM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP at [**Hospital6 2399**], [**Hospital Ward Name 23**] Clinical Center [**Location (un) **], South suite
(Primary Care).
[**8-8**] at 9:00 AM: Dr. [**First Name (STitle) 20862**] [**Name (STitle) 20863**] at the [**Hospital **]
Medical Building, [**Location (un) **] (4B) (Rheumatology).
Medications on Admission:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
5. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Lantus 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous twice a day: SQ once in AM and once in PM, spaced
12 hours apart.
12. Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous
four times a day: Please use sliding scale as provided by
Diabetes doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
13. Glucagon (Human Recombinant) 1 mg Kit Sig: One (1)
Injection as needed: Please use as needed for hypoglycemia.
Disp:*5 5* Refills:*0*
14. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
three times a day: with meals.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO Every other
day.
5. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO twice a day.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Insulin Glargine 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous twice a day.
12. Insulin Lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: Please use sliding scale as
provided by
Diabetes doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]. .
13. Glucagon Emergency 1 mg Kit Sig: One (1) Injection kit: Use
as needed for hypoglycemia.
14. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
16. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
18. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Seizure
2. Diabetes, type I
Secondary
ESRD [**12-29**] DM1
Hypertension.
Hyperuricemia.
Graves' disease.
Diastolic congestive heart failure with LVH
Discharge Condition:
Patient discharged in stable condition.
Discharge Instructions:
1. You were admitted for a seizure, which was due to
hypoglycemia or low blood sugar. While admitted, you were
evaluated by the endocrinologists, who you will have to
follow-up as indicated below.
2. You should continue to take you medications as taken prior to
hospitalization unless otherwise indicated. It is very
important that you take your medications as prescribed.
3. It is very important that you make all of your doctors
[**Name5 (PTitle) 4314**].
4. If you develop a fever, chest pain, shortness of breath,
seizures, or other concerning symptoms, please call your PCP or
go to your local Emergency Department immediately.
Followup Instructions:
Please follow-up with your endocrinologist, Dr. [**Last Name (STitle) 10088**] at the
[**Hospital **] Clinic in 1 week. You can schedule an appointment by
calling ([**Telephone/Fax (1) 17240**].
Please follow-up with your nephrologist, Dr.[**Doctor Last Name 4849**] at the
[**Hospital **] Clinic in 1 week. You can schedule an appointment by
calling ([**Telephone/Fax (1) 817**]
Please schedule an appointment with the renal transplant clinic.
You can schedule an appointment by calling ([**Telephone/Fax (1) 3618**].
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] in [**11-28**] weeks.
You can schedule an appointment by calling ([**Telephone/Fax (1) 1300**].
Completed by:[**2126-7-15**]
|
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icd9cm
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[
[
[]
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[
"96.04",
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icd9pcs
|
[
[
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4675, 6008
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304, 316
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11782, 11824
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,284
| 121,591
|
48612
|
Discharge summary
|
report
|
Admission Date: [**2155-7-19**] Discharge Date: [**2155-7-22**]
Date of Birth: [**2090-10-10**] Sex: F
Service: MEDICINE
Allergies:
fentanyl / Cipro / Pemetrexed
Attending:[**First Name3 (LF) 87302**]
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 y.o female with primary peritoneal carcinoma last round of
Topotecan ending [**2155-7-1**], lung metastases, and recent right
humerus fracture with 2 recent admissions for
cellulitis/dehydration ([**Date range (1) 62150**]/[**2154**]) presenting with
hypotension, decreased p.o intake and mild dyspnea. Her symptoms
have been gradually worsening over the past 2 days, immediately
post discharge.She endorses decreased p.o intake because she
gets "full very quickly." She also had 3-5 episodes of nausea
and bilious non bloody vomiting the last 2 days. These symptoms
were associated with chills and slowed mentation. This afternoon
she was noticed by her family to be less responsive, confused
and have labored breathing. She was brought to the emergency
room for further evaluation.
.
Ms. [**Known lastname **] has had 2 recent admissions (discharged on [**2155-7-9**] and
[**2155-7-17**] from [**Hospital1 18**]) for cellulitis around her peritoneal catheter
site. During the first admission she was started on vancomycin
and discarged on this medication; however, when she was admitted
on [**2155-7-14**], her vanc level was 51.6 and this antibiotic was
discontinued. Patient was discharged on [**2155-7-17**] without
vancomycin.
Patient states that her symptoms of malaise, fatigue, and fever
have increased since her discharge on [**7-17**]. Her symptoms are
associated with chills and slowed mentation. On day of admission
she was found by her family to be less rsponsive, confused, and
with labored breating.
Initial vitals in the ED were: 102, 136 99/71 12 91% RA. Patient
was given Zosyn and Vancomycin, rectal tylenol. She had blood
and urine cultures sent. She was given 2 liters of fluid. A FAST
ultrasound revealed complete collapse of IVC consistent with
hypovolemic shock.
In the MICU patient was in no acute distress. She was given a
total of 8L of fluid over the course of about 24 hours. She was
initially started on azithromycin for atypical lung pathogens
(source of fever had not been entirely elucidated) but this was
stopped. A CXR showed "mediastinal contours are similar in
appearance with a bulging appearance, compatible with known
lymphadenopathy. There is ill definition of the vasculature,
bilateral effusions and bilateral lower lobe volume
loss/infiltrate. The overall impression is that of worsening
CHF. An underlying infectious infiltrate cannot be excluded." A
CT chest was done and is still pending.
On transfer from MICU vitals were: 104, 98/61, 97.9, 26, 98% on
2L NC. Patient was comfortable but with anasarca. Put out about
20-30cc of fluid in the last few hours. Upon arrial to 11R
vitals are: 97.2, 98/60, 95, 18, 95% on 2L. She is comfortable,
surrounded by her family. Alert and oriented. Complains of
banging in her right ear.
ROS: Positive for malaise, fatigue, constipation. Hears banging
in her right ear. Denies headache, chest pain, shortness of
breath, abdominal pain, nausea, vomiting, diarrhea, other other
concerning signs or symptoms.
Review of systems:
Obtained from patient
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. 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.
Past Medical History:
- Primary Peritoneal Carcinoma -- papillary serous
adenocarcinoma
- ([**5-/2152**]) diagnosed stage 4 with malignant ascites, pleural
effusions, and axillary nodes
- lung metastases
-- most recently treated with Topotecan
- Right Humerus Fracture -- recent
-Chronic Kidney Disease -- Stage 3
-Hypertension
-Hypothyroidism
-Asthma
-Mitral Valve Prolapse
-Dupuytren's Disease
- Anemia
-HSV-1 Infection
.
PAST ONCOLOGIC HISTORY:
[**5-17**] Malignant ascites, extensive peritoneal disease, pleural
effusion and axillary nodes, papillary serous ca, stage IV. CA
[**Telephone/Fax (1) 102264**].
[**2152-6-15**] Carboplatin/taxol x 4
[**2152-8-29**] Expl lap, omentectomy, TAH/BSO, appendectomy with
radical debulking, Dr. [**Last Name (STitle) 102265**], with all visible disease
removed or separated from adjacent organs. Pathology showed
papillary serous adenocarcinoma involving omentum and
peritoneum. Tumor involved left ovary and tube as serosal and
surface adhesions, with no parenchymal involvement.
[**2152-9-18**] [**Doctor Last Name **]/taxol x 3. CA 125 5.
[**Date range (1) 102266**] No Chemo.
[**5-18**] CT torso: Stable pulm nodules, none new. Evidence of
recurrent disease as demonstrated by soft tissue thickening and
implants within the pelvis, as well as along the right paracolic
gutter, left upper quadrant, and perihepatic regions. New trace
ascites. Nodule along the wall of the gallbladder may represent
a focal peritoneal implant or gallbladder metastasis. CA125 156.
[**Date range (1) 102267**] Carboplatin/Doxil x 6.
[**2153-6-20**] Avastin added.
[**2153-9-3**] CT Torso: No evidence of residual tumor within the
peritoneal cavity. Interval resolution of the ascites and left
pleural effusion. No evidence of residual left axillary
adenopathy. 3 2-mm nonspecific pulmonary nodules. CA 125=7
[**2153-11-5**] Cycle #6 given without Avastin due to HTN, epistaxis.
[**2153-12-4**] CT Torso:
IMPRESSION: No interval change since [**2153-9-3**].
[**2153-12-11**] Avastin as monotherapy for maintenance - last dose
[**2154-4-3**]
[**2154-3-29**] CT Torso: (CA 125 rising) Mild thickening and narrowing
of the distal ileum which is likely due to contraction. Clinical
correlation is recommended. Otherwise, the study is essentially
unchanged since previous examination.
[**2154-5-20**] CT Torso: New recurrent free fluid in the pelvis. New
and enlarging mesenteric lymph nodes. The largest lymph node
measures 12 mm in the small bowel mesentery within the pelvis.
This was not demonstrated previously. Unchanged small bilateral
pulmonary nodules. CA125 = 359
[**7-19**] Evaluated at [**Hospital1 2025**] for clinical trial but patient declined
participation for fear of alopecia.
[**2154-7-31**] Started gemzar. Tolerated poorly after 3 doses.
[**2154-8-21**] CT Torso: Multiple lung nodules range in size from 2-6
mm in the right and left lung. The largest nodule, in the
lingula, is 6 mm. There is bilateral trace pleural effusion and
minimal basilar atelectasis. Thyroid gland is normal. In
addition to subcarinal 3.8 x 3 cm conglomerate lymph node mass,
enlarged lymph nodes are seen in the precarinal (15 mm), right
lower paratracheal (13.3 mm), left parasternal (12 mm), thoracic
inlet (14 mm right side) and right subclavicular regions (12
mm). Multiple other lymph nodes in the prevascular and
presternal region are less than 10 mm in short axis. Note is
made of diffuse smooth thickening of the lower esophageal wall.
The heart is normal size without pericardial effusion.
Atherosclerotic calcification in the left anterior descending
artery is mild. Abdomen/pelvis: Extensive peritoneal,
mesenteric, and omental metastases. Exam severely limited; no
acute process identified. 2. Sigmoid diverticula. The study and
the report were reviewed by the staff radiologist.
[**2154-8-23**] Abd ultrasound showed ascites not extensive, too little
to tap.[**2154-8-27**] Cardiac echo done for dyspnea. The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. Received 2 u
PC's.
[**Date range (1) 102268**] Weekly taxol, 60 mg/m2 (120 mg) x 3 cycles.
[**2154-11-1**] CT Torso: 1. Significant interval increase in number,
size and extent of innumerable mesenteric, retroperitoneal and
pelvic lymph nodes and omental caking, as described, seen in
association with moderate volume perihepatic and perisplenic
ascites tracking into the dependent recesses of the peritoneal
cavity.
2. Scattered colonic diverticula, none acutely inflamed.
[**2154-11-4**] Start Carboplatin (lifetime dose #14)
[**2154-11-27**] [**Doctor Last Name **] dose #2
[**2154-12-18**] [**Doctor Last Name **] dose #3
[**2155-1-19**] [**Doctor Last Name **] # 4 in FL
[**2155-2-17**] Gemzar in FL, last dose [**2155-2-27**] (reduced by 50%) - No
response, marked myelosuppression.
[**2155-3-21**] Altima dose #1
[**3-28**] Seen for dehydration and drug rash, hydrated, given IV
steroids and benadryl
[**Date range (1) 21715**] Admitted [**Hospital1 18**] for progressive allergic reaction
including essentially erythroderm, fever and rigors, no mucous
membrane involvement. Cultures negative
[**2155-4-11**] Cycle #1 Cytoxan and Doxil
[**2155-4-14**] underwent paracentesis at the [**Hospital1 18**] with removal of 5.3
liters of ascites
[**2155-4-23**] Seen at [**Hospital1 18**] for blood transfusion and orthostatic. Had
been started on Cipro [**4-22**] for UTI and had vomiting and
diarrhea.
[**2155-4-24**] neutropenic. Urine cx with Kleb pneumonie. Given 1 dose
Rocephin and course of Ceftin. Sx resolved.
[**2155-5-1**] Cycle #2 Cytoxan and Doxil with neulasta
[**2155-5-9**] Transfusion 1 unit pRBC at [**Hospital1 18**]
[**2155-5-13**] Paracentesis at [**Hospital1 18**], 5 liters.
[**Date range (3) 102269**] for pain control following a fall resulting in a
comminuted fracture of the right proximal humerus. She was
evaluated by orthopedics and managed conservatively with
non-surgical interventions. She also had a peritoneal drain
placed by IR prior to discharge
[**Date range (3) 102270**] admitted for port-a-cath placement, and received
a chemotherapy [**6-4**] with Topotecan.
[**2155-6-4**] Given #1 Topotecan at dose reduction to 2mg/m2
[**2155-6-12**] Pancytopenic, chemo held
[**2155-6-20**] Topotecan with further dose reduction, Neupogen day
2,3,4
[**2155-6-27**] Topotecan
[**2155-7-14**]- CT abdomen and pelvis w/o contrast New extra-abdominal
metastases noted along the partly visualized right
lower chest wall
[**2155-7-17**]- RUQ u/s with multiple liver metastasis no portal vein
thrombosis
Social History:
Married, husband is very supportive. She is retired from work as
a Phys Ed teacher and team coach. No cigarettes or alcohol
currently.
Family History:
NC
No history of breast or ovarian cancer. Both parents have lived
to advanced ages. Mother died of lung cancer, was a remote
smoker. Her sister died of head and neck cancer, perhaps
related to smoking, at the age of 65. She has several aunts,
all in good health.
Physical Exam:
Admission physical exam:
Vitals: T:99.0 BP:105/60 P:120 R:12 18 O2:96% 2L NC
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally with decreased breath
sounds toward the bases, no wheezes, rales, ronchi
Abdomen: soft, non-tender, distended, bowel sounds present, no
organomegaly . Erythema around LLQ catheter site with associated
rubor outlined by pen approx 7cm-8cm.
GU: foley in place with dark yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2
+edema b/l to the knees.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.Mild asterixis, right
arm in sling.
Pertinent Results:
ADMISSION LABS:
[**2155-7-19**] 08:00PM BLOOD WBC-10.3# RBC-3.80* Hgb-12.0 Hct-35.9*
MCV-95 MCH-31.7 MCHC-33.5 RDW-17.8* Plt Ct-287
[**2155-7-19**] 08:00PM BLOOD Neuts-91* Bands-0 Lymphs-0 Monos-9 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2155-7-19**] 08:00PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL
[**2155-7-19**] 08:00PM BLOOD PT-13.7* PTT-23.7* INR(PT)-1.3*
[**2155-7-19**] 08:00PM BLOOD Glucose-110* UreaN-24* Creat-2.0* Na-130*
K-4.4 Cl-100 HCO3-19* AnGap-15
[**2155-7-19**] 08:00PM BLOOD ALT-21 AST-44* AlkPhos-222* TotBili-0.3
[**2155-7-19**] 08:00PM BLOOD cTropnT-<0.01
[**2155-7-19**] 08:00PM BLOOD Albumin-1.9*
[**2155-7-20**] 04:28AM BLOOD Calcium-7.2* Phos-2.9 Mg-1.5*
[**2155-7-19**] 08:00PM BLOOD Osmolal-268*
[**2155-7-19**] 08:00PM BLOOD TSH-13*
[**2155-7-19**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-7-19**] 07:47PM BLOOD Glucose-89 Lactate-4.4* Na-129* K-4.2
Cl-99 calHCO3-16*
[**2155-7-20**] 12:21AM BLOOD Type-[**Last Name (un) **] pH-7.36
[**2155-7-20**] 12:21AM BLOOD Lactate-1.8 calHCO3-21
[**2155-7-19**] 07:47PM BLOOD Hgb-16.0 calcHCT-48
IMAGING:
CXR [**7-19**]: Mild pulmonary edema and small left pleural effusion.
Possible small right pleural effusion. Unchanged mediastinal
lymphadenopathy.
CT Chest [**2155-7-20**]:
IMPRESSION:
1. Increased size of the bilateral axillary lymph nodes, right
paratracheal
lymph node, and prevascular mediastinal mass, highly concerning
for
progression of disease.
2. Interval development of upper lobe predominant multifocal
patchy
ground-glass and heterogeneous airspace opacities with a
central/paramediastinal distribution. Findings may be related
to an
infection/inflammatory process; however, a neoplastic process
cannot be
excluded in this patient with peritoneal carcinoma and other
findings of
disease progression in the chest.
3. Bilateral lower lobe consolidation is likely related to
subsegmental/compressive atelectasis from bilateral pleural
effusions which
are enlarged since the prior exam. However, underlying
infection is difficult
to exclude.
4. Stable abdominal ascites.
5. Continued thickening of the gastroesophageal junction is
poorly evaluated
in the absence of enteric contrast.
6. Comminuted fracture involving the right proximal humerus
with mild
angulation and displacement may be pathologic. Sclerotic focus
in the
midthoracic spine would be better evaluated with bone scan to
decipher
malignant potential.
Echo [**2155-7-21**]
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is no
ventricular septal defect. with normal free wall contractility.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve is not well seen. The mitral valve
leaflets are not well seen. Mitral regurgitation is present but
cannot be quantified. Tricuspid regurgitation is present but
cannot be quantified. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2154-8-26**], no
major change.
Renal ultrasound [**2155-7-21**]
1. No evidence of hydronephrosis.
2. Redemonstration of hypoechoic hepatic lesions consistent with
metastases.
Moderate ascites.
[**2155-7-22**] 05:24AM BLOOD Glucose-62* UreaN-24* Creat-2.1* Na-127*
K-3.4 Cl-97 HCO3-19* AnGap-14
[**2155-7-22**] 05:24AM BLOOD ALT-18 AST-36 LD(LDH)-684* AlkPhos-236*
TotBili-0.4
[**2155-7-22**] 05:24AM BLOOD Calcium-7.4* Phos-3.2 Mg-2.1
Brief Hospital Course:
64 y.o female with primary peritoneal carcinoma last round of
Topotecan ending [**2155-7-1**], lung metastases, and recent right
humerus fracture with 2 recent admissions for
cellulitis/dehydration ([**Date range (1) 62150**]/[**2154**]) presenting with
hypotension and mild dyspnea.
# Goals of care: Patient became increasingly volume overloaded
and dyspneic after arrival to floor. Diuresis was attempted
without success (see below) due to acute kidney failure. Given
progressive cancer on imaging and poor overall prognosis, goals
of care were discussed with the family and the decision was made
to pursue comfort measures only. Palliative care was involved
and patient was given IV dilaudid and ativan and given
hyoscyamine to manage secretions and zofran for nausea. She
passed away [**2155-7-22**] surrounded by her family.
#Hypotension- Likely sepsis with catheter associated cellulitis
as source with element of volume depletion. Given recent
admission covered with Vancomycin/Zosyn/azithro empirically. Got
3L NS in ED. Systolic blood pressure stable at approx 100 on
admission. In the MICU patient was in no acute distress. She was
given a total of 8L of fluid over the course of about 24 hours.
Obtained blood, peritoneal, and urine cultures which showed no
growth.
#Anion Gap acidosis: likely from lactic acidosis due to
dehyrdation/potential sepsis and concurrent acute renal failure.
Anion gap only 10 but albumin is 2.0 and there elevated anion
gap acidosis. resolved with IVF.
#Dyspnea: denied dyspnea on arrival to MICU. Weaned down from 6L
to 2L NC overnight. No known history of heart failure though
mild pulm edema seen on CXR. No chest pain or orthopnea. No
pericardial effusion seen in ED on ultrasound. Obtained TTE for
full eval of cardiac function in setting of new effusion and low
voltage EKG (new finding this admission). TTE showed normal EF,
trivial pericardial effusion, mitral and tricuspid regurgitation
and mild pulmonary hypertension. Also obtained CT chest non-con
to eval new pleural effusion in setting of malignancy. CT chest
showed increased lymphadenopathy concerning for cancer
progression, enlarging pleural effusions and possible pathologic
fracture of right humerus. Upon arrival to the floor, patient
appeared very volume overloaded, with anasarca. She became
increasingly dyspneic throughout her hospitalization, which was
attributed to volume overload
#ARF: likely due to hypotension . Most recent baseline thought
to be around 1.5 from a previous baseline of 0.8. Was 2.0 on
admission. Urine lytes c/w prerenal. Worsened to 1.9-2.1 and
urine output dropped significantly. Renal was consulted. She was
given albumin in an attempt to improve intravascular volume, and
later given albumin and Lasix in attempt for diuresis, but these
efforts were unsuccessful. Patient and family decided against
pursuing dialysis given goals of care.
#Hyponatremia: recent baseline has been between 128-130 .
Currently 130, likely dehyrdation is contributing. Normal
thyroid and adrenal function as of [**2153**].
#Primary Metastatic Peritoneal Carcinoma- s/p Topotecan late
[**2155-6-8**]. Progressive. Currently not neutropenic but
immunosuppressed given recent chemo.
#Nausea/vomiting/decreased p.o intake- the patient endorses
early satiety and 3-5 episodes of small vomiting. Likely related
to ascites pressure from malignant ascites and slowing of
gastric motility. Reassuring patient is having bowel movements
making ileus or obstruction less likely. Patient denied frank
diarrhea and gastroenteritis/c.diff less likely. Though staph
gastroenteritis could be possible. Given IVF as above and zofran
for nausea.
Medications on Admission:
Medications HOME:Per DC summary [**2155-7-17**]
Discharge Medications:
1. CeftriaXONE 1 gm IV Q24H
RX *ceftriaxone 1 gram 1 gram IV q24 hours Disp #*3 Gram
Refills:*0
2. Outpatient Lab Work
Please recheck CBC and chem 7 on [**2155-7-24**]. Please fax results
to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28049**] at [**Telephone/Fax (1) 6808**]
3. IV fluids
Please adminster 1 L NS at 100cc/hr once a week
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
5. Docusate Sodium 100 mg PO QID:PRN constipation
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 300 mg PO BID
8. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Lorazepam 0.5 mg PO Q4H:PRN nausea
11. Lorazepam 1-2 mg PO HS:PRN insomnia
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Sarna Lotion 1 Appl TP QID:PRN itching
14. Senna 1 TAB PO BID
15. Magnesium Oxide 400 mg PO DAILY:PRN constipation
16. Omeprazole 40 mg PO DAILY:PRN heartburn/during chemo
17. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary peritoneal carcinomatosis
Sepsis
Acute renal failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2155-8-5**]
|
[
"263.9",
"585.3",
"788.5",
"197.0",
"273.8",
"V66.7",
"403.90",
"493.90",
"244.9",
"276.2",
"276.1",
"584.9",
"158.9",
"424.0",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20799, 20808
|
16014, 19671
|
305, 311
|
20912, 20922
|
12214, 12214
|
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|
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20771, 20776
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|
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11358, 12195
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3359, 3736
|
254, 267
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339, 3340
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12230, 15991
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3758, 10880
|
10896, 11034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,622
| 159,206
|
24781
|
Discharge summary
|
report
|
Admission Date: [**2144-9-6**] Discharge Date: [**2144-9-10**]
Date of Birth: [**2091-10-11**] Sex: M
Service: MEDICINE
Allergies:
morphine / Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest and Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52M transferred from [**First Name8 (NamePattern2) **] [**Hospital3 **] where he presented
hypontensive to the 80's with back and chest pain. Given his
history of a known type B aortic dissection, there was concern
for conversion to type A. In their ED he had a non-con CT chest
they were concerned about being converted to a type A dissection
and transferred him to the [**Hospital1 **]. Prior to arrival a femoral CVL
was placed and he was given 1L NS with improvement of his
pressures to the 130's.
.
On arrival to the [**Hospital1 **] he was tachycardic to the 120's with BPs in
the 140's with non-invasive, but once an A-line was placed they
were found to be elevated in the to as high as the 200's.
Cardiothoracic surgery was called to the bedside and asked for a
nitro-drip to be titrated to an SBP goal of 100. Per report an
A-line pulsus was 15. CT angigogram had to be repeated in our
ED because OSH studies were non-con. Once type A dissection was
ruled out, and tamponade became a concern esmolol and
nitro-drips were d/c'd. Cards was called and performed a
bedside Echo which revealed some RV diastolic collapse. The
decision was made to bring the patient to the CCU in
anticipation of a aortogram and possible pericardiocentesis in
the cath lab. Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] were called in from
home.
.
The patient was noted to have waxing and [**Doctor Last Name 688**] mental status.
Initial concern was for CO2 retention because the patient
desaturates to 80's when falling asleep. An ABG was checked and
revealed, a pH of 7.25 with a pCO2 of 48.
Of note the patient's WBC was elevated to 31.6. HCT up from 40
-> 50. Urine sent, got vanc/zosyn.
.
He is s/p discharge [**7-29**] after a bout of idiopathic
pancreatitis. This writer spoke with the [**First Name8 (NamePattern2) **] [**Location (un) 1131**] room
radiologist who stated that CT abdomen here revealed no s+s of
pancreatitis and lipase was 65.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
CVA
Hypertension
Type II DM
h/o MIs in the past (s/p cath with ?stents)
h/o "mild" CVAs
morbid obesity
+smoker
Peripheral vascular disease
gout
chronic atrial fibrillation
chronic renal insufficiency
chronic type B aortic dissection since [**2138**]
Tonsillectomy
L AKA
s/p PPM with ICD
Social History:
Smoked 3-4 packs/day. History of previous EtOH
abuse, but patient has not had EtOH in 1.5 years.
Family History:
Father died of leukemia
Mother- alive and healthy
[**Name (NI) 8614**] healthy
Physical Exam:
ON ADDMISSION
VS: T=96.0 axillary BP=166/96 HR=112 RR= O2 sat=94% RA
Pulsus-30
GENERAL: c/o of pain. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP non-visible at 30, 60, and 90 degrees,
though patient's beard is obscuring exam
CARDIAC: PMI non-palpable. RR, Heart sounds very distant,
?normal S1, S2.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Obese, non-tender, no distension> that explained by
obesity No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: warm, no edema, pulses dopplerable x 3, Left AKA
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Guaiac: confirmed negative
ON DISCHARGE
Pertinent Results:
[**2144-9-6**] 11:40AM PT-22.0* PTT-27.7 INR(PT)-2.0*
[**2144-9-6**] 11:40AM PLT COUNT-260#
[**2144-9-6**] 11:40AM WBC-31.6*# RBC-5.78# HGB-17.6# HCT-50.1
MCV-87 MCH-30.5 MCHC-35.2* RDW-14.4
[**2144-9-6**] 11:40AM ALBUMIN-4.0 CALCIUM-8.6 PHOSPHATE-5.6*#
MAGNESIUM-1.8
[**2144-9-6**] 11:40AM CK-MB-7 proBNP-5158*
[**2144-9-6**] 11:40AM cTropnT-0.01
[**2144-9-6**] 11:40AM ALT(SGPT)-36 AST(SGOT)-33 LD(LDH)-251*
CK(CPK)-96 ALK PHOS-63 AMYLASE-81 TOT BILI-0.3
[**2144-9-6**] 07:00PM D-DIMER-3667*
ECHO ([**2138**]):
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy with normal cavity size and
hyperdynamic systolic function (EF>75%). There is a mild resting
left ventricular outflow tract obstruction but no valvular [**Male First Name (un) **].
Right ventricular chamber size and free wall motion are normal.
The ascending aorta and aortic arch are mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
valvular aortic stenosis. The increased transaortic gradient is
likely related to high cardiac output. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no systolic anterior motion of the mitral valve leaflets. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion.
IMPRESSION: Hypertrophic obstructive cardiomyopathy.
Based on [**2130**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a moderate risk (prophylaxis
recommended). Clinical decisions regarding the need for
prophylaxis should be based on clinical and echocardiographic
data.
ECHO ([**2144-9-6**]): Left ventricular wall thicknesses and cavity
size are normal. Left ventricular systolic function is probably
grossly preserved/normal but views are suboptimal. Cannot
exclude segmental wall motion abnormalities. The right
ventricular cavity appears small. Right ventricular free wall
systolic motion appears normal. Valvular regurgitation was not
adequately assesed except focused views obtained of the aortic
valve; focused views revealed no significant aortic
regurgitation. There is a small to moderate sized pericardial
effusion. There is right atrial and right ventricular
compression/collapse consistent with tamponade. Echodense
material present along the visceral surface of the pericardial
space consistent with possible fat, thrombus/fibrin or other
mass.
IMPRESSION: Probably normal LV function. No significant aortic
regurgitation. RA and RV diastolic collapse consistent with
tamponade physiology. Small to moderate pericardial effusion.
CXR ([**2144-9-6**]): Again is seen a left pacer unit with the leads
projecting over the right atrium and right ventricle. The heart
size is enlarged. The
mediastinal contours appear widened, similar to slightly
increased from prior study. The lung volumes are low,
accentuating subtle perihilar opacities. There is no large
pleural effusion or pneumothorax.
CTA TORSO ([**2144-9-6**]):
1. As compared to the [**2144-7-26**] CT examination, there has
been interval marked proximal progression vs new thrombosed
thoracic aortic dissection, with the proximal margin at the
takeoff of the left subclavian artery, and extending
hemicircumferentially distally to the level of the diaphragm.
There is a possible stable ulceration or pseudoaneurysm at this
proximal portion. There is also a moderate-sized
hemopericardium.
2. Unchanged chronic aneurysmal dissection of the
infradiaphragmatic/
suprarenal abdominal aorta, with the lumen predominantly
occupied by a large mural thrombus.
3. Stable bilobed infrarenal aortic aneurysm.
4. Markedly thickened left ventricular walls raises the
possibilty a
hypertrophic cardiomyopathy.
5. Reflux of contrast into the hepatic veins suggest right sided
cardiac
failure.
6. Separate origins of the left anterior descending and
circumflex arteries from the aorta. Independent origin of the
left vertebral artery from the aorta.
NCHCT ([**2144-9-6**]): There is no evidence of acute intracranial
hemorrhage, edema, mass, mass effect, or large vascular
territorial infarction. The ventricles and sulci are normal in
size and configuration. There is normal opacification of the
principal vessels of the circle of [**Location (un) 431**] and major dural venous
sinuses. There is no acute fracture. Mucus-retention cysts are
present within the right maxillary sinus (2:3). The middle ear
cavities, mastoid air cells, and remaining included paranasal
sinuses appear clear.
ECHO ([**2144-9-7**]): The left atrium is mildly dilated. The
estimated right atrial pressure is 0-5 mmHg. 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 - ?hypokinesis of the basal
half of the inferior [**Last Name (un) **], but global function is good (LVEF
>45%) 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 (?#) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is a small circumferential pericardial
effusion most prominent around the right atrium and seen in
apical views (clip [**Clip Number (Radiology) **]). No right atrial or right ventricular
diastolic collapse is seen. Prominent epicardial fat is noted.
IMPRESSION: Suboptimal image quality. Small circumferential
pericardial effusion without evidence for tamponade physiology.
Mild symmetric left ventricular hypertrophy with good global
systolic function.
Compared with the prior study (images reviewed) of [**2144-9-6**],
the heart rate is slower and the effusion is smaller.
RENAL DOPPLER ([**2144-9-7**]): 1. Limited examination secondary to
respiratory motion and poor acoustic windows. Within these
limitations, there is gross patency of the bilateral main renal
arteries.
2. Incidentally noted diffusely increased echogenicity of the
liver, most
compatible with fatty infiltration. Other forms of liver disease
including
more significant liver disease such as hepatic
fibrosis/cirrhosis cannot be excluded on this study.
Brief Hospital Course:
52M with chest and back pain and known type B aortic dissection
as well as horrible vascular disease being admitted to the CCU
in the setting of HD significant pericardial effusion concerning
for hemorrhagic cardiac tamponade.
.
Aortic Dissection: Patient initially presented to [**Hospital2 **] [**Hospital3 6783**]
hospital with back pain and hypotension to the 80s, given his
known history of a type B aortic dissection, there was concern
that his disection may have evolved. He received a non-contrast
CT torso at the OSH and 1L of NS with improvement in his
systolic pressures to the 130s prior to transfer. In the [**Hospital1 18**]
ED patient was tachycardic to the 120s and had an A-line placed
showing systolic pressures to the 200s. Cardiothoracic surgery
was consulted and a nitro-drip was begun for a goal SBP of 100.
Patient then recived a CTA Torso which showed slight proximal
expansion of the dissection and concerns of a hemmorhagic
pericardial effusion were raised. Esmolol and nitro drips were
discontinued an a Bed Side ECHO preformed by cardiology showed
RV diastolic collapse. Patient was fluid resusitated with an
additional 5 L and admitted to the CCU. Patient remained stable
and a repeat ECHO was preformed the next morning showing
enhancement of the pericardium, but no significant effusion
lowering the possibility of true tamponade or pericardial
fistula. Renal dopplers were preformed with sub-optimal
quality, but did not show obvious involvement of the renal
arteries. Vascular and Cardiothoracic surgery signed off on the
patient as there was no role for surgical correction.
.
Hypertension: In the setting of possible unstable aortic
dissection with proximal extension the patient's BP was
aggressively monitored and treated. The patient had known
refractory hypertension treated with carvedilol 50 mg TID,
Clonidine 0.1 mg TID, Hydralazine 10 mg QID, amlodipine 10 mg
daily, doxazosin 8 mg [**Hospital1 **], isosorbide mononitrate 60 mg daily,
Lisinopril 40 mg daily. This may be partially exacerbated by
withdrawl of home hydral and clonidine. Patient's home PO
anti-hypertensives were initially held and his BP maintained on
lobatelol drip with hydral boluses. Transitioned back to home
regimen with following medications: carvedilol 50mg [**Hospital1 **],
nifedipine CR 60mg daily, doxazosin 8 mg [**Hospital1 **], isosorbide
mononitrate 60 mg daily, Lisinopril 40 mg daily, clonidine patch
0.1mg/24 hrs weekly. Was normotensive at time of discharge.
.
Leukocytosis: Intially 33 at the time of presenation with a
corresponding HCT of 50 suggesting hemoconcentration, however
given the patient's acute state Vanc/cefepime was started. As
patient was volume resusitated the white count dropped
significantly, but remained elevated. Throughout his CCU course
there were no other signs of infection including negative blood
and urine cultures. The antibiotics were stopped and his
leukocytosis was attributed to demargination stress response.
.
ATN: On admission creatine was 1.8 and rose to peak of 3.1.
Urine showed muddy brown casts and pt was volume resuscitated
with IVF. Additionally, renal arteries were normal on renal US,
so no concern for bilateral dissection or stenosis. At time of
discharge cr had improved to 1.2.
.
IDDM/hyperglycemia: BG was very difficult to control and at
time of admission he was only on NPH nightly and PO glipizide.
He does not use a glucometer and A1C was 14 at time of
admission. [**Last Name (un) **] was consulted and he was started on ISS and
[**Hospital1 **] NPH and sugars improved. He was instructed on how to use a
sliding scale and instructed to purchase a new glucometer. He
was discharged on ISS and [**Hospital1 **] NPH and will f/u with [**Last Name (un) 387**] one
week after d/c to re-asssess.
.
atrial fibrillation: Initially pt's coumadin was held because of
concern for potential hemorrhagic tamponade, which was
ultimately ruled out with repeat echo. Pt was restarted on
coumadin and at time of discharge, INR was still subtherapeutic,
but was scheduled for close follow up and INR check. Pts
carvedilol was increased to 50mg [**Hospital1 **] at time of discharge.
.
CAD: Pt was continued on simvastatin, asa and plavix at time of
discharge.
.
Transitional issues:
needs home blood pressure cuff, glucometer
Needs [**Last Name (un) **] f/u
outpt INR
Medications on Admission:
Simvistatin 40 mg PO daily
Coumadin 10 mg PO daily
Carvedilol 25 mg PO TID
Clonidine 0.1 mg PO TID
Hydralazine 10 mg PO QID
Albuterol MDI 2 puffs QID PRN
NTG SL PRN
Allopurinol 100 mg PO daily
Norvasc 10 mg PO daily
Plavix 75 mg PO daily
Colchicine 0.6 mg PO daily
Colace 100 mg PO BID
Cardura 8 mg PO BID
Neurontin 100 mg PO TID
Glipizide 10 mg PO IBD
NPH insulin 45U SC qhs
Imdur 60 mg PO daily
Lisinopril 40 mg PO daily
Plavix
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
4. carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
Disp:*240 Tablet(s)* Refills:*2*
5. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday) as needed for hypertension.
Disp:*4 Patch Weekly(s)* Refills:*1*
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
12. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous twice a day: take one injection in the
morning and one at bedtime.
Disp:*1 bottle* Refills:*2*
13. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
14. Outpatient Lab Work
INR/Chem 10
can be collected between [**2144-9-12**] and [**2144-9-16**]
please forward results to Cardiologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 40420**]
15. gabapentin 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
16. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
17. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO daily PRN as
needed for gout treatment.
18. glucometer test strips
One touch ultra test strips
Check blood glucose QID with meals
Please fill for one months supply
#120
19. insulin lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QID with meals: PRN as needed for blood sugar >150:
please follow attached insulin sliding scale regimen.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] VNA
Discharge Diagnosis:
ATN
diabetes mellitus
hypertension
hypotension
chronic aortic dissection
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 71**],
It was a pleasure taking care of you. You were transferred to
[**Hospital1 18**] because you had very low blood pressures and there was
concern that your aortic dissection had extended. We evaluated
you with imaging and it was determined that your dissection had
not worsened and there was no need for surgery at this point.
You were also worked up for a condition called pericadial
tamponade, and after extensive imaging and monitoring, we
determined that you did not have this.
.
During this admission your blood sugars were extremely elevated
and we made some changes to your diabetes medications. We would
like you to be followed by our endocrinologists at the [**Last Name (un) **]
Center because your insulin will likely need additional
adjustment in the near future. For the time being, please check
you blood glucose four times daily and record the measurements
in a journal. This will assist the doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] [**Name5 (PTitle) **].
You will need to purchase a blood glucose meter to record your
sugars. We recommend one touch brand, it is relatively
inexpensive but reliable and can be bought at any pharmacy. I
have written you a prescription for blood glucose strips for a
one touch monitor. Remember never to take insulin until you
have checked your blood sugars first.
.
We have also made several changes to your blood pressure
medications. It is very important to have good blood pressure
control with your chronic medical conditions, particularly
aortic dissection.
.
The following changes have been made to your medications:
.
STOP: clonidine 0.1mg TABLET and START clonidine 0.1mg/24hr
weekly patch
STOP: hydralazine, glipizide, amlodipine
START: Nifedipine CR 60mg tablet take one tablet daily
CHANGE: isosorbide mononitrate from 60mg tablet extended release
once daily TO 90 mg extended release once daily
CHANGE: carvedilol from 25mg tab three times per day TO 50mg tab
twice daily
CHANGE: insulin from NPH & regular 45 units at bedtime TO
insulin NPH 30 units in the morning and 30 units at night.
START: insulin sliding scale. We have attached your sliding
scale to your discharge paperwork.
.
You will also need to have your INR checked. The results of
this should be sent to your primary cardiologist before your
appointment with him.
.
Followup Instructions:
Name: [**Last Name (LF) 10088**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] -Endocrinology
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 16420**]
Appt: Tuesday [**9-15**] at 9:30am
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] -Cardiology
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Doctor Last Name 40418**], [**Location (un) **],[**Numeric Identifier 40419**]
Phone: [**Telephone/Fax (1) 40420**]
Appt: Thursday [**9-17**] at 2:30pm
|
[
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"429.89",
"412",
"327.23",
"441.01",
"305.1",
"423.0",
"425.4",
"276.2",
"V49.75",
"278.01",
"V45.01",
"357.2",
"423.3",
"584.5",
"443.9",
"403.90",
"V58.67",
"274.9",
"427.31",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
17845, 17900
|
10793, 15056
|
302, 308
|
18017, 18017
|
4299, 10770
|
20587, 21295
|
3285, 3366
|
15644, 17822
|
17921, 17996
|
15189, 15621
|
18200, 20564
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3381, 4280
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15077, 15163
|
243, 264
|
336, 2844
|
18032, 18176
|
2866, 3154
|
3170, 3269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,953
| 198,167
|
4677
|
Discharge summary
|
report
|
Admission Date: [**2116-1-16**] Discharge Date: [**2116-1-18**]
Date of Birth: [**2046-12-23**] Sex: M
Service: MEDICINE
Allergies:
Mirapex
Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 9449**] is a 69 year-old male with a PMHx significant for DM
type 1, ESRD on HD (M,W,F), CAD s/p 3-vessel CABG in [**2107**]
following a silent MI, CHF with EF 20-25% in [**9-/2115**] with severe
MR, HTN, and COPD per report, who presents with a 4-day history
of progressive dyspnea on exertion.
By the patient account, he noticed worsening DOE 3 days PTA
while walking uphill from his car. He notes that his DOE became
progressively worse over the ensuing days, with associated
wheezing. He denies any dyspnea at rest. History of chronic
cough, without any significant change over the past few days. He
is not on any standing inhalers at home, and uses Atrovent as
needed. He did not use it PTA [**2-12**] expired. No chest pain,
orthopnea or PND. No leg swelling. No hemoptysis. No N/V or
abdominal pain. No myalgias, no sore throat or rhinorrea. He
notes subjective fevers on the day prior to admission, but
temperature not measured. Occasional chills. No known sick
contact.
He underwent HD on Wednesday per schedule. He is also s/p
removal of a PD catheter 2 days PTA at [**Hospital1 2025**]. He has received his
flu shot this year and has received Pneumovax in the past.
In the ED, blood cultures sent, patient given Combivent nebs X
3, Levoquin 500 mg PO X1. Patient also cultured in HD on
[**2116-1-15**].
Past Medical History:
1. ESRD on hemodialysis M/W/F
2. DM type 1
3. CAD s/p 3-vessel CABG in [**2107**]. s/p recent admission with
dyspnea in [**2115-9-11**].
- Stress MIBI on [**2115-9-12**]: 7 minutes of a modified [**Doctor Last Name 4001**]
protocol, stopped [**2-12**] fatigue and hypotension. No typical
anginal symptoms, but progressive SOB. No new EKG changes. MIBI
with moderately severe, fixed perfusion defect in apical portion
of anterior wall and apex. Global HK and apical akinesis.
- Cath [**2115-9-13**]: Right dominant, 60-70% proximal RCA stenosis,
patent LIMA to LAD, SVG to OM. Occluded SVG to PDA.
4. CHF with EF 20-25% in [**9-/2115**] and severe MR.
5. Hypertension
6. Retinopathy
7. Neuropathy
8. hypothyroidism
9. Hypercholesterolemia
10. COPD per patient report. No PFT's online. No prior
psteroids, no intubation.
Social History:
Lives alone, retired. Social EtOH use. Smoked 1 ppdx35 yrs, quit
2 months ago.
Family History:
Father MI at 62, Sister DM2, Brother CVA, Brother CAD
Pertinent Results:
[**2116-1-16**] 08:44AM WBC-6.5 RBC-3.45* HGB-11.9* HCT-35.9*
MCV-104* MCH-34.4* MCHC-33.1 RDW-14.1
[**2116-1-16**] 08:44AM NEUTS-80.1* LYMPHS-15.2* MONOS-4.1 EOS-0.1
BASOS-0.5
[**2116-1-16**] 08:44AM PHOSPHATE-4.9* MAGNESIUM-1.7
[**2116-1-16**] 08:44AM CK-MB-4
[**2116-1-16**] 08:44AM cTropnT-0.11*
[**2116-1-16**] 08:44AM GLUCOSE-361* UREA N-34* CREAT-3.7* SODIUM-133
POTASSIUM-6.0* CHLORIDE-93* TOTAL CO2-23 ANION GAP-23*
[**2116-1-16**] 09:02AM LACTATE-4.8*
[**2116-1-16**] 07:30PM CK-MB-4
[**2116-1-16**] 07:30PM cTropnT-0.21*
[**2116-1-16**] 07:41PM LACTATE-3.6*
[**2116-1-17**] 05:30AM BLOOD WBC-7.8 RBC-3.31* Hgb-11.4* Hct-32.9*
MCV-100* MCH-34.3* MCHC-34.5 RDW-13.6 Plt Ct-240
[**2116-1-18**] 06:00AM BLOOD Glucose-203* UreaN-32* Creat-3.4* Na-136
K-4.4 Cl-103 HCO3-26 AnGap-11
[**2116-1-17**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2116-1-17**] 05:30AM BLOOD Vanco-13.5*
[**2116-1-18**] 06:00AM BLOOD Vanco-22.6*
Bl Cx 1/5/5 staph coag neg epi 2 bottles
Brief Hospital Course:
A/P: 69 y.o male with DM type 1, ESRD on HD, CAD s/p CABG, CHF
with EF 20-25% on last echo, COPD per patient account, admitted
with 4-day history of progressive DOE, cough, and wheezing.
*
1) Bacteremia: Sputum, urine cx negative. Blood cultures have
grown staph epi. Pt was maintained on vancomycin throughout
admission, and with his chronic renal failure the levels have
remained quite high. He will go home with followup at dialysis
on monday at which point he will get blood cultures drawn again
along with vancomycin level to determine his next dosing. He
will need Vanco doses at HD with levels <15 for two weeks.
*
2) SOB/wheezing: Likely was a COPD exacerbation, triggered by
viral infection vs tracheobronchitis. His history of subjective
fevers, chills, and cough certainly raises suspicion for
influenza which was ruled out by aspirate. CXR without
consolidation, WBC normal, remained afebrile. He has true CAD
without any prior history of typical angina (likely silent
angina [**2-12**] DM), but EKG is without changes and he ruled out by
enzymes for MI. No CHF clinically or on CXR.
-Continue Levofloxacin to cover for community acquired
organisms, although no clear evidence of pneumonia.
*
2) CAD: s/p CABG. Rule out as above. Continue ASA, Plavix, BB,
ACEI, statin on discharge.
*
3) Hypertension: Continued Losartan, Metoprolol, Accupril in
hospital and on discharge. HCTZ was discontinued.
*
4) ESRD: Pt will need dialysis as regularly scheduled. At
dialysis he needs blood cultures and vanco levels drawn then
vanco dosed per level for two weeks. Continue renagel. Patient
being considered for possible kidney transplant.
*
5) DM type 1: Sugars in 300s in ED. Continue out-patient NPH 24
units qAM and 2 units qPM, with Humalog sliding scale QID.
Needs diabetes outpt followup
*
6) Psudohyponatremia: Sodium 133 in setting of glucose 350.
Clinically, patient euvolemic to hypovolemic. Trended up
through admission and pt remained stable.
Medications on Admission:
asa, atorvastatin, levothyroxine, losartan, atenolol, plavix,
sevelamer
Discharge Medications:
1. Quinapril HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours): Last dose on [**2115-1-21**].
Disp:*4 Tablet(s)* Refills:*2*
10. Vancomycin 1g dosed at hemodialysis prn serum level <15 x 2
weeks
Discharge Disposition:
Home
Discharge Diagnosis:
1. Bacteremia
2. COPD exacerbation
3. End-stage renal failure
4. Coronary artery disease
5. Diabetes mellitus type 1
6. Hypertension
7. Congestive heart failure
Discharge Condition:
Patient discharged home in stable condition.
Discharge Instructions:
Please call your PCP and schedule an appointment to see him
within 1-2 weeks of discharge.
We have stopped your Hydrochlorothiazide, given poor efficacy in
the setting of renal failure. Please continue to take your other
blood pressure medications.
You will take a new medicine levofloxacin every other day until
1/12/5 for your upper respiratory infection.
You will recieve a two week course of vancomycin for the
bacteria in your blood (staph epidermidis), dosed at
hemodialysis
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], and schedule an appointment
to see him within 1-2 weeks of discharge.
Provider: [**Name10 (NameIs) 19761**],[**Name11 (NameIs) **] PHYSICAL THERAPY -CC2 Where: [**Hospital 273**] REHABILITATION SERVICES Phone:[**Telephone/Fax (1) 2484**]
Date/Time:[**2116-1-21**] 9:00
Provider: [**Name10 (NameIs) 13228**] [**Name11 (NameIs) 13229**], [**First Name3 (LF) **] Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2116-1-28**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 6197**] Date/Time:[**2116-2-13**] 10:30
|
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"244.9",
"V45.81",
"790.7",
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
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] |
6645, 6651
|
3719, 5684
|
289, 304
|
6856, 6902
|
2704, 3696
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|
2629, 2685
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|
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5710, 5783
|
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|
230, 251
|
332, 1674
|
1696, 2517
|
2533, 2613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,222
| 134,846
|
35442
|
Discharge summary
|
report
|
Admission Date: [**2154-5-29**] Discharge Date: [**2154-6-10**]
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 year old male with prolonged and complicated hospital course
after mitral valve replacement and coronary artery bypass graft
surgery with respiratory failure, renal failure requiring
hemodialysis, and ischemic leg requiring amputation. He was
transferred to rehab and returned due to hypotension.
Past Medical History:
s/p Bare Metal Stents [**May 2153**]
coronary artery disease s/p PCI
CABG/MVR [**2154-4-19**]
Atrial Fibrillation
Hypertension
Hypercholesterolemia
Ascites
Chronic renal insufficiency
low back pain
Depression
Obstructive sleep apnea
TURP
Heparin Induced thrombocytopenia
Bilateral inguinal hernia repair
Bilateral carpal tunnel surgery
[**5-12**] perc trach, lap->open J-tube, chole tube, incidental
gangren
GB
[**5-9**] R BKA
[**4-28**] R leg thrombectomy, peroneal/BK [**Doctor Last Name **] stent, fem-[**Doctor Last Name **] bpg
[**4-26**] PPM
[**4-23**] RLE [**Doctor Last Name **] Stent, AT Aplasty/Stent
Social History:
Retired.
Owned wholesale groceries.
Lives with wife (who has [**Name (NI) 11964**]) and daughter.
Quit tobacco 48 years ago. (2packs per day x ? years)
Family History:
Brother passed away at age 84 from heart attack
Both parents had a stroke in their 60s-70s.
Physical Exam:
Pulse:76 Resp: O2 sat: 70's to 80's
B/P Right: 80/40 Left:
Height: Weight:
General:
Skin: Dry [] intact []
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs decreased bilaterally []
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+
[]
Extremities: Warm [], well-perfused [] Edema Varicosities: None
[]
Neuro: moves spontaneously left foot
Pulses:
Femoral Right: +3 Left:+3
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Pertinent Results:
[**2154-6-10**] 01:35AM BLOOD WBC-16.3* RBC-2.46* Hgb-7.8* Hct-23.3*
MCV-95 MCH-31.8 MCHC-33.7 RDW-20.0* Plt Ct-203
[**2154-5-28**] 03:21AM BLOOD WBC-11.6* RBC-3.13* Hgb-9.5* Hct-29.0*
MCV-93 MCH-30.5 MCHC-32.8 RDW-20.2* Plt Ct-117*
[**2154-5-30**] 03:15AM BLOOD Neuts-92.0* Lymphs-5.4* Monos-2.6 Eos-0
Baso-0.1
[**2154-6-10**] 01:35AM BLOOD Plt Ct-203
[**2154-6-10**] 01:35AM BLOOD PT-29.6* PTT-34.4 INR(PT)-2.9*
[**2154-5-28**] 03:21AM BLOOD Plt Ct-117*
[**2154-5-28**] 03:21AM BLOOD PT-20.6* PTT-31.1 INR(PT)-1.9*
[**2154-6-10**] 01:35AM BLOOD Glucose-129* UreaN-112* Creat-2.4*
Na-130* K-3.3 Cl-97 HCO3-20* AnGap-16
[**2154-5-28**] 03:21AM BLOOD Glucose-111* UreaN-108* Creat-3.2* Na-134
K-4.1 Cl-100 HCO3-20* AnGap-18
[**2154-5-31**] 01:23AM BLOOD ALT-45* AST-61* LD(LDH)-295* AlkPhos-85
Amylase-153* TotBili-10.5*
[**2154-6-10**] 01:35AM BLOOD Calcium-7.8* Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 6330**] was readmitted to the cardiac surgical intensive care
unit at the [**Hospital1 18**] on [**2154-5-30**] for further management of
hypotension. Neosynephrine was started for his hypotension. The
renal team followed him for his chronic renal failure.
Hemodialysis was continued. The neurology service was consulted
who did not observe any significant improvement in his neuologic
status since their last evaluation. Enterococcus bacteremia was
found on blood cultures and he was treated with vancomycin.
After discussion with the family, he was made DNR (Do Not
Resuscitate). His renal function stabilized and hemodialysis was
discontinued. After multiple meetings with family and decision
was made not to increase care. Continued with family
discussions and the decision was made to withdraw care.
Medications on Admission:
ASA 325', Diltiazem SR 240', Furosemide 80", Metolazone 2.5 Q
M-W-F, Metoprolol 25', Warfarin 2alt4mg, Potassium 20'''
Discharge Disposition:
Expired
Discharge Diagnosis:
Bacteremia
mitral regurgitation s/p MVR
Coronary artery disease s/p CABG
Complete heart block s/p PPM
acute renal failure
Respiratory failure s/p tracheostomy
Nutritional deficit
gangrenous gall bladder
ischemic right leg with subsequent BKA
seizures s/p arrest
Thrombocytopenia
s/p respiratory arrest
hypertension
hypercholesterolemia
atrial fibrillation
ascites
sleep apnea (uses CPAP)
low back pain
depression
acute heart failure
Discharge Condition:
deceased
Completed by:[**2154-6-10**]
|
[
"038.0",
"427.31",
"V44.0",
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"V45.01",
"585.9",
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"995.92",
"V43.3",
"724.2",
"272.4",
"414.01",
"327.23",
"287.5",
"584.9",
"V49.75"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.95",
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"38.93"
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icd9pcs
|
[
[
[]
]
] |
3976, 3985
|
2976, 3806
|
240, 246
|
4462, 4501
|
2082, 2953
|
1396, 1489
|
4006, 4441
|
3832, 3953
|
1504, 2063
|
189, 202
|
274, 576
|
598, 1210
|
1226, 1380
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,898
| 118,459
|
6995
|
Discharge summary
|
report
|
Admission Date: [**2190-12-15**] Discharge Date: [**2190-12-23**]
Date of Birth: [**2134-11-10**] Sex: M
Service: MEDICINE
Allergies:
Bactrim DS / Nafcillin
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
56M with CKD s/p renal transplant, renal artery stenosis s/p
stent last year, DM1, recent admission for MSSA osteomyelitis
and subsequent admission for rash and acute renal failure
presumably from Nafcillin and is now presenting with shortness
of breath and fever.
.
The patient reports he has intermittently felt fatigued and
dyspneic for the past few weeks since his discharge from [**Hospital1 18**]
on [**10-23**] and has seen various providers in outpatient clinic. He
has experienced shortness of breath, worst when laying down flat
but also on exertion, dry cough, and fatigue which has been
worse for the past week. His home spO2 was in the high 80's and
he reports his systolic blood pressures were in the 130's, which
is slightly lower than usual. He also reports progressive pedal
edema. He was febrile at home with low grade fevers in the
100's. Additionally, he had one episode of nausea and vomiting
yesterday but denies any further episodes since, and denies
abdominal pain or diarrhea and denies dysuria. He denies sick
contacts or recent travel. He notes his dry weight is 176 lb
and was 184 lb at home, which is close to his usual baseline
weight.
.
He had been told to discontinue his Lisinopril, which he has.
He also had his Prednisone dose increased [**12-13**] from 5 mg daily
to 20 mg daily for a possible COPD exacerbation and did notice
improvement of his wheezing. He was seen again on [**12-14**] for
recurrence of dyspnea and was then told to increase his Lasix
dose to 80 mg [**Hospital1 **] but instead increased it from 40 mg [**Hospital1 **] to 60
mg [**Hospital1 **] due to concerns of over-stressing his kidneys. He
reports his dyspnea has continued to worsen, and called his PCP
today and was advised to go to the ED.
.
Of note, the patient was admitted to [**Hospital1 18**] from [**Date range (1) 26205**] for a
diabetic foot ulcer and suspicion for osteomyelitis, and was
treated with Nafcillin, Cipro, Flagyl. He was admitted to [**Hospital1 18**]
again on [**11-27**] for a rash believed to be a drug reaction to
Nafcillin and acute renal failure secondary to hypovolemia from
diarrhea secondary to antibiotics.
.
In the ED, initial VS were: 98.8 89 158/60 24 88%
The patient was initially 88% on RA and was placed on a
non-rebreather with PO2 94%. He has been on bipap in the past.
He was found to be febrile to 101, and received Vancomycin 1 gm
and Cefepime. He was given Albuterol, Ipratropium nebulizers,
Methylprednisolone, and Acetaminophen. CXR was obtained.
.
On arrival to the MICU, the patient had dyspnea on exertion but
was able to be rapidly weaned to a nasal cannula and face mask
with high flow oxygen. He denied other symptoms at this time.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies 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:
PAST MEDICAL HISTORY:
-Type I diabetes (last A1c=6.9% on [**2190-4-27**])
-ESRD s/p renal transplant x2 ([**2165**] and [**2168**] [cadaveric]);
baseline Cr = 1.5-1.8
-Recurrent LLE cellulitis (previously MRSA+)
-HTN (well-controlled, per patient)
-Diastolic CHF (EF > 55%)
-PVD
-Vitamin D deficiency
-Gout
-Psoriasis
-Sciatica s/p TENS
-squamous and basal cell carcinoma of the nose and cheek
-Charcot changes and multiple fractures in right foot s/p
multiple surgeries
-L achilles tendon rupture
-b/l cataracts s/p surgery
-L heel osteomyelitis
Social History:
- Tobacco: 30+ pack year smoking history; quit in [**2182**].
- Alcohol: Denies.
- Illicits: Denies.
Lives at home with his wife.
Family History:
Extensive history of type I/II diabetes, CAD, and hyperlipidemia
on both father and mother's side.
Physical Exam:
ADMISSION EXAM:
.
General: Alert, oriented, no acute distress with face mask in
place
HEENT: Pupils equal and round, sclera anicteric, MMM
Neck: Supple, JVP ~11 cm, no LAD
CV: Regular rate and rhythm, normal S1 + S2, GII systolic murmer
at RUSB, GIII holosystolic murmer at LSB
Lungs: Crackles at bases and up to lower mid-lung fields b/l,
good air exchange bilaterally, no wheezes or rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
well healed transplant scars on lower lateral abdomen
bilaterally, left sided kidney transplant
Extr: Warm, well perfused, 2+ pitting edema of RLE, 1+ pitting
edema of RLE, 2+ DP pulses, no clubbing, cyanosis
Neuro: Alert and oriented, moving all extremities
.
DISCHARGE EXAM:
.
VITALS: 100.0 / 98.9 133/62 78 20 96% RA
WEIGHT: 80.5 kg (179 lbs)
I/Os: 1200 | 1300 + BRP BG: 97-405 mg/dL
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy.
CVS: Regular rate and rhythm, 2/6 systolic murmur without
radiation, no rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases bilaterally with faint
bilateral inspiratory crackles. No wheezing, rhonchi. Stable
inspiratory effort.
ABD: soft-obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses,
right greater than left lower extremity dorsal surface with
pitting edema to ankle up to mid-shin without open lesions or
ulcers which is improved. Upper extremity extensor surfaces with
urticarial patches.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred. No asterixis.
Pertinent Results:
ADMISSION LABS:
.
[**2190-12-15**] 11:00AM BLOOD WBC-9.8 RBC-3.06* Hgb-9.5* Hct-28.7*
MCV-94 MCH-30.9 MCHC-32.9 RDW-15.5 Plt Ct-377
[**2190-12-15**] 11:00AM BLOOD Neuts-82.5* Lymphs-13.1* Monos-3.8
Eos-0.3 Baso-0.3
[**2190-12-15**] 11:00AM BLOOD PT-12.9* PTT-31.8 INR(PT)-1.2*
[**2190-12-15**] 11:00AM BLOOD Glucose-231* UreaN-78* Creat-2.0* Na-137
K-4.1 Cl-103 HCO3-20* AnGap-18
[**2190-12-16**] 04:21AM BLOOD ALT-23 AST-14 CK(CPK)-34* AlkPhos-159*
TotBili-0.3
[**2190-12-15**] 11:00AM BLOOD proBNP-[**Numeric Identifier 26206**]*
[**2190-12-15**] 11:00AM BLOOD cTropnT-0.09*
[**2190-12-15**] 10:47PM BLOOD CK-MB-3 cTropnT-0.07*
[**2190-12-15**] 11:00AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.8
[**2190-12-15**] 12:22PM BLOOD tacroFK-2.6*
[**2190-12-15**] 11:07AM BLOOD Lactate-1.6
.
DISCHARGE LABS:
.
[**2190-12-23**] 07:35AM BLOOD WBC-8.7 RBC-2.97* Hgb-8.7* Hct-27.7*
MCV-93 MCH-29.3 MCHC-31.4 RDW-15.5 Plt Ct-406
[**2190-12-21**] 07:05AM BLOOD PT-13.9* PTT-31.2 INR(PT)-1.3*
[**2190-12-21**] 12:35PM BLOOD ESR-67*
[**2190-12-23**] 07:35AM BLOOD Glucose-77 UreaN-57* Creat-1.8* Na-140
K-4.3 Cl-102 HCO3-24 AnGap-18
[**2190-12-16**] 04:21AM BLOOD CK-MB-2 cTropnT-0.06*
[**2190-12-15**] 10:47PM BLOOD CK-MB-3 cTropnT-0.07*
[**2190-12-15**] 11:00AM BLOOD cTropnT-0.09*
[**2190-12-15**] 11:00AM BLOOD proBNP-[**Numeric Identifier 26206**]*
[**2190-12-23**] 07:35AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1
[**2190-12-21**] 12:35PM BLOOD CRP-93.6*
[**2190-12-20**] 10:20AM BLOOD Vanco-36.6*
[**2190-12-23**] 07:35AM BLOOD tacroFK-4.2*
[**2190-12-17**] 03:35AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-NEGATIVE
[**2190-12-17**] 03:35AM BLOOD B-GLUCAN-NEGATIVE
.
MICROBIOLOGY DATA:
[**2190-12-15**] Blood culture ?????? no growth
[**2190-12-15**] MRSA screen ?????? negative
[**2190-12-15**] Urine culture ?????? negative
[**2190-12-16**] Blood culture ?????? pending
[**2190-12-20**] Urine culture - pending
[**2190-12-20**] Blood culutre (x 2) - pending
[**2190-12-21**] Rapid respiratory viral screen - pending
[**2190-12-22**] Urine legionella - negative
.
IMAGING:
[**2190-12-16**] 2D-ECHO - Normal left ventricular cavity size and wall
thickness with preserved global left ventricular systolic
function. Increased left ventricular filling pressure. Mild
aortic stenosis. Moderate functional stenosis due to severe
mitral annular calcification. Mild mitral regurgitation.
Moderate to severe pulmonary artery systolic hypertension.
Dilated main pulmonary artery. Compared with the prior study
(images reviewed) of [**2189-10-7**], the findings are similar. The
absence of valvular vegetations on transthoracic echocardiogram
does not preclude their presence. If clinical suspicion for
endocarditis is high a transesophageal echocardiogram may be
considered.
.
[**2190-12-16**] PORTABLE ABDOMEN - Suboptimal exam, but no bowel
dilatation or free air.
.
[**2190-12-17**] CHEST (PORTABLE AP) - Right upper lobe pneumonia
continues to develop. Pulmonary edema is clearing. Bibasilar
consolidation, unchanged since [**12-15**], could be more
pneumonia or combination of edema and basal atelectasis. The
heart is partially obscured, probably moderately enlarged.
Small-to-moderate bilateral pleural effusions unchanged. No
pneumothorax.
.
[**2190-12-21**] CT CHEST W/O CONTRAST - Moderately severe, but improving
pulmonary edema, and stable small pleural effusions, right
greater than left. Right upper lobe consolidation could be
concurrent pneumonia or if the patient has mitral regurgitation,
asymmetric edema. Mild adenopathy is reactive either to
infection or edema
.
[**2190-12-21**] BILAT LOWER EXT VEINS B - No vascular flow identified in
the mid-to-distal portion of one of the left peroneal veins in
the left calf. This could represent old clot; however DVT at
this location cannot be excluded. Since this is a peripheral
segment of this vein, a follow-up ultrasound in [**1-23**] days is
recommended to assess stability. No DVT seen in the remainder of
the veins of both legs
.
[**2190-12-22**] UNILAT UP EXT VEINS US - negative for clot burden or DVT.
Brief Hospital Course:
IMPRESSION: 56M with a PMH significant for ESRD (s/p cadaveric
renal transplant in [**2165**], [**2168**]; renal artery stenosis s/p
stenting, baseline creatinine 1.5-1.8), DM1, CHF (with preserved
EF), HTN, with recent admission for recurrent LLE cellulitis vs.
MRSA osteomyelitis with subsequent admission for rash and acute
renal failure (presumably from Nafcillin) who presented with
shortness of breath and fevers.
.
# RECURRENT, LOW-GRADE FEVERS - The patient had concern for
pneumonia given his dyspnea and CXR findings, and was initially
covered broadly for HCAP given his immunosuppression and recent
hospitalization, completing an 8-day course of broad-spectrum
antibiotics (Vancomycin and Meropenem). However, the etiology of
his dyspnea was attributed partially to volume overload given
his elevation in BNP and volume overload on clinical exam and
imaging. He responded to IV Lasix infusion and diuresed
appropriately. Following his improvement in respiratory status
and improvement with diuresis on floor transfer, he subsequently
developed cyclic, recurring low-grade temperatures to the
100.0-101.0 range. Given his recent antibiotic use, recent
hospitalizations, and immune compromise in the setting of his
prior renal transplantation, the differential was extensive.
Infectious sources were considered. Infectious disease was
consulted. Blood, urine, legionella antigen were all negative.
His WBC remained normalized and without evidence of
leukocytosis. A 2D Echo earlier in his hospitalization was
without vegetations. A drug reaction was considered given some
intermittent urticaria and extensor pruritic rash that resolved
with benadryl around the times of the fevers (and given his
prior reaction to Nafcillin). A line infection was unlikely
given only peripheral access. He had no clinical evidence of
occult intra-abdominal infection or sinusitis. He was not
having loose stools to send C.diff toxins and he had no diabetic
foot ulcers or open wounds. Inflammatory causes were considered
and his ESR and CRP were slightly elevated, but he had no
evidence of joint swelling, erythema, gouty arthritis. We
performed bilateral lower extremity U/S which showed no clot
burden, but one of the deep peroneal left-sided veins was not
well visualized. On further review, this was deemed
sub-clinical. Fungal infections were considered and B-glucan and
galactomannan were negative for invasive fungemia. LFTs and LDH
were normal. A chest CT was eventually performed prior to
discharge and showed moderately severe, but improving pulmonary
edema with RUL consolidation that could be his prior pneumonia -
although he had completed his antibiotic course. Upon discharge,
he was having improved low grade temperatures below 100.0 and
was feeling clinically well. We discharged him with close
follow-up.
.
# DYSPNEA, SHORTNESS OF BREATH - The patient presented with
dyspnea associated with fever that worsened with lying flat and
with exertion x 1-week prior to admission; and has been on
immunosuppression for his cadaveric renal transplant. CXR
showing new opacity in the RML. He was initially admitted to the
medical ICU given his poor clinical status and oxygen
requirement and was treatment with broad-spectrum antibiotics
for healthcare-associated pneumonia in the setting of his immune
compromise with Vancomycin and Meropenem for 8-days. A component
of CHF exacerbation was also treated given his pulmonary
effusion, oxygen requirement and BNP (29,000) on admission -
with response to diuresis. TTE this admission showing preserved
LVEF > 55%, normal LV systolic function, moderate pulmonary HTN
without vegetations; similar to prior study. Of note, he had
some evidence of demand ischemia with cardiac biomarkers
(Troponin) peaking at 0.09. He was also treated with pulse
steroids given his diagnosis of COPD with significant prior
smoking history. We weaned his oxygen requirement and he was
comfortable and satting well on room air, he completed 8-days of
antibiotics, and was restarted on his Lasix 40 mg PO BID (his
recent home dose). We also continued his nebulizers as needed
and encouraged incentive spirometry.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - The patient has a
diagnosis of type I diabetes (last HbA1c = 6.9% on [**2190-4-27**]); no
reported retinopathy; history of ESRD s/p renal transplant and
on immunesuppression; no history of neuropathy. History of left
heel MRSA osteomyelitis and cellulitis. Charcot changes of right
foot with multiple fractures. We resumed his Lantus dosing of 40
units daily when he resumed diet and covered him with his usual
Lispro insulin sliding scale (self-adjusts). His glucose
remained in the 150-300 mg/dL range.
.
# END STAGE RENAL DISEASE, S/P TRANSPLANT - The patient is s/p
cadaveric renal transplant in [**2165**], [**2168**]; renal artery stenosis
s/p stenting, baseline creatinine 1.5-1.8 per our records - all
in the setting of ESRD from type 1 diabetes mellitus. He was
admitted with a creatinine of 2.0. ACEI previously held and he
was told to increase his home Lasix from 40 to 80 mg (but he
only increased the dose to 60 mg) [**Hospital1 **] prior to admission. On
admission, he was aggressively diuresed with IV Lasix and his
older home dose of Lasix 40 mg PO BID was resumed. We continued
to hold his ACEI therapy. Transplant nephrology was consulted
and helped manage his immune suppresion. His immune suppression
regimen was continued, but his Tacrolimus was dropped from 4 mg
to 3 mg in the QAM, but his evening dose of Tacrolimus 3 mg PO
QHS was maintained. His Tacrolimus levels were reassuring
overall. His Prednisone 5 mg PO daily, Mycophenolate 500 mg PO
BID) were continued. He also had evidence of a normocytic anemia
of chronic disease related to his ESRD which was stable this
admission. We continued his vitamin D supplementation for bone
metabolism and renally dosed all medications, while avoiding
nephrotoxins. Calcium acetate was discontinued this admission,
per Transplant nephrology given stable calcium levels.
.
# CONGESTIVE HEART FAILURE, PRESERVED EF ?????? As noted above,
admitted with possible component of diastolic failure
exacerbation, but primarily HCAP. 2D-Echo showing LVEF > 55%,
preserved LV function, moderate pulmonary HTN. Home medications
include: ACEI (recently held), Labetalol, Lasix. We opted to
continue holding his ACEI (previously on Lisinopril), but
continued his Labetalol 600 mg PO BID and resumed his previous
home Lasix dose of 40 mg PO BID. We monitored daily weights,
monitored I/Os, and set a goal for diuresis of 0.5-1L daily.
.
# HYPERTENSION ?????? We continued his Nifedipine and Labetalol. We
continued his daily Aspirin 81 mg PO daily. ACEI on hold for
now, as above.
.
# GOUT ?????? We continue Allopurinol 100 mg PO QAM.
.
TRANSITION OF CARE ISSUES:
1. At the time of discharge, respiratory viral screen, blood and
urine cultures from admission were still pending.
2. Consider restarting ACEI therapy if creatinine improves,
given cardiac history and kidney disease.
3. Outpatient follow-up scheduled with Transplant Nephrology to
monitor immune suppression regimen and creatinine. On MMF,
Prednisone and Tacrolimus.
4. He will follow-up with his primary care physician as well;
this has been scheduled.
Medications on Admission:
- Aspirin 81 mg daily
- Allopurinol 100 mg qAM
- Insulin glargine 40 mg qhs
- Insulin lispro
- Labetalol 300 mg Tablet Sig: Two (2) Tablet PO twice a day.
- Mycophenolate mofetil 500 mg [**Hospital1 **]
- Nifedipine 60 mg Tablet Extended [**Hospital1 **]
- Prednisone 20 mg daily ***recently increased***
- Tacrolimus 1 mg Capsule: 4 Capsules PO QAM
- Tacrolimus 1 mg Capsule: 3 Capsules PO qPM
- Cholecalciferol (vitamin D3) 400 units daily
- Multivitamin Tablet Sig: One (1) Tablet PO DAILY
- Vitamin E 400 unit daily
- Furosemide 60 mg [**Hospital1 **] ***recently increased***
- Calcium acetate 667 mg [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
4. insulin lispro 100 unit/mL Solution Sig: [**11-22**] units
Subcutaneous per sliding scale.
5. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
6. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
8. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO QAM (once a
day (in the morning)).
10. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO QPM (once
a day (in the evening)).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Healthcare-associated pnuemonia
2. Acute on chronic exacerbation of diastolic heart failure
3. Fever or unknown origin
.
Secondary Diagnoses:
1. Insulin-dependent diabetes mellitus
2. End-stage renal disease status-post cadaveric renal
transplant
3. Hypertension
4. Gout
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 Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your shortness of breath and fevers. You were treated for
pneumonia with broad-spectrum antibiotics and aggressive
diuresis for a component of heart failure. You did have some
recurrent, low grade fevers following overall improvement and
this was extensively worked up without identifiable source and
you were discharged feeling well. You will follow-up with your
primary care physician and the transplant kidney specialists.
.
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: NONE
.
* We CHANGED the following medications:
We DECREASED: Lasix from 60 mg to 40 mg by mouth twice daily
We DECREASED: Tacrolius from 4 to 3 mg by mouth in the morning;
the evening dose is the same
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
Calcium acetate 667 mg [**Hospital1 **]
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2191-1-3**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 805**], [**First Name3 (LF) **] E. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appt: [**1-6**] at 1:30pm
|
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68,655
| 116,598
|
48855
|
Discharge summary
|
report
|
Admission Date: [**2191-7-1**] Discharge Date: [**2191-7-6**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
PICC line placement
flexible sigmoidoscopy
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] YOF with a history of Crohns, DM type II,
and CAD who presented to the ED with diarrhea, abd pain and
nausea, vomiting. Pt reports 1 week of watery, non-bloody,
non-melena diarrhea about 5-6 episodes/day. Pt reports
associated N/V, 1 episode of non-bloody emesis. Pt has assoc
[**5-29**] abd pain below the umbilicus, that was non-radiating. No
alleviating or aggravating factors. Pt reports decreased po
intake (food and fluids). No fevers or chills, CP, or SOB.
.
In the ED, initial VS: 97.8 80 144/83 20 100% 2L. Physical exam
was significant for pt well looking, guiaic positive. Labs
showed Cr 4.9 (baseline 1.9 in [**2184**]), Na 132, K 5.2 and bicarb
8, BUN 96. Lactate was 0.9 and phos 8.9. CBC was normal except
for Hct 33.6 and serum osms 310. Serum aspirin and
acetaminophen levels negative. UA showed Lg LE, tr bld, many
bacteria, 30 prot, < 1 epi, neg nit. Bld cx negative x 2. The
pt received 1L NS. She was seen by renal who requested that the
pt admitted to medicine for bicarb drip, and eval of renal
failure. The recommended starting a Bicarb drip in the ED (with
1L 1/2NS + 1amp bicarb @ 125ml/hr) as well as VBG. However,
bicarb drip not started in ED as pt only had a 22 G peripheral
IV. She was admitted to MICU for better access to start bicarb
gtt.
.
On the floor, the patient was comfortable. She stated that she
did not have any recent changes in her urination, changes in
medications, increased NSAID use, suprapubic pain, flank pain or
dysuria. She states she was diagnosed with Crohns 10 years ago
and gets flares a few times a year with the current flare being
no worse than usual. She is not followed by anyone for this.
Her last Creatinine was probably drawn in [**2190-8-20**] by her
PCP. [**Name10 (NameIs) **] stated she was not particularly thirsty.
Past Medical History:
1. CAD s/p IMI in [**2157**]. Prior cath, no intervention.
2. Hypertension
3. Hypercholesterolemia
4. Diabetes mellitus type 2
5. Chronic diarrhea (?Crohn's disease vs malabsorp vs colitis)
6. History of TIA
7. Peptic ulcer disease. Prior history of GI bleed (>5 years
ago)
Past surgical history:
1. Status post bowel resection in [**2173**] following colonoscopy
complicated by perforation.
Social History:
Ms. [**Known lastname **] lives alone in an assisted-living facility. She is
an ex-smoker, with a 10 pack-year smoking history, quit in [**2157**].
No EtOH use.
Family History:
NC
Physical Exam:
Admission Exam
T 95.4, HR 101, BP 122/95, O2 sat 99% on RA
General: well appearing elderly lady, Alert, oriented x 3, no
acute distress, mild tremor but no asterixis
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
LUNGS: CTAB
CV: Regular rate and rhythm, systolic murmur radiating to the
axilla
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley with pale yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact, moving all extremitites, nml
sensation
Discharge Exam
VS: 98.1 129-196/60-82 59-70 18 97%
GENERAL: well-appearing in NAD. Oriented x3. Mood, affect
appropriate
CARDIAC: RRR, no mrg
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Right ankle pain resolved
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission Labs:
[**2191-7-1**] 06:30PM BLOOD WBC-9.5 RBC-3.76* Hgb-11.5* Hct-33.6*
MCV-89 MCH-30.5 MCHC-34.2 RDW-15.1 Plt Ct-255#
[**2191-7-1**] 06:30PM BLOOD Neuts-75.2* Lymphs-16.6* Monos-6.1
Eos-1.8 Baso-0.3
[**2191-7-1**] 06:30PM BLOOD Glucose-127* UreaN-96* Creat-4.9*#
Na-132* K-5.2* Cl-105 HCO3-8* AnGap-24*
[**2191-7-1**] 06:30PM BLOOD Calcium-8.9 Phos-8.9*# Mg-2.1
[**2191-7-1**] 06:30PM BLOOD Osmolal-310
[**2191-7-1**] 06:30PM BLOOD ASA-NEG Acetmnp-NEG
[**2191-7-2**] 06:33PM BLOOD freeCa-1.09*
[**2191-7-1**] 09:55PM BLOOD Lactate-0.9
[**2191-7-1**] 09:55PM BLOOD Type-[**Last Name (un) **] pO2-74* pCO2-29* pH-7.09*
calTCO2-9* Base XS--20
.
[**2191-7-2**] 02:30AM BLOOD Type-[**Last Name (un) **] pH-7.19*
[**2191-7-2**] 06:01AM BLOOD Type-[**Last Name (un) **] pH-7.29*
[**2191-7-2**] 12:57PM BLOOD Type-ART Temp-36.1 pH-7.38 Comment-GREEN
TOP
[**2191-7-2**] 06:33PM BLOOD Type-[**Last Name (un) **] pH-7.41 Comment-GREEN TOP
.
[**2191-7-2**] 02:25AM BLOOD Glucose-194* UreaN-87* Creat-3.9* Na-135
K-4.2 Cl-110* HCO3-10* AnGap-19
[**2191-7-2**] 05:45AM BLOOD Glucose-176* UreaN-84* Creat-3.7* Na-135
K-3.5 Cl-109* HCO3-14* AnGap-16
[**2191-7-2**] 12:43PM BLOOD Glucose-151* UreaN-76* Creat-3.5* Na-141
K-3.0* Cl-106 HCO3-20* AnGap-18
[**2191-7-2**] 06:07PM BLOOD Glucose-144* UreaN-71* Creat-3.3* Na-140
K-3.3 Cl-105 HCO3-22 AnGap-16
.
Discharge Labs:
[**2191-7-6**] 03:44AM BLOOD WBC-8.7 RBC-3.76* Hgb-11.3* Hct-33.6*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.2 Plt Ct-200
[**2191-7-6**] 03:44AM BLOOD Glucose-106* UreaN-47* Creat-2.3* Na-141
K-3.9 Cl-110* HCO3-21* AnGap-14
[**2191-7-3**] 11:47AM BLOOD calTIBC-215* VitB12-177* Folate-12.2
Hapto-238* Ferritn-66 TRF-165*
.
Flexible Sigmoidoscopy [**2191-7-6**]:
Brief Hospital Course:
[**Age over 90 **] yo F with Chrohns, admitted in renal failure after worsening
diarrhea. Initially sent to the MICU then called out to the
floor.
ACUTE:
# Metabolic acidosis and acute on chronic renal failure
secondary to diarrheaa: The patient was admitted to the MICU
where she recieved 2L of D5W each with 3 amps of NaHCO3. Lytes
were check q4 hours and bicarb and pH steadily improved. Calcium
gluconate was given to replete ionized Ca. PICC line was placed
for better access. FeNa 0.6%, and Cr improved with IVF. When her
acidemia had corrected, she was called out to the floor. On the
floor, her creatinine and lytes continued to improve with
encouraged PO intake. She continued to have frequent diarrhea,
but her creatinine improved to baseline with PO intake only.
.
# Anemia - Initially admitted with a Hct of 33.6. Decreased to
21.7 within 2 days. And then bumped to 32.0 with 2 units of
PRBCs, and remained stable. Discharged with Hct of 33.6. By
report, guaiac positive brown stools in the MICU but guaiac
negative on the floor. Remained hemodynamically stable. No
etiology of the bleeding.
# Crohn's disease/diarrhea: Pt continued having diarrhea which
was guaic + without gross blood. Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] was consulted and
recommended a flexible sigmoidoscopy and stool studies for
evaluation. C diff toxin was negative. Flex sig revealed normal
colon. Biopsies sent and pending.
.
# Bactiuria: Pt was given levoflox x1 in the in ED. Given she
was asymptomatic, further abx were held in the MICU. UCx showed
no growth.
.
# Gout: Left medial ankle became swollen and red in the MICU.
Per the patient, she typically uses colchicine at home. She was
given one dose of colcichine with significant worsening of her
diarrhea, so further doses were held. Tylenol given for pain
control and her gout resolved without further intervention.
TRANSITIONAL:
# Stool culture - sent on [**2191-7-5**] and still pending on discharge
# Blood culture - sent on [**2191-7-1**] and pending
# Colon biopsies - taken by flex sig on [**2191-7-6**] and pending
Medications on Admission:
(per PCP [**Name Initial (PRE) 626**] [**2-/2191**])
ASA 81mg daily
amlodipine 10mg daily
glyburide-metformin 5-500mg [**Hospital1 **]
Coreg CR 80mg daily
simvastatin 80mg daily
losartan-HCTZ 100-25mg daily
hydroxizine 50 qHS and 25mg [**Hospital1 **] PRN
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. glyburide-metformin 5-500 mg Tablet Sig: One (1) Tablet PO
twice a day.
4. Coreg CR 80 mg Cap, ER Multiphase 24 hr Sig: One (1) Cap, ER
Multiphase 24 hr PO once a day.
5. losartan-hydrochlorothiazide 100-25 mg Tablet Sig: One (1)
Tablet PO once a day.
6. hydroxyzine HCl 50 mg Tablet Sig: One (1) Tablet PO at
bedtime: and 25mg [**Hospital1 **] PRN allergies.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) gram Injection once a week for 4 weeks: subcutaneous
injection. starting after daily injection x3.
9. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) gram Injection once a day for 3 days: subcutaneous
injection.
10. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) gram Injection once a month: subcutaneous injection. after
completion of weekly injection x4.
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehabilitation & [**Hospital **] Care Center - [**Location (un) **]
Discharge Diagnosis:
Acute on chronic kidney injury
Diarrhea
The Gout
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:
Ms. [**Known lastname **], you were admitted to the hospital for your severe
diarrhea. You were given IV fluids to improve your kidney
function. You also underwent a flexible sigmoidoscopy which
showed no evidence of Chrohns, biopsies were taken.
Medication Changes:
# Start albuterol inhalers up to four times daily as needed for
wheezing
# Start Vitamin B12 subcutaneous injection daily for 3 days,
then weekly for 4 weeks, then monthly
# Start iron daily
Followup Instructions:
Department: ADULT MEDICINE
When: WEDNESDAY [**2191-7-13**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8471**], 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: Nephrology
When: THURSDAY [**2191-7-21**] at 10:30 AM
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD
Phone: [**Telephone/Fax (1) 721**]
Department: Gastroenterology
When: [**2191-8-1**] 1:30pm
Building: [**Last Name (NamePattern1) **]. [**Hospital Unit Name **]
With: Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]
Phone: [**Telephone/Fax (1) 682**]
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
|
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48,076
| 176,653
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16881
|
Discharge summary
|
report
|
Admission Date: [**2187-7-7**] Discharge Date: [**2187-8-24**]
Date of Birth: [**2123-1-22**] Sex: M
Service: SURGERY
Allergies:
Captopril
Attending:[**Known firstname 4748**]
Chief Complaint:
right leg ischemia and infection
Major Surgical or Invasive Procedure:
[**2187-7-10**] R below-knee amputation and excision of infected [**Month/Day/Year **]
[**2187-7-11**] closure of R BKA site and groin incisions
[**2187-7-25**] incision and drainage, right common femoral to above
knee popliteal [**Month/Day/Year **] removal
[**2187-7-27**] Right groin washout, sartorius flap placement,
VAC-placement
[**2187-8-8**] Right IJ tunnel catheter
History of Present Illness:
64M well known to the vascular service s/p recent discharge from
our
service on [**2187-6-12**] after PTA RCIA and stent RCIA, then a redo
femoral
to posterior tibial artery bypass with PTFE, who presented with
leukocytosis to 26, nausea, emesis and ischemic right leg. Pt
was seen by Dr. [**Last Name (STitle) 1391**]
[**2187-7-6**] for discussion regarding failed bypass and need for
amputation. He was sent home and felt well until this am when he
was hypoglycemic to the 60s and nauseous. He vomited foodstuff
x3 and called the ambulance. He was initially evaluated at
[**Hospital3 **], where he complained of mild abdominal pain. +
BM this
am, Nn diarrhea, no Abx use,+ fevers and chills x 24hrs. No
sputum production, no dysuria, patient states he has been making
the usual amount of urine. No pain over kidney [**Hospital3 **] nor over
vascular [**Hospital3 **] site. Patient denies pain at RLE, but states
that
the mottling of RLE is worse. Sensation in RLE is intact and
there is no weakness. He was also noted to have minimal drainage
from the medial portion of his wound, stable for a few days, no
foul smell. Temperature on arrival to OSH 102.6 HR 110 with Bp
150/ 58. He was found to have a leukocytosis to 26.7 w 13 bands
at OSH. Vancomycin, Cipro and Flagyl given to patient prior to
transfer.
Past Medical History:
hypertension, congestive heart failure (EF 25-30%)
coronary artery disease, s/p MI , PVD, diabetes type 2, ESRD s/p
renal transplant [**10-14**], history of MRSA bacteremia
PAST SURGICAL HISTORY:
[**2176**]: CABGx3
[**2179-2-4**]: Right common femoral artery to above knee popliteal
with nonreverse greater saphenous vein
[**2180-6-20**]: Left upper arm A-V fistula
[**2180-6-20**]: Left femoral to above popliteal bypass [**Month/Day/Year **] with PTFE
[**10-14**]: renal transplant ([**Hospital6 **])
[**2181-2-15**]: Left common femoral artery to below-knee popliteal
artery
bypass with polytetrafluorethylene(PTFE)[**Month/Day/Year **].
[**2181-8-16**]: Re-do right femoral to below knee popliteal bypass with
PTFE
[**2187-6-4**]: Right lower extremity arteriogram with balloon
angioplasty of right common iliac artery and stent placement at
right common iliac artery
[**2187-6-7**]: Redo femoral to posterior tibial artery bypass with
PTFE
Social History:
married, lives in [**Location **] with wife, quit smoking [**2173**], denies
etoh/ilicit drugs
Family History:
DM2 - maternal & external, CAD - maternal (both deceased)
Physical Exam:
on admission:
VS: 99.3 96 133/65 18 98% RA
Gen: NAD, A&Ox3, Uncofortable c/o back pain, flushed, very warm
to touch
CVS: RRR
Pulm: Clear anteriorly
Abd: Soft, ND, mild tenderness in LLQ no Rebound, no guarding.
No CVA tenderness.
Ext: RLE with mottling and cyanosis foot, delayed cap refill.
Motor intact, sensation intact bilaterally. Medial distal thigh
with 0.3 cm opening with trace brown fluid, no fluctuance, no
collections palpated no erythema of thigh. Trace calf erythema
with blanching, no edema. Dry gangrene 1rst and 2nd digits.
Pulses: Right and left femoral palp. Bilateral popliteal
signals.
No signals on the right Dp and pt,
+ signals Left dp and PT
Pertinent Results:
[**2187-7-7**] 06:35PM LACTATE-3.1*
[**2187-7-7**] 07:00PM PT-29.4* PTT-31.2 INR(PT)-2.9*
[**2187-7-7**] 07:00PM NEUTS-84* BANDS-13* LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2187-7-7**] 07:00PM WBC-30.7*# RBC-3.90* HGB-11.3* HCT-33.2*
MCV-85 MCH-29.0 MCHC-34.1 RDW-14.9
[**2187-7-7**] 07:00PM CALCIUM-9.8 PHOSPHATE-2.6* MAGNESIUM-1.5*
[**2187-7-7**] 07:00PM GLUCOSE-258* UREA N-49* CREAT-1.8* SODIUM-133
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-20* ANION GAP-21*
[**2187-7-7**] 10:11PM LACTATE-3.4*
[**2187-7-8**] 08:10AM BLOOD WBC-24.9* RBC-3.76* Hgb-11.0* Hct-32.9*
MCV-88 MCH-29.3 MCHC-33.5 RDW-15.4 Plt Ct-192
[**2187-7-9**] 03:00AM BLOOD WBC-22.0* RBC-3.63* Hgb-10.4* Hct-31.2*
MCV-86 MCH-28.6 MCHC-33.2 RDW-15.0 Plt Ct-168
[**2187-7-9**] 07:52PM BLOOD WBC-17.6* RBC-3.16* Hgb-9.0* Hct-26.6*
MCV-84 MCH-28.4 MCHC-33.8 RDW-14.9 Plt Ct-166
[**2187-7-10**] 06:00AM BLOOD WBC-15.5* RBC-3.31* Hgb-9.4* Hct-28.0*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.9 Plt Ct-159
[**2187-7-11**] 03:45AM BLOOD WBC-14.3* RBC-3.53* Hgb-10.1* Hct-29.4*
MCV-83 MCH-28.5 MCHC-34.2 RDW-16.0* Plt Ct-179
[**2187-7-11**] 06:07PM BLOOD WBC-14.3* RBC-3.46* Hgb-9.9* Hct-29.1*
MCV-84 MCH-28.7 MCHC-34.2 RDW-16.3* Plt Ct-198
[**2187-7-12**] 03:26AM BLOOD WBC-12.6* RBC-3.40* Hgb-9.2* Hct-28.6*
MCV-84 MCH-27.1 MCHC-32.2 RDW-16.5* Plt Ct-201
[**2187-7-13**] 06:15AM BLOOD WBC-12.2* RBC-3.50* Hgb-9.8* Hct-29.8*
MCV-85 MCH-27.8 MCHC-32.7 RDW-16.3* Plt Ct-222
[**2187-7-14**] 09:00AM BLOOD WBC-12.1* RBC-3.68* Hgb-10.0* Hct-31.0*
MCV-84 MCH-27.1 MCHC-32.3 RDW-16.7* Plt Ct-282
[**2187-7-15**] 04:40AM BLOOD WBC-12.7* RBC-3.68* Hgb-10.2* Hct-30.6*
MCV-83 MCH-27.8 MCHC-33.4 RDW-16.8* Plt Ct-286
[**2187-7-16**] 06:30AM BLOOD WBC-11.9* RBC-3.79* Hgb-10.5* Hct-32.4*
MCV-86 MCH-27.6 MCHC-32.3 RDW-16.7* Plt Ct-337
[**2187-7-8**] 08:10AM BLOOD Glucose-162* UreaN-39* Creat-1.4* Na-136
K-4.4 Cl-101 HCO3-19* AnGap-20
[**2187-7-16**] 06:30AM BLOOD Glucose-200* UreaN-34* Creat-1.6* Na-129*
K-4.8 Cl-95* HCO3-20* AnGap-19
[**2187-7-8**] 08:10AM BLOOD CK-MB-18* cTropnT-0.13*
[**2187-7-8**] 07:30PM BLOOD CK-MB-17* MB Indx-2.9 cTropnT-0.28*
[**2187-7-9**] 03:00AM BLOOD CK-MB-12* MB Indx-1.7 cTropnT-0.34*
[**2187-7-8**] 08:10AM BLOOD tacroFK-4.1*
[**2187-7-16**] 06:30AM BLOOD tacroFK-8.9
[**2187-7-7**] 6:10 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2187-7-13**]): STAPH AUREUS COAG +.
[**2187-7-8**] 9:00 am BLOOD CULTURE SET 2.
**FINAL REPORT [**2187-7-11**]**
Blood Culture, Routine (Final [**2187-7-11**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2187-7-9**] 4:00 pm SWAB Site: GROIN RIGHT GROIN.
GRAM STAIN (Final [**2187-7-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2187-7-12**]):
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2187-7-13**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
[**2187-7-9**] 4:00 pm SWAB Site: LEG RIGHT THIGH [**Month/Day/Year **].
GRAM STAIN (Final [**2187-7-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
WOUND CULTURE (Final [**2187-7-12**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final [**2187-7-13**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
[**2187-7-10**] 2:53 pm BLOOD CULTURE Source: Line-cvl.
Blood Culture, Routine (Final [**2187-7-16**]): NO GROWTH.
[**2187-7-10**] 5:45 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2187-7-16**]): NO GROWTH.
CT abd/pelvis [**2187-7-7**]: 1. Post surgical change in the right
groin subjacent to superior aspect of recently placed femoral to
posterior tibial [**Month/Day/Year **]. 2. Bilateral common femoral to
popliteal grafts and right femoral to posterior tibial [**Month/Day/Year **] are
present, however, patency cannot be evaluated without contrast
administration. 3. Moderate diffuse atherosclerotic disease. 4.
4.4 x 4.0 cm infrarenal aortic aneurysm.
abdominal x-ray [**2187-7-15**]: No previous images. Bowel gas pattern is
essentially within normal limits without evidence of obstruction
or significant ileus. There are calcifications of the vas
deferens bilaterally, suggesting the possibility of underlying
diabetes.
ECHO:
Very poor image quality.The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. Overall left
ventricular systolic function is probably moderately depressed
(LVEF= 35 %) with global hypokinesis. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The ascending aorta is mildly dilated. The aortic valve
is not well seen. No aortic regurgitation is seen. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Very poor image quality. Moderately depressed LVEF
(35%). Compared to the prior report [**2187-7-16**] no definite change.
US:
IMPRESSION:
1. Minimally complex fluid in the left lower quadrant - consider
CT if
clinically warranted.
2. Small pleural effusion.
3. No hepatobiliary abnormality detected.
CT SCAN [**8-13**]:
IMPRESSION:
1. No left lower quadrant fluid collection is seen. Minimal free
fluid in
the abdomen without organized collection.
2. Small bilateral pleural effusions with associated compressive
atelectasis.
3. Extensive atherosclerotic calcification of the aorta,
coronary arteries, SMA, and renal arteries. There is a 4.3-cm
saccular infrarenal abdominal aortic aneurysm, unchanged
compared to prior.
4. Postoperative changes in the right groin.
Brief Hospital Course:
Patient was admitted to the vascular service and continued on
vancomycin and Zosyn. Transplant nephrology was consulted for
management of his immunosuppression and antihypertensives in the
setting of sepsis. Patient's Coumadin was held and he was given
vitamin K and started on a heparin drip. On [**7-9**], the decision
was made the the patient's right leg was not salvageable due to
critical ischemia, and he underwent a right below-knee
amputation with excision of his prior [**Month/Year (2) **]. Refer to Dr. [**Name (NI) 47545**] note for further details. The stump, thigh, and groin
incisions were left open and packed, due to tissue and blood
cultures positive for MRSA, and a JP drain was placed. Blood
cultures obtain on [**7-9**] and since have been negative. Patient
was transferred stable and extubated to the PACU and then to the
VICU. Patient received 1 u pRBCs for an HCT of 26.6, with
increase to 28.0. The heparin drip was discontinued. Due to
patient's prior cardiac history, including a bypass and MI,
serial troponins and EKGs (showing non-specific ST-T
abnormalities) were obtained. Troponins range from 0.33 to 0.44.
Patient was asymptomatic for chest pain and shortness of breath.
On [**7-10**] home cellcept was restarted and antihypertensives were
reintroduced. patient received 1 unit of pRBCs for an HCT of
25.9 with increase to 29.4. Cardiology was consulted and felt
troponin elevation was due to demand ischemia. Home diltiazem
was stopped and replaced with metoprolol.
On [**7-11**] patient went to the OR for closure of his stump, thigh,
and groin wounds after clearance from cardiology.Patient was
diuresed for fluid overload (h/o CHF with EF 25-30%), with
improvement in blood pressure. Patient's confusion, present
since admission, had resolved. Since [**7-14**] sodium has ranged
between 129 to 132, with institution of fluid restriction to 1 L
and holding of home chlorthalidone. On [**7-15**] patient experienced
nausea without vomiting. A cardiac workup and abdominal xray
were negative. Patient had loose stools without abdominal pain,
but c diff antigen was checked and was negative. Patient was
evaluated by infectious disease for his bloodstream infection,
with recommendations for 6 weeks of intravenous vancomycin.
Patient worked with physical therapy since his amputation. From
a surgical and infectious perspective patient was doing very
well. His amputation site was healing well. The erythema had
decreased. He had no fevers and his Wc and decreased to normal.
However starting on [**7-16**] he began to have a rise in his
creatinine. His ACE-I and lasix were stopped. Urine lytes
looked c/w decreased pre-load but UA looked c/w ATN. Gentle IV
fluids were re-instated. Tacrolimus level was elevated to 12
and with renal tx recommendations, dosing was decreased.
On [**7-22**] the patient had flash pulmonary edema and was
transferred to the ICU. He was stabilized on BIPAP. However,
on [**7-25**] he acutely became hypotensive and developed severe R
thigh pain. Zosyn was added empirically to his antibiotic
regimen. A CT of the pelvis was done which revealed infection
of his RLE bypass [**Last Name (LF) **], [**First Name3 (LF) **] he was taken to the operating room
emergently and the [**First Name3 (LF) **] was resected. Likely due to this
second hypotensive insult, his transplant kidney stopped
working. He was started on CVVHD and gradually transitioned to
intermittent HD. His left upper extremity fistula was difficult
to access because it was too deep, so a right IJ tunneled
dialysis line was placed by IR. A VAC dressing was applied to
his open thigh wound and eventually transitioned to wet to dry
dressings. Gastroenterology was consulted after he had several
episodes of guaiac positive stools Cdif was sent on multiple
occasions but always returned negative. Eventually he was
extubated successfully and transferred to the VICU. Psychiatry
was consulted for his depressed affect and he was started on
citalopram. Nutrition became an issue, as his appetite was
decreased due to depression and he could not tolerate tube
feeding via a dobhoff. He was started on Marinol and his PO
intake improved. He worked with physical therapy and it was
determined that he needed acute rehab. He also had an EGD on
[**8-20**] that was grossly normal.
By the time of discharge his oral intake was improved. He was
still getting intermittent dialysis three times a week. His
mood was somewhat improved. His vital signs were stable.
To note recieved four weeks Zosyn, this was DC. He will remain
on Vancomycin untill follow-up with ID.
Medications on Admission:
Humalog SS/Insulin detemir 30U AM, Coumadin 5mg (held)
Prograf 0.5 mg qAM/ 0.5mg qPM, Diovan 80mg daily
Diltiazem 30mg QID, Isosorbide mononitrate 30mg daily
Lipitor 80mg daily, Metolazone 2.5mg qMon
Lasix 80mg daily, Aspirin 325mg daily
Cellcept 250mg [**Hospital1 **], Chlorthalidone 50mg [**Hospital1 **]
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
3. nystatin 100,000 unit/g Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
DAILY (Daily) as needed for itching.
5. levothyroxine 25 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
6. sodium chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**2-11**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for stuffy nose.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Four (4) Inhalation Q4H (every 4 hours) as needed for wheezes.
8. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes.
9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**2-11**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. citalopram 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
13. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
14. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for yeast.
15. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
16. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
17. atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. insulin regular human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED).
19. dronabinol 2.5 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID (2
times a day).
20. nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
21. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q6H
(every 6 hours).
22. midodrine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
23. tacrolimus 0.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q12H
(every 12 hours).
24. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for for sleep.
25. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
26. mycophenolate mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
TID (3 times a day).
27. digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
28. loperamide 1 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO TID (3 times a
day).
29. 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.
30. heparin (porcine) 1,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection PRN (as needed) as needed for line flush.
31. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
32. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
33. Calcium Gluconate 2 g IV PRN ICa<1.12
34. Vancomycin 500 mg IV HD PROTOCOL
35. Ondansetron 4 mg IV Q8H:PRN nausea
36. 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.
37. Coumadin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: MD
will adjust to keep INR [**3-15**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Infected occluded right femoral to posterior tibial artery
bypass, s/p right BKA
MRSA sepsis
s/p kidney transplant
ATN currently HD dependent
hyponatremia
cardiac demand ischemia
atrial fibrillation, rate-controlled
type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) d/t R BKA
Discharge Instructions:
You underwent a right leg below-knee amputation and [**Location (un) **]
excision for infection and thrombosis. During your hospital
course, you received hemodialysis to facilitate your kidneys
post-operatively/
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
.
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
An appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Call Dr.[**Name (NI) 1392**] office at ([**Telephone/Fax (1) 4852**] to schedule an
appointment to be seen in 2 weeks after discharge.
[**2187-9-4**] 10:10a ID,[**Location (un) **],[**Location (un) **]
LM [**Hospital Unit Name **], BASEMENT
ID WEST (SB)
Call [**Telephone/Fax (1) 673**] to schedule an appointment with the transplant
service (Dr. [**Last Name (STitle) **]. You will need your your AV fistula
superficialized once you are off antibiotics.
You do not have aa cardiologist, you should make an appointment
with a cardiogist regarding your new-onset atrial fibrillation.
After rehab you should make an appointment with a psychiatrist
in your area.
You should follow up with nephrology at the [**Hospital6 **]
Completed by:[**2187-8-24**]
|
[
"401.9",
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"276.7",
"285.1",
"411.89",
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"518.5",
"428.0",
"787.20",
"424.1",
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"276.2",
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"309.0",
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"250.80",
"V62.84",
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icd9cm
|
[
[
[]
]
] |
[
"84.15",
"45.16",
"96.72",
"39.31",
"39.49",
"86.22",
"38.93",
"83.82",
"86.28",
"39.95",
"96.6",
"96.04",
"38.95",
"38.88"
] |
icd9pcs
|
[
[
[]
]
] |
21719, 21793
|
12659, 17278
|
300, 678
|
22069, 22069
|
3888, 8793
|
27708, 28469
|
3123, 3182
|
17638, 21696
|
21814, 22048
|
17305, 17615
|
22261, 24152
|
2242, 2994
|
3197, 3197
|
10236, 12636
|
228, 262
|
24164, 27008
|
27031, 27685
|
706, 2023
|
3211, 3869
|
22084, 22237
|
2045, 2219
|
3010, 3107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,052
| 118,182
|
4271
|
Discharge summary
|
report
|
Admission Date: [**2125-9-28**] Discharge Date: [**2125-10-2**]
Date of Birth: [**2064-1-10**] Sex: M
Service: [**Doctor Last Name 1181**]
CHIEF COMPLAINT: Fever and shortness of breath.
HISTORY OF PRESENT ILLNESS: Patient is a 61-year-old male
with a history of chronic obstructive pulmonary disease and
laryngeal cancer, status post laryngectomy and tracheostomy
and recurrent pneumonias, who two weeks prior to admission
developed shortness of breath and green sputum. He was given
a ten day course of levofloxacin, however, his symptoms
returned two days after completing the ten days at which time
he was restarted on levofloxacin. He presented to the
Emergency Department on the 4th with persistent symptoms and
fever to 102 despite that antibiotic therapy. He says that
he was still able to eat. He denied any headache, neck
stiffness, but did complain of myalgias. He denied any chest
pain, abdominal pain, dysuria or frequency. Patient reports
that his baseline oxygen saturation was 87% which is how he
presented and that he is comfortable at that level.
PAST MEDICAL HISTORY:
1. Laryngeal cancer, diagnosed in [**2110**], status post
laryngectomy, status post tracheostomy and radiation
therapy.
2. Patient had a right-sided pneumothorax in [**2112**].
3. Chronic obstructive pulmonary disease.
4. History of Methicillin resistant Staphylococcus aureus
pneumonia.
5. Hypothyroidism.
6. Cervical stenosis, status post laminectomy.
7. Right ear surgery.
8. Left clavicular fracture and surgery.
9. Right hemiplegia secondary to his laminectomy surgery.
MEDICATIONS ON ADMISSION: Synthroid 0.125 mg q.d., baclofen
40 mg q. 4 hours and trazodone 200 mg q.h.s.
ALLERGIES: Morphine and codeine which cause rash and Kefzol.
SOCIAL HISTORY: The patient is a retired truck driver. He
lives with his wife. [**Name (NI) **] had a 60 pack year smoking history
and quit 14 years ago. Reports occasional alcohol use.
FAMILY HISTORY: Significant for a sister with a brain tumor.
EXAM ON ADMISSION: Temperature of 101.2. Heart rate 109.
Blood pressure 96/56 down to 74/52. Respiratory rate 17.
Oxygen saturation 84% on room air. In general, he was easily
arousable. He did not appear in any respiratory distress,
but was ill-appearing. On head, eyes, ears, nose and throat
exam, he had a left eyelid droop. His pupils were equal and
reactive. His oropharynx was diffusely erythematous. His
neck had no jugular venous distention or lymphadenopathy.
The anatomy was very distorted from his laryngeal resection
and tracheostomy. His lungs had bibasilar crackles. His
heart exam was regular without murmur and tachycardic. His
abdomen was soft, nontender, nondistended. He had no
hepatosplenomegaly and normal bowel sounds. His extremities
had trace edema.
LABS ON ADMISSION: He had a white blood cell count of 20.4
with 83% neutrophils, and 10 lymphocytes. Hematocrit was
50.6 and platelet count 177,000. Chem-7 was not available at
the time. Urinalysis showed specific gravity of 1.005.
Positive for nitrate and moderate leukocyte esterase and
[**11-14**] white blood cells with many bacteria. Blood cultures
were drawn and were pending. Chest x-ray showed question of
a right lower lobe infiltrate.
HOSPITAL COURSE:
1. Infectious Disease: In the Emergency Department, the
patient was started on Ceftriaxone and vancomycin based on
his history of Methicillin resistant Staphylococcus aureus
pneumonia and became acutely hypotensive in the Emergency
Department. He was given three liters of normal saline for
blood pressure that got as low as systolic in the 60s at one
point. Right femoral line was placed and the patient was
started on dopamine 5 mg/kg with good response raising his
systolic blood pressure into the 100s. The patient remained
tachycardic in the 120s. Oxygen saturations maintained in the
80s on room air and improved to 93-100 on trachea collar.
Throughout the event the patient was mentating well. He was
admitted to the Medical Intensive Care Unit. It was unclear
at the time, what the cause of his hypotensive event was,
whether it was sepsis from the pneumonia or urinary tract
infection.
Once in the Medical Intensive Care Unit, he was started on
Neo-Synephrine to keep his mean blood pressure greater than
60. He was also bolused with fluids as necessary. He was
able to be quickly weaned from the Neo-Synephrine, was
continued on the vancomycin and Ceftriaxone and transferred
to the floor on [**2125-9-30**]. At the time of transfer,
his white blood cell count had come down to 10.5. His
hematocrit was 43.8. Electrolytes were within normal limits.
Blood cultures at the time were negative times two. Urine
culture grew out gram negative rods in which the speciation
was pending at that time. Sputum culture had coag positive
Staph sensitivities pending. Cultures eventually revealed
Methicillin resistant Staphylococcus aureus growing from the
sputum and Klebsiella pneumonia growing from the urine.
Methicillin resistant Staphylococcus aureus was sensitive to
vancomycin and the Klebsiella to Ceftriaxone, so he was
continued on those two agents.
The right femoral line was pulled and the catheter tip was
cultured. Catheter tip showed greater than 15 colonies of
gram negative rods and greater than 15 colonies of Staph
species. At the time of discharge, the gram negative rods
are not yet typed and the Staph species is coag negative,
likely sensitive to vancomycin. He was given a PICC line and
sent with prescriptions for vancomycin and Ceftriaxone to
complete a three week course of each. The gram negative rods
from the femoral line likely are either Klebsiella from the
initial episode of sepsis or E. Coli as a contaminant from
the groin area, both of which would be covered by the current
antibiotic regimen.
2. Cardiovascular: The patient's blood pressure remained
stable after the initial event. No further fluid boluses or
pressors were required.
3. Pulmonary: The patient had minimal cough and sputum
productive. Neither aggressive suctioning nor chest physical
therapy were necessary.
DISCHARGE DIAGNOSES:
1. Methicillin resistant Staphylococcus aureus pneumonia.
2. Klebsiella pneumonia urinary tract infection.
3. Sepsis.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: The patient was discharged to home with
VNA.
FOLLOW-UP: Patient is to follow-up with his primary care
doctor, [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **].
DISCHARGE MEDICATIONS:
1. Levothyroxine 125 mcg po q.d.
2. Baclofen 40 mg po q. 4 hours.
3. Trazodone 200 mg po q.h.s.
4. Ceftriaxone 1 gram intravenously q. 24 hours times 20
days.
5. Vancomycin 1 gram intravenous q. 12 hours times 20 days.
6. Naproxen 500 mg po q. 12 hours prn pain.
7. Percocet 1 tablet po q. 6 hours prn pain.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 16316**]
Dictated By:[**First Name3 (LF) 18523**]
MEDQUIST36
D: [**2125-10-2**] 17:22
T: [**2125-10-5**] 20:49
JOB#: [**Job Number 18524**]
|
[
"038.9",
"599.0",
"V10.21",
"496",
"482.41",
"V44.0",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6288, 6528
|
1978, 2029
|
6144, 6266
|
6551, 7166
|
1626, 1769
|
3282, 6123
|
174, 206
|
235, 1092
|
2832, 3264
|
1114, 1599
|
1786, 1961
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,482
| 122,797
|
45694
|
Discharge summary
|
report
|
Admission Date: [**2183-9-10**] Discharge Date: [**2183-10-10**]
Date of Birth: [**2129-1-14**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atazanavir / fresh fruit / Cephalosporins /
raltegravir / maraviroc / Hydralazine
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Fluid overload, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 yo F with h/o HIV on HAART (CD4=437 [**8-3**]), DM2 (diet
controlled), CKD, R-sided CHF w/severe pulm HTN, with two recent
admissions to [**Hospital1 112**] for hypersensitivity reaction c/b
polymicrobial bacteremia (including VRE/MRSA), iatrogenic
[**Location (un) 3484**], C. diffcolitis (currently finishing a course of oral
vanco). HAART and CHF regimen (hydral, metoprolol, isosorbide,
torsemide) held on d/c; CHF regimen switched to ethacrynic acid
and clonidine, now
with increased weight from 118 baseline to 155 lbs.
Pt was admitted to [**Hospital1 112**] from [**Date range (1) 97386**]/12 after p/w severe rash
with desquamation of skin on palms, soles and oral/vaginal
mucosal involvement. Suspicious for SJS but w/u in burn unit at
[**Hospital1 112**] ultimately felt more c/w desquamating lichenoid
hypersensitivity reaction thought to be from ART, specifically
recently started raltegravir and maraviroc (new as of [**5-3**]) +/-
ceftriaxone use. Admit there c/bCoNS BSI (?line-related), ARF,
mental status changes, brief bout of iatrogenic [**Location (un) **]
presumed d/t mucosal use of topical steroids. Ultimately d/c to
[**Hospital **] rehab and returned [**Date range (1) 97387**] with polymicrobial
bacteremia (VRE, MRSA, proteus, klebsiella and ESBL Ecoli--?skin
breakdown, ?line) and cdiff colitis along with worsening of her
rash again. She was again briefly in the burn ICU and intubated,
but quickly transferred to the floor where skin improved with
topical therapies (bactroban,
steroid cream, vaseline) and she was treated with
imipenem/vanco/metronidazole for her bacteremia and PO vanco for
C diff.
She was also restarted on a new HAART regimen [**2183-8-29**] after
discussion with her ID team of fosamprenavir 1400mg [**Hospital1 **],abacavir
300mg [**Hospital1 **] and lamivudine 150mg daily. During this time her
prior CHF regimen of
furosemide/metoprolol/isosorbide/hydralazine was stopped,
reportedly d/t concerns that some may have contributed to her
rash though association not clear. She was ultimately d/c'd
home [**2183-9-5**] off many of her long-standing meds and newly on
ethacrynic acid 50mg [**Hospital1 **] and clonidine 0.1mg daily for her HTN
and CHF.
Since d/c home patient reports she has felt increasingly SOB for
the last 3 days and is having increased LE edema. She gets SOB
walking down her [**Doctor Last Name **] and has gained >10lbs since d/c (138 on
d/c up to 155 in clinic). Today she describes that she could not
walk to the door of her hospital room without becoming markedly
fatigued. She denies CP/palps/F/C/abd pain/N/V. She has been
taking her meds as prescribed. She reports not using the
recommended ointments and creams today and is c/o cracking of
the skin on her hands and feet as well as diffuse dryness and
itching. Lips still sore, but no vaginal soreness currently.
Patient arrived to floor this AM eating 2 slices of pizza.
On the floor, vs were: T98.7 P90 BP143/73 R O2 sat 100RA
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
- HIV, diagnosed in [**2158**], on HAART (CD4=437 [**8-3**]),
-Patient recently presented to [**Hospital1 18**] ED on [**7-11**] with severe
desquamating rash and transferred to [**Hospital1 112**] burn unit. Rash was
determined to desquamating lichenoid hypersensitivity reaction
which was treated by stopping ART, avoidance of cephalosporins
and drugs of abuse such as cocaine. Dermatology was consulted on
admission and recommended wrapping patient in saran wrap and
using Vaseline for skin care. No mucosal involvement was noted
on admission. She was given copious IVF, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Hugger was
utilized given insensible losses and impaired thermoregulation.
Dermatology re-evaluation on [**2183-8-11**] revealed worsening mucosal
involvement and new erythroderma. This raised concern for
progression of her severe drug hypersensitivity eruption. This
was felt to be secondary to ART, specifically abacavir and
lamuvidine, and potentially ceftriaxone to her recent admission
to [**Hospital1 112**]. She is not currently on any related medications. Of
note, her last attempted ART was on [**7-29**] resulting in
maculo-papular rash. s/p Transfer to [**Hospital1 756**] Burn Unit [**8-11**]
- Hepatitis C - no response to PEG-IFN/Ribavirin
- Shingles
- Migraines
- HTN
- DM II
- History of MRSA
- Recurrent UTI
- Recurrent nephrolithiasis
- HSV
- Pancytopenia [**1-23**] HAART medications
- CKD baseline creatinine 2.85-3.0, followed by Dr. [**Last Name (STitle) 118**]
(nephrolithiasis, pyelonephritis & perinephric abscess c/b
perinephric hematoma during stenting [**8-/2182**])
Social History:
Lives at home in [**Location (un) 745**]. Has 3 children: one son [**Name (NI) 2855**] is her
HCP, one daughter with hydrocephalus/seizure disorder is in a
nursing home ([**Location (un) 511**] Pediatric Care), 3rd child (female)
died in childhood from complications of HIV.
- Worked as a counselor (no longer working)
- Former heavy smoker, currently 1 pack q2 weeks.
- Former ETOH abuse, none since [**2174**]
- Former IVDU, none since [**2174**]
- Recent cocaine use ([**2182**])
Family History:
- Father died of MI
- Mother with diabetes
- Sister with lung cancer at age 38 and was a heavy smoker.
- Brother with diabetes
Physical Exam:
ON ADMISSION
Vitals: T98.7 P90 BP143/73 R O2 sat 100RA Weight 155.8kg
Gen: chronically ill appearing female, NAD
HEENT: sclera anicteric, OP with persistant desquamation/dryness
around lips, no segmented/well demarcated areas of
hyperpigmentation of oral mucosa
Neck: supple; +JVD up to angle of mandible
Cor: S1S2, RRR, holosystolic murmur across precordium,
hyperdynamic, ?RV heave
Lungs: CTAB, no wheezes/rales
Abd; distended, normal BS, soft, NT, +hepatomegaly, no
splenomegaly, +fluid wave
Ext: 3+pitting edema up to thighs b/l
Skin: diffusely dry and flakey; areas of persistent
cracking/oozing on palms, soles by heels and b/t toes, no other
obvious
desquamation or blistering at this point
ON DISCHARGE
VS: 98.5 127/66 64 18 100%RA
I/O: 1010/450+; Wt: 58.9kg-->58.7
GENERAL - Sleeping in bed this morning, NAD
HEENT: sclera anicteric, OP with persistant hypopigmented
desquamation around lips, no segmented/well demarcated areas of
hyperpigmentation of oral mucosa
NECK: supple, no appreciable JVD
HEART: S1S2, RRR, holosystolic murmur across precordium, faint
diastolic murmur auscultatation
LUNGS: B/L crackles, new today, no wheezing, rhonchi
ABD; distended, normal BS, soft, NT, +hepatomegaly, no
splenomegaly
EXT: 1+ LE edema unchanged w/tenderness, no joint erythema.
SKIN: desquamation slowly healing, minimal cracking on palms,
soles by heels and b/l toes, no other obvious desquamation or
blistering
Pertinent Results:
ON ADMISSION
[**2183-9-10**] 08:00PM GLUCOSE-130* UREA N-37* CREAT-2.0*#
SODIUM-138 POTASSIUM-4.9 CHLORIDE-111* TOTAL CO2-16* ANION
GAP-16
[**2183-9-10**] 08:00PM CALCIUM-7.9* PHOSPHATE-3.9 MAGNESIUM-1.7
[**2183-9-10**] 08:00PM WBC-8.4 RBC-2.68* HGB-7.9* HCT-26.3* MCV-98
MCH-29.4 MCHC-30.0* RDW-18.2*
[**2183-9-10**] 08:00PM PLT COUNT-155#
[**2183-9-10**] 08:00PM PT-12.1 PTT-33.7 INR(PT)-1.1
Notable Labs/Reports
CXR [**9-10**]
Cardiomegaly is unchanged, moderate to severe as well as
prominence of the main pulmonary artery, findings that might be
consistent with pulmonary hypertension. Lungs are essentially
clear. No focal consolidations, pleural effusion, or
pneumothorax is seen. No definitive pulmonary edema is noted as
well.
ECG [**9-10**]
Sinus rhythm. Left atrial abnormality. Non-specific ST segment
changes in the anterolateral leads. Borderline low voltage in
the limb leads. Compared to the previous tracing of [**2183-8-9**] the
ventricular rate is slower.
TEE [**2183-9-26**]:
The left atrium is normal in size. 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.There are simple atheroma in the
aortic arch and descending thoracic aorta. Overall left
ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. Mild to moderate ([**12-23**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate ([**12-23**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. No discrete
vegetation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate to severe tricuspid regurgitation. Mild
moderate aortic regurgitation. Mild to moderate mitral
regurgitation. No discrete vegetation or abscess seen. Moderate
pulmonary artery systolic hypertension. Simple atheroma in the
arch and descending thoracic aorta.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD
Type and Screen AB positive:
In the future, Ms. [**Known lastname 97330**] should be transfused with E
antigen
negative red cells. Approximately 70% of ABO compatible blood
will be E
antigen negative.
[**2183-9-23**] 11:20 pm BLOOD CULTURE
**FINAL REPORT [**2183-9-28**]**
Blood Culture, Routine (Final [**2183-9-28**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # 355-5657B [**2183-9-23**].
Anaerobic Bottle Gram Stain (Final [**2183-9-24**]):
Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 650PM
[**2183-9-24**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2183-9-26**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2183-9-24**] 1:00 pm URINE
**FINAL REPORT [**2183-9-25**]**
URINE CULTURE (Final [**2183-9-25**]): NO GROWTH.
[**2183-9-26**] 3:19 am BLOOD CULTURE Site: CENTRAL LINE
**FINAL REPORT [**2183-10-2**]**
Blood Culture, Routine (Final [**2183-10-2**]): NO GROWTH.
DISCHARGE LABS:
[**2183-10-10**] 05:37AM BLOOD WBC-6.4 RBC-2.42* Hgb-7.1* Hct-22.5*
MCV-93 MCH-29.3 MCHC-31.4 RDW-18.1* Plt Ct-171
[**2183-10-4**] 05:46AM BLOOD PT-12.1 PTT-45.1* INR(PT)-1.1
[**2183-10-10**] 05:37AM BLOOD Glucose-83 UreaN-45* Creat-2.6* Na-128*
K-4.8 Cl-99 HCO3-19* AnGap-15
[**2183-10-10**] 05:37AM BLOOD Calcium-7.6* Phos-4.5 Mg-2.0
Brief Hospital Course:
54F with PMHX HIV on HAART, R sided Heart failure, and recent
erythrodermic skin eruptions s/p 2 complicated burn unit
admissions since [**Month (only) 205**] possibly med induced now presents in fluid
overload on new CHF regimen of ethacrinic acid.
ACTIVE ISSUES:
#Fluid Overload/Weight Gain- Likely an acute on chronic CHF
exacerbation. Patient presented approximately 30 pounds above
her dry weight (155.8 lb on admisson). Some of her fluid
overload may be attributed to steroid use. She was treated with
Lasix gtt and Metolazone until Euvolemic and her weight was
54.7kg. The Heart Failure service suggested that she undergo a
RHC and Echo during this hospital admission to assess her
intravascular volume and severity of pulmonary HTN. She was
diuresed until euvolemic. However, RHC was not pursued during
this admission [**1-23**] to hypotension and sepsis (see below). Her
diuretics were d/c prior to discharge [**1-23**] worsening kidney
function thought to be [**1-23**] to intravascular volume depletion
(see below). Her volume status will be monitored closely and
diuretics reinitiated when appropriate.
#MRSA Septiciemia: Patient was febrile and hypotensive on the
general medicine floor. Was transferred to the MICU for
suspected sepsis and need for central venous access. Patient was
transferred on [**2183-9-24**] AM. A left femoral CVL was placed since
patient would not cooperate for a IJ line placement. She was
found to have four positive blood cxs with MRSA. She was
initially started on Daptomycin IV and Meropenem IV and
eventually narrowed to Vancomycin IV (ID was following). She had
a fever on [**2183-9-24**] AM, was subsequently cultured, and did not
have any fevers since that time. She was bolused a total of 2L
over the first 24 hours of her MICU admission. Has not had any
hypotensive events since the first 24 hours. A TTE and TEE were
performed which did not show evidence of IE.
#Erythroderma/Skin Breakdown
Rash appears stable with fresh wound on palms of hands, heels,
and waist. Skin break down is causing the patient a lot of pain.
Derm recommended Bactroban cream TID on affected areas and to
keep gloves on hands at all times. She was given oxycodone for
pain control. During her hospitalization, her skine
desquamation decreased and skin fissures began to heal nicely.
Derm recommendations were ordered while she was in the MICU. She
was also started on Benadryl 12.5mg IV q6h for puritus since the
patient scratches at her skin (risk for further bacteremia).
Once the puritus improved IV benadryl was discontinued and she
was continued on the skin regimen as recommended by Dermatology
as listed above.
#C Diff Infection
She was continued on Vancomycin PO until [**9-17**] and then stopped.
On [**9-23**] she spiked a fever to 101.4, and had increased watery
BM's. Vancomycin PO was restarted at 125mg PO Q6H. Continued
this dose while the patient until her vancomycin IV was
completed on [**10-8**]. During this time her diarrhea decreased in
frequency to maximum of 2 per day and stools began to become
more formed.
# Hyponatremia: Sodium has been down trending over the last few
days, 128 today. Serum osmolality is isotonic at 285 on [**10-5**].
Serum Lipid levels are pending. However, given her complicated
medical history she could have potentially hypertonic and
hypotonic etiologies for her hyponatremia making her serum
osmolality difficult to interpret. Her volume status is
difficult to assess given known dCFH and low albumin with
possible third spacing. Hyponatremia is likely multifactorial
given patient on diuretics for CHF. AM Cortisol was 11, 13.3 on
repeat slightly lower than expected, patient was on prednisone
5mg daily which was stopped prior to this admission, so unlikely
that adrenal insufficiency is contributing, but is possible.
Would not pursue CRH stimulation test at this point given
multiple contributing factors to her hyponatremia, which appears
to be improving with accurate free water restriction. She also
had a TSH of 50, fT4 0.79, but this is after she became septic
and found to have MRSA bacteremia as well as chronic C. diff
which can elevate the TSH. Lipid panel showed slightly elevated
triglycerides otherwise unremarkable. Combination of
hyponatremia and hyperkalemia may be [**1-23**] to intravascular volume
depletion leading to increased proximal tubule reabsorption of
both sodium and potassium. Therefore, due to intravascular
volume depletion we stopped her diuretics. Her electrolytes and
fluid status will be monitored very closely by her PCP and
diuretics reintroduced when appropriate.
#Chronic Kidney Disease
Baseline creatinine around 2, and increased to 2.9 with
diuresis. At this point, patient was euvolemic and aggressive
diuresis was discontinued. She was switched to Torsemide as
outlined above for discharge. Trending down while in the MICU
and stabilized around 2 upon transfer to the floor where it
remained until discharge, but increased to 2.6 prior to
discharge which is when diuretics were held as outlined above.
#Positive Urine culture- growing Klebsiella- as per ID, can hold
off treating unless she is symptomatic. Avoiding Foley catheter.
Was treated briefly with Meropenem while in ICU and then
coverage was stopped. Repeat urine culture was negative.
#Metabolic Acidosis: Bicarb was 16, likely from RTA. Currently
19 with diuresis. Her Chem panel was followed daily and Bicarb
flutuated between 19-20 up until discharge. Given her overall
decline in kidney function, this will continue to be monitored
upon discharge while off diuretics for better assessment of her
kidney function.
# Elevated Uric Acid: Noted on [**9-17**] to be 18.5 -- but now
trending downward. Unclear cause. Patient has a family history
of gout. Can be elevated uric acid with heart failure. No clear
signs of active gout on exam, but given aggressive diuresis, she
is at risk for precipitation of crystals. Repeat on [**10-3**] was
13. There were no signs of acute gout attack up until
discharge.
CHRONIC ISSUES:
#HIV
Currently 10d into new HAART with unboosted fosamprenavir 1400mg
[**Hospital1 **], abacavir 300mg [**Hospital1 **] and lamivudine 150mg daily. These
medications were ontinued while she was inpatient. Lamuvidine
was decreased to 100mg due to renal insufficiency while in the
MICU and was continued at this dose until discharge.
TRANSITIONAL ISSUES:
- Patient was discharged off diuretics, please weigh her daily.
If weight increases by more than 3 lbs, please evaluate for
volume overload and consider restarting diuretics with Torsemide
- Patient should be evaluated by OT and social work prior to d/c
home
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. CloniDINE 0.1 mg PO BID
Hold for SBP<90
2. Ethacrynic Acid 50 mg PO BID
3. Fosamprenavir 1400 mg PO Q12H
4. LaMIVudine 150 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. PredniSONE 5 mg PO DAILY
7. vancomycin *NF* 250 mg Oral Every 6 hours Duration: 7 Days
8. Abacavir Sulfate 300 mg PO BID
Discharge Medications:
1. Abacavir Sulfate 300 mg PO BID
2. Fosamprenavir 1400 mg PO Q12H
3. LaMIVudine 150 mg PO DAILY
4. Aquaphor Ointment 1 Appl TP DAILY
5. Aveeno Bath 1 PKG TP [**Hospital1 **]
6. BuPROPion (Sustained Release) 150 mg PO QAM
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO BID severe pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth twice daily
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
CHF exacerbation (worsening heart failure)
MRSA Bacteremia (blood stream infection)
Clostridium difficile colitis (diarrhea caused by an infection)
Discharge Condition:
Mental Status: Confused - sometimes, but otherwise alert and
oriented.
Level of Consciousness: Alert and interactive, but lethargic at
times.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 97330**], you were admitted to [**Hospital1 827**] after presenting with extra fluid in your legs
and lungs and worsening heart failure. You were treated with
water pills to get the extra fluid off of your body. You also
have a blood stream infection and infection in your bowels
causing diarrhea that both were treated with antibiotics.
Overall, your medical condition is much improved, but because
you are very weak you will be discharged to a rehabilitation
center. You will not be discharged on water pills, but Dr.
[**Last Name (STitle) **] and the physicians at the rehabilitation center will be
monitoring your fluid status very closely and will restart the
water pills if your weight starts to increase meaning that you
are holding on to too much fluid.
You were not eating very much while in the hospital and we
encourage you to increase your food intake so that you do not
become too malnourished. Please limit your salt intake to 2
grams per day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please see below for your follow-up appointments.
It was a pleasure caring for you and we wish you a speedy
recovery!
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2183-10-15**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: THURSDAY [**2183-10-16**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,821
| 127,376
|
48613
|
Discharge summary
|
report
|
Admission Date: [**2135-10-16**] Discharge Date: [**2135-10-22**]
Service: MEDICINE
Allergies:
Neurontin / Keflex / Bactrim
Attending:[**First Name3 (LF) 242**]
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
L hip, femur ORIF
History of Present Illness:
Briefly, Ms. [**Known lastname **] is a [**Age over 90 **] yo female with a history remarkable
for HTN, DM type 2, atrial fibrillation s/p pacemaker placement,
not on Coumadin [**3-2**] history of hemorrhagic CVA, now brought in
from home following a fall.
.
Per patient, she was on her way to the bathroom without her
walker, and fell on her left side. She reports acute left leg
pain, with inability to move it. She denies preceding
lightheadeness, no palpitations, no chest pain, no shortness of
breath. She did not hit her head.
.
She was brought in by EMS. In ED, HR 65, BP 117/44, RR 16, Sat
98% on RA. X-rays consistent with left subcapital fracture and
left mid shaft fracture, as well as osteopenia. Given Morphine 1
mg IV X 3.
.
ROS negative for history of exertional discomfort, no history of
shortness of breath, no orthopnea, no PND. She is currently
undergoing investigation of multiple pulmonary nodules, and was
scheduled for bronchoscopy on Monday with BAL for further eval.
Diabetes well-controlled
Past Medical History:
1. Atrial fibrillation s/p pacemaker placement. Previously on
Coumadin, discontinued [**3-2**] hemorrhagic CVA.
2. LV systolic dysfunction per echo [**3-/2131**], with EF 30-35%, 2+
MR and 2+ TR.
3. DM type 2, last hemoglobin A1c 7.1 on [**2135-4-1**]
4. Hypertension
5. Hypercholesterolemia
6. Chronic renal insufficiency with baseline creatinine 1.6-1.9
7. Mild dementia
8. Peptic ulcer disease
9. History of CVA X 3
10. Negative colonoscopy [**1-/2132**], negative EGD [**2-/2134**]
11. Multiple pulmonary nodules found on chest CT, under
investigation. Planned for bronchoscopy with BAL on [**10-17**].
Differential includes vasculitis, malignancy or infection.
Social History:
She currently lives with her daughter, and goes to day care 5
days a week. No tobacco, no EtOH. She ambulates with a walker at
baseline.
Family History:
noncontributory
Physical Exam:
GEN: Appears comfortable at present. Lying flat in bed.
Restraints in place.
HEENT: Anicteric. PERRLA, EOMI. OP clear, MM dry.
NECK: Distended EJV, JVP difficult to assess.
RESP: Bilateral inspiratory crackles at bases, ?slightly
improved from yesterday.
CVS: RRR. Normal S1, S2. No S3, S4. faint SEM heard throughout
precordium, loudest at lower sternal border.
GI: Abdomen soft, mild LLQ tenderness. No rebound or guarding.
NABS.
EXT: 1+ pitting edema in both lower extremities. Distal pulses
intact (by doppler), sensation to light touch intact, able to
wiggle toes.
RLE pain with hip flexion. Not externally rotated, no tenderness
to palpation. Pain with palpation or passive ROM R knee, but
improved.
NEURO: limited sensorimotor examination intact in both LE,
AA&Ox2 today (person and place)
Pertinent Results:
[**2135-10-16**] 12:44AM GLUCOSE-110* UREA N-30* CREAT-1.7* SODIUM-141
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15
[**2135-10-16**] 12:44AM WBC-7.2# RBC-3.79* HGB-11.9* HCT-35.7* MCV-94
MCH-31.3 MCHC-33.2 RDW-15.7*
[**2135-10-16**] 12:44AM NEUTS-67.0 BANDS-0 LYMPHS-24.5 MONOS-6.2
EOS-2.1 BASOS-0.2
[**2135-10-16**] 12:44AM PLT COUNT-141*
[**2135-10-16**] 12:44AM PT-12.1 PTT-25.8 INR(PT)-1.0
[**2135-10-16**] 12:05AM URINE HOURS-RANDOM
[**2135-10-16**] 12:05AM URINE GR HOLD-HOLD
[**2135-10-16**] 12:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2135-10-16**] 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
.
L hip XRAY: Left femur, AP and lateral on [**2135-10-17**]; since
[**2135-10-16**], patient is status post placement of three [**Doctor Last Name 33754**] pins
transfixing the left femoral subcapital fracture. There is also
a new intramedullary rod transfixing a comminuted fracture of
the mid femur shaft. Distal fracture fragement is laterally and
posteriorly displaced. No evidence for hardware loosening. A
large suprapatellar joint effusion is present. Postoperative
edema, emphysema and skin staples are noted.
.
R knee XRAY: Frontal and lateral views of the right knee
demonstrate generalized osteopenia. There are some mild
degenerative changes and vascular calcifications. No fracture is
identified.
Brief Hospital Course:
#. Hip/femoral fracture: The patient sustained a L femoral neck
and comminuted midshaft fracture during her mechanical fall at
home. Pain control was achieved with morphine. Cardiology
evaluation revealed that the patient was of moderate risk for a
medium risk procedure, and the patient was cleared for surgery.
The patient was taken to the OR where a left hip ORIF was
performed, with good postoperative result. The patient continue
to complain of pain in the RLE, particularly the knee. Plain
films of the right knee revealed no fracture, although there was
a question of ligamentous laxity with valgus force on
orthopedics examination. The patient could not get a right knee
MRI due to her pacemaker. The patient was fitted with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
brace to the right knee, which improved her ability to
weight-bear. Lovenox was used for postoperative DVT
prophylaxis, and should be continued for 6 weeks
postoperatively. The patient was discharged to rehab for
strength, balance, and functional mobility training, with
touch-down weightbearing to the LLE. Pain control was acheieved
on discharge with Percocet. Several days prior to discharge,
the patient suffered a fall from bed. Head CT was negative, and
hip films revealed no interval changes to the postoperative
sites.
.
#. Fever: early in the postoperative period the patient spiked a
temperature to 101.9. A urine culture and urinalysis was
checked and was unremarkable. A CXR was performed that revealed
a questionable L retrocardiac opacity. The patient was judged
to be a large aspiration risk as well, and so Levaquin and
Flagyl were started. The fevers improved on this regimen, and
the patient was discharged with instructions to complete a 7 day
course.
.
#. Pulmonary nodules: The patient is in the process of having an
outpatient workup performed by Dr. [**Last Name (STitle) **] [**Name (STitle) **] for her
pulmonary nodules. Dr. [**Last Name (STitle) **] [**Name (STitle) **] was made aware of the
patient being in house. Further work-up is deferred until the
current medical problem has been stabilized.
.
#. DM type 2: The patient's outpatient oral hypoglycemic regimen
was held on admission, and the patient was placed on a regular
insulin sliding scale. The patient had good glucose control on
this regimen during her hospitalization. The patient was
restarted on her usual outpatient oral regimen on discharge.
.
#. Cardiovascular: The patient was continued on her home regimen
of [**Last Name (LF) 17339**], [**First Name3 (LF) **], and lopressor during her stay. She was also
given her usual dose of PO lasix. No changes were made to this
regimen during her stay. Because she received several units of
blood and IV hydration in the early postoperative period, IV
lasix was used to maintain slightly negative I/O ratio.
.
#. Afib: The patient has atrial pacing on her PM. Amiodarone
was continued per her usual outpatient regimen. No changes were
made to her regimen during her stay. Precautions were taken in
the operating room by anesthesiology given her prolonged use of
amiodarone.
Medications on Admission:
Glyburide 1.25 mg PO QAM
FeSO4 325 mg PO BID
[**First Name3 (LF) **] 20 mg PO QAM
Lopressor 12.5 mg PO BID
Avandia 4 mg PO QD
Lasix 20 mg PO QAM
Amiodarone 200 mg PO QAM
Aspirin 325 mg PO QAM
Tylenol qAM
Timolol 0.5% 1 drop left eye qAM
Xalatan 0.5% 2 drops OU qHS
Albuterol MDI 2 puffs [**Hospital1 **]
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
13. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mL syringe
Subcutaneous Q24H (every 24 hours): Please continue for a total
of 6 weeks postoperatively.
14. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
15. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Dx:
L hip fracture
L femur fracture
Delirium
CHF
Discharge Condition:
Stable
Discharge Instructions:
If you experience fevers, chills, nausea, vomiting, chest pain,
shortness of breath, or any other concerning symptoms, contact
your physician or return to the emergency room.
Followup Instructions:
Please follow up with your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], at
the date and time indicated. Please follow up with Dr. [**Last Name (STitle) **]
(Orthopedics) in [**4-1**] weeks. Call [**Telephone/Fax (1) 9118**] for an
appointment.
.
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2135-11-9**]
10:40
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2135-11-14**] 10:45
.
Completed by:[**2135-10-21**]
|
[
"998.89",
"997.3",
"294.8",
"E885.9",
"250.00",
"428.0",
"V45.01",
"593.9",
"427.31",
"820.09",
"733.90",
"780.09",
"401.9",
"518.89",
"507.0",
"821.01",
"276.0",
"272.0",
"780.6",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.55",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
9266, 9345
|
4487, 7624
|
248, 268
|
9446, 9455
|
3026, 4464
|
9678, 10396
|
2176, 2193
|
7979, 9243
|
9366, 9425
|
7650, 7956
|
9479, 9655
|
2208, 3007
|
198, 210
|
296, 1315
|
1337, 2006
|
2022, 2160
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,916
| 136,031
|
37538
|
Discharge summary
|
report
|
Admission Date: [**2102-12-5**] Discharge Date: [**2102-12-8**]
Date of Birth: [**2040-12-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a 61yo RHF with SCA-3 who was admitted to [**Hospital1 18**] after an
episode on unresponsiveness. She was in her usual state of
health on Tuesday when she slumpt down in her wheelchair. She
claims she was aware of what was going on during this entire
event but unable to open her eyes or talk. Nursing staff tried
to get her to respond but she could not. EMS arrived and
performed sternal rubs, which she claims to remember, again she
was not responding. She remembers the EMT's placing an IV en
route to the OSH. At [**Hospital3 4107**] FS 193, She received Narcan
without effect. CT head was negative for bleed. Tox screen was
withinl normal. CXR was negative. She was intubated for airway
protection and transferred to [**Hospital1 18**] for further management. In
the MICU she was following commands but initially only breathing
when encouraged to do so. After sedation was weaned, she
self-extubated. She was responsive, verbal, and cooperative
thereafter. Her only complaint was a sensation of a sensation of
falling to the left. Today she feels pretty much back to
baseline and has a fairly clear recolection of all the recent
events. She denies any recent HA's, worsening vision symptoms,
N/V, etc... She denies ever havinng a seizure or similar event
in the past.
She saw her outpateient neurology, Dr [**Last Name (STitle) **] on [**11-22**] at which
time pt appeared much worse than baseline to her. Dr.
[**Last Name (STitle) 3675**] checking CBC, UA to look for possible infection and
also increased her Sinemet dose. UA was not performed at that
time. Also of note, pt apparently was in the [**Hospital1 756**] ER s/p MVA
on [**11-27**]. She apparently hit her head during that time.
ROS:
Gen: No fevers/chills/sweats, CP, SOB, palpitations, N/V, URI,
cough, abd pain, dysuria, melena, BRBPR, rash, travel
Past Medical History:
SCA3 - [**Last Name (un) 32665**]-[**Doctor Last Name 122**]-Azorean disease - baseline findings per
primary neurologist include nystagmus, slow speech, dystonic
face, distal weakness, ataxia L>R
- Depression
- Psychosis
- Anxiety
- UTI causing altered mental status [**1-23**] at [**Hospital1 112**]
- HTN
- HLD
Physical Exam:
VS: BP 103/85 HR 89 100RA
GEN: Alert, following commands, in NAD
HEENT: MMM, no cervical, supraclavicular, or axillar LAD, neck
is supple, no JVD
CV: RRR, NL S1S2 no S3S4 MRG
PULM: CTABL, no wheezes or ronchi
ABD: soft, nontender, nondistended, no masses or HSM, + BS
EXT: contraction of right 1st finger at DIP; no clubbing,
tremors, or cyanosis, no edema, pulses 2+
SKIN: No skin breakdown, no rashes, no petechiae; healing
excoriations on knees bilaterally
NEURO: Pupils are symmetric and reactive to light, Unable to
perform upgaze bilaterally, horizontal nystagmus noted,
remaining CNs intact though facial movement is slow; full visual
fields; Strength 5/5 at biceps; 5-/5 at triceps; [**4-18**] grip
strength bilaterally; trace reflexes in upper extremities; LEs:
legs are splayed outward in flexion at the knee; strength is [**2-16**]
at HFs bilaterally and KF; DF/PF is [**4-18**]; reflexes are trace at
knee and ankle; Babinski's are mute
Sensation intact to light touch throughout
Pertinent Results:
[**2102-12-5**] 05:55PM WBC-6.0 RBC-3.52* HGB-11.2* HCT-35.0*
MCV-100* MCH-31.9 MCHC-32.1 RDW-12.8
[**2102-12-5**] 05:55PM NEUTS-64.1 LYMPHS-30.6 MONOS-3.7 EOS-1.5
BASOS-0.1
[**2102-12-5**] 05:55PM PLT COUNT-210
[**2102-12-5**] 05:55PM PT-11.3 PTT-28.0 INR(PT)-0.9
[**2102-12-5**] 05:55PM TSH-1.3
[**2102-12-5**] 05:55PM T4-4.7
[**2102-12-5**] 05:55PM GLUCOSE-113* UREA N-15 CREAT-0.7 SODIUM-142
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13
[**2102-12-5**] 05:55PM CK-MB-4 cTropnT-0.01
[**2102-12-5**] 05:55PM ALT(SGPT)-10 AST(SGOT)-22 LD(LDH)-213
CK(CPK)-189* ALK PHOS-83 TOT BILI-0.3
[**2102-12-5**] 05:55PM LIPASE-14
[**2102-12-5**] 05:55PM VIT B12-648
[**2102-12-5**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2102-12-5**] 06:00PM URINE RBC-0-2 WBC-[**5-24**]* BACTERIA-OCC
YEAST-NONE EPI-[**5-24**]
[**2102-12-5**] 06:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2102-12-5**] 07:00PM TYPE-ART PO2-453* PCO2-39 PH-7.42 TOTAL
CO2-26 BASE XS-1
[**2102-12-6**] 02:19AM BLOOD CK-MB-4 cTropnT-0.02*
[**2102-12-5**] 05:55PM BLOOD ALT-10 AST-22 LD(LDH)-213 CK(CPK)-189*
AlkPhos-83 TotBili-0.3
[**2102-12-7**] 06:25AM BLOOD cTropnT-<0.01
[**2102-12-5**] 05:55PM BLOOD CK-MB-4 cTropnT-0.01
URINE CULTURE (Final [**2102-12-7**]):
GRAM NEGATIVE ROD(S). ~4000/ML.
MRSA SCREEN (Final [**2102-12-8**]): No MRSA isolated.
FINDINGS: There are innumerable, nearly punctate foci of
elevated T2 signal within the white matter of both cerebral
hemispheres, with some coalescence in the periatrial white
matter and along the ependymal surface of the left lateral
ventricle posteriorly. A vague, somewhat flame-shaped area of
slightly elevated T2 signal also is present in the left frontal
cortical and subcortical white matter posteriorly (see image 18,
series 15). None of these areas undergo pathological
enhancement, or exhibit diffusion or susceptibility
abnormalities. The etiology is nonspecific, although the left
frontal cortical lesion could certainly represent an area of
infarction, as could the punctate regions of T2 hyperintensity.
There is moderate cerebellar atrophy, as well as the visualized
cervical cord, which presumably corresponds to the stated
diagnosis of spinocerebellar atrophy.
MR angiography of the head, using a 3D time-of-flight imaging
protocol,
appears to be within normal limits. The study is somewhat
suboptimal, in that there is substantial obscuration of the
posterior circulation vasculature on the projected images by
what is likely fat within the skull base.
The MR angiography of the neck arterial vasculature is of very
poor quality due to gross venous contamination, secondary to an
injection timing error. Within the severe limitations, no overt
abnormality is seen although there is essentially no imaging of
the vertebral arteries, which may also reflect lack of inclusion
of a portion of this vascular territory within the imaging
volume. If this information regarding vascular status is of
clinical importance, the study should either be repeated or,
alternatively a CT angiogram could be performed.
CONCLUSION: Findings suggestive of chronic infarcts.
Inflammatory disease
could be considered, though less likely, given the absence of
contrast
enhancement of the lesions. Atrophy of the cerebellum and spinal
cord. See
above report for additional observations.
[**2102-12-6**] CXR FINDINGS: As compared to the previous examination,
the endotracheal tube and the nasogastric tube have been
removed. Lung volumes are unchanged. The pre-existing small left
pleural effusion and the retrocardiac atelectasis have resolved.
Mild retrocardiac areas of bronchiectasis are now visible.
Overall, the lung volumes remain small. The size of the cardiac
silhouette is at the upper range of normal. However, no evidence
of pulmonary edema is seen. No focal parenchymal opacity
suggesting pneumonia. No hilar or mediastinal lymphadenopathies.
[**2102-12-7**] Neurophysiology EEG Not Finalized
Brief Hospital Course:
bA/P: 61 yo W with PMH of spinocerebellar ataxia here with
episode of unresponsiveness.
.
.
# Unresponsiveness: Pt was found to be non-repsponsive at her
home. Etiology is unclear. [**Name2 (NI) **] hx of prior seizures. No clear new
focal deficits on exam. She does have UTI which may be
underlying cause. CT at outside hospital negative for bleed or
midline shift. She was intubated at outside hospital for airway
protection. She was transferred to [**Hospital1 18**] for further evaluation.
Sedation was weaned and patient self extubated. According to
patient and family, pt was close to her baseline the following
morning. EEG, MRI/MRA head and neck were performed to evaluate
for seizure or stroke as possible etiology. Neurology inpatient
team was consulted. CRP and homocysteine level were checked.
Homocysteine was pending at time of d/c. CRP was very elevated
for unclear reasons. Fasting lipid panel was checked to evaluate
stroke risk, though patient was on simvastatin 40mg daily.
Aspirin 81mg daily was added to her regimen. CRP was ordered as
requested by neurology. Although the level was elevated to 91,
the utility of this information for further management is
unclear. Similarly for homocysteine, there is currently no data
to suggest B12 or folate alters risk for stroke and likely this
does not add value to management of her cardiovascular risk.
# Anemia: Baseline unknown. Iron studies consistent with anemia
of chronic disease. B12, folate normal.
.
# Communication: Daughter [**Name (NI) 84282**] [**Telephone/Fax (1) 84283**] HCP
# Code: Full
Medications on Admission:
Lactulose 30 mL PO/NG DAILY:PRN constipation
- Carbidopa-Levodopa (25-100) 1.5 TAB PO/NG 9AM AND 1PM
- Carbidopa-Levodopa (25-100) 1 TAB PO/NG 5AM, 9AM, 5PM, 9PM
- Multivitamins 1 TAB PO/NG DAILY
- FoLIC Acid 1 mg PO/NG DAILY
- Comtan *NF* 200 mg Oral 5x/day
- Simvastatin 40 mg PO/NG QHS
- BuPROPion 100 mg PO QPM
- Lisinopril 10 mg PO/NG DAILY
- Tolterodine 2 mg PO QHS
- Baclofen 5 mg PO QAM
- Atenolol 50 mg PO/NG DAILY
- Citalopram Hydrobromide 20 mg PO/NG DAILY
- Quetiapine Fumarate 50 mg PO/NG [**Hospital1 **]
- Gabapentin 100 mg PO/NG TID
- Lactulose PRN
- Senna PRN
- Colace PRN
- Tylenol PRN
- Compazine PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Unresponsiveness
Urinary tract infection
Anemia of chronic disease
Secondary:
Spinocerebellar ataxia
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital after an episode of
unresponsiveness. You appear to be back to your baseline. The
reason for this episode is still unclear. [**Name2 (NI) **] had an EEG and MRI
for evaluation and were seen by our neurologists. The MRI did
not show any signs of recent stroke to explain this event. The
EEG was preliminarily normal. Our team will follow up the
official report of this study and contact you with anything
abnormal. Your lipid panel was within normal and You also had a
small amount of bacteria in your urine. You received 3 days of
antibiotics to treat this.
You were started on a daily baby aspirin.
Please follow up with your neurologist Dr [**Last Name (STitle) **], in the next two
weeks.
Please contact your doctor or return to the emergency room with
any concerning symptoms.
Followup Instructions:
Please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 63931**] to set up a follow up
appointment in [**12-16**] weeks.
|
[
"334.8",
"285.29",
"272.4",
"599.0",
"401.9",
"041.85",
"300.4",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9923, 9996
|
7680, 9252
|
331, 343
|
10178, 10178
|
3566, 7657
|
11190, 11327
|
10017, 10157
|
9278, 9900
|
10348, 11167
|
2553, 3547
|
275, 293
|
371, 2200
|
10192, 10324
|
2223, 2538
|
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