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31,051
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46409
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Discharge summary
|
report
|
Admission Date: [**2201-2-4**] Discharge Date: [**2201-2-9**]
Date of Birth: [**2136-11-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 64 year old woman with history of CVA with multiple
falls over the past 2 years. She was cooking dinner this evening
when she developed
some R arm shaking and R eye twitching and needed her son to
help her get to a chair. She was taken to OSH where CT showed
B/L acute SDH. She denies any recent trauma though her son
admits she falls pretty frequently. She is on ASA/Plavix for
previous CVA 3 years ago. She currently has no complaints of
headache, muscle weakness, increased speech difficulty (previous
CVA). She did
receive 2 units of platelets at the OSH.
Past Medical History:
Afib
Epilepsy stopped AED's in her 30's
COPD (retains CO2)
syncope
CHF
DM
shoulder pain
CV ds
dyspnea
PVD
postherpetic neuralgia
CAD s/p multiple MIs
CHOL
colonic adenoma
hearing loss
L CEA [**2192**] with 100% flow at the time, 50% in [**2194**]
TIA in [**2192**]
Social History:
smokes, denies alcohol and drug use
Family History:
not elicited
Physical Exam:
On Admission: Mental status: Awake and alert, cooperative with
exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: unable to recall [**3-28**] objects at 5 minutes.
Language: Some word finding difficulties and dysarthria
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
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.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-30**] in LUE, BLE, 4+/5 on the RUE.
No
pronator drift
Sensation: Intact to light touch
At discharge:
Nonfocal
Pertinent Results:
[**2201-2-4**] 07:45PM GLUCOSE-165* UREA N-33* CREAT-1.7* SODIUM-139
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-31 ANION GAP-15
[**2201-2-4**] 07:45PM estGFR-Using this
[**2201-2-4**] 07:45PM PHOSPHATE-4.8* MAGNESIUM-2.0
[**2201-2-4**] 07:45PM WBC-13.2* RBC-3.54* HGB-9.3* HCT-29.0*
MCV-82# MCH-26.2*# MCHC-32.0 RDW-17.0*
[**2201-2-4**] 07:45PM WBC-13.2* RBC-3.54* HGB-9.3* HCT-29.0*
MCV-82# MCH-26.2*# MCHC-32.0 RDW-17.0*
[**2201-2-4**] 07:45PM PLT COUNT-309
[**2201-2-4**] 07:45PM PT-11.3 PTT-30.1 INR(PT)-1.0
CT head [**2201-2-5**]
Stable bilateral small subdural hematomas
Brief Hospital Course:
Ms [**Known lastname **] was admitted to [**Hospital1 18**] SICU on [**2201-2-4**] with SDH after
partial motor seizure. She was on Keppra and Q1 hr neuro checks.
She received platelets due to ASA and plavix use. On [**2-5**], she
had a repeat CT head that was stable. She was changed to Q2hr
neruo checks as she was neurologically stable, with baseline
deficits s/p CVA. ASA and Plavix were being held. SDU transfer
orders were written. Her diet was advanced. Her PCP was
[**Name (NI) 653**] as was Dr. [**Last Name (STitle) **], her neurologist. HE agreed with the
plan for Keppra for seizure prophylaxis. She was traqsnitioned
OOB. PT was ordered. HEr SBP fluctauted from 80-110. She was not
on pressors. Her anti-hypertensives were held. Home meds were
ordered other than these agents. Cardiology was consulted and
made some medicine changes and her SBP was within normal.
She remained stable and she was discharged to rehab on [**2201-2-9**]
Medications on Admission:
amiodarone 200 QD
crestor 20 QD
Lantus 16 QHS
lasix 60/40
lorazepam .5 prn
advair 50/500 Use 1 inhalation twice daily
fluoxetine 10 QD
B12 1000 QD
nitro prn
metoprolol 12.5 QD
lisinopril 2.5 QD
pramipexole .125 QHS
plavix 75
asa 81 QD
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
2. furosemide 20 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
3. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheszing.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
11. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. insulin glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous at bedtime: Give along with Insulin sliding
scale.
14. insulin regular human 100 unit/mL Solution Sig: Sliding
Scale Injection Before meals.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
SDH
Seizure
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:
Instructions for Follow up for Subdural, Epidural or
Subarachnoid Hemorrhages
Non-Surgical
Dr. [**Last Name (STitle) 24275**] [**Name (STitle) 739**]
?????? Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
?????? You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine, you will not require blood work
monitoring.
?????? Do not drive until your follow up appointment.
** You may resume Aspirin 10 days from admission ([**2201-2-15**]) and
Plavix in one month ([**2201-3-7**]). ***
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
?????? We recommend you follow-up with Dr. [**Last Name (STitle) **]
(cardiology) and NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18915**] within 1 month of discharge.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2201-2-9**]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,694
| 160,549
|
32002+57775
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-1-14**] Discharge Date: [**2194-1-19**]
Date of Birth: [**2148-5-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
45 y.o. with SOB and palpitation now Homograft Bentall procedure
[**1-14**]
s/p.
Major Surgical or Invasive Procedure:
S/p Homograft Bentall procedure [**1-14**]
History of Present Illness:
45 y.o male who developed palpitations and SOB since [**8-17**]. He
was admitted to [**Hospital 1474**] Hospital and found to be in CHF and AF.
A cardiac Cath was negative for CAD however the echo revealed
severe AI with an ascending aortic aneurysm. He now presents for
surgical evaluation.
Past Medical History:
PMH: Bicusp AV, dil Aortic root / AI, AF, CHF with EF 40-50%,
c'myopathy, HTN, Anxiety
Social History:
Occupation: Fleet foreman
Tobacco: none
Lives with: Wife and 2 daughters
ETOH: 12 [**Name2 (NI) 17963**] a day, stopped [**9-17**]
Race: Caucasian
Family History:
Family history: none. Mother alive with AAA (in her 80s)
Physical Exam:
Pre-operative physical Exam
Pulse: 88 Resp:16 Right BP:152/92 Left BP: 148/90 Ht:73"
Wgt:180lb
General: Anxious/talkative
Skin: Warm, dry, scar on right shin
HEENT: NCPT, PERRL, Anickric sclera, op benign, teeth in poor
repair
Neck: Supple, full ROM no JVD, no thyromegally
Lungs: Lungs CTA bilat
Heart: RRR NS1/S2, III/VI Diastolic murmur
Abdomen: Soft, non-tender, +bowel sounds, no hepatomegally
Extremities: Warm, well perfused, no edema
No varicosities
Neuro: A+OX3, gait steady, strength 5/5
Pulses: Femoral, DP, PT, Radial equal bilaterally 2+
Carotid: Radiating bruit right side
Discharge Physical exam
Pertinent Results:
[**2194-1-14**] 01:42PM GLUCOSE-125* NA+-136 K+-4.4
[**2194-1-14**] 01:32PM UREA N-13 CREAT-0.8 CHLORIDE-107 TOTAL CO2-25
[**2194-1-14**] 01:32PM WBC-9.8 RBC-3.50* HGB-11.8* HCT-33.2* MCV-95
MCH-33.8* MCHC-35.7* RDW-14.2
[**2194-1-14**] 01:32PM PLT COUNT-196
[**2194-1-14**] 01:32PM PT-13.8* PTT-34.8 INR(PT)-1.2*
[**2194-1-17**] 07:55AM BLOOD WBC-5.7 RBC-2.94* Hgb-9.7* Hct-27.7*
MCV-94 MCH-33.1* MCHC-35.1* RDW-14.9 Plt Ct-154
[**2194-1-17**] 07:55AM BLOOD Glucose-143* UreaN-14 Creat-0.7 Na-138
K-4.0 Cl-100 HCO3-31 AnGap-11
[**2194-1-14**] 01:32PM BLOOD PT-13.8* PTT-34.8 INR(PT)-1.2*
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2194-1-16**] 2:27 PM
CHEST (PORTABLE AP)
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
45 year old man s/p cardiac surgery
REASON FOR THIS EXAMINATION:
eval for pneumothorax s/p chest tube removal
HISTORY: Status post chest tube removal, to evaluate for
pneumothorax.
FINDINGS: In comparison with the study of [**1-14**], the tubes have
all been removed. There is no evidence for pneumothorax. Mild
atelectatic changes persist at the left base.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**Doctor First Name **] [**2194-1-16**] 4:24 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 74968**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 74969**]
(Complete) Done [**2194-1-14**] at 9:51:46 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2148-5-14**]
Age (years): 45 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Congestive heart
failure. Pulmonary hypertension. Shortness of breath.
ICD-9 Codes: 428.0, 786.05, 441.2, 424.1
Test Information
Date/Time: [**2194-1-14**] at 09:51 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW21-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 50% >= 55%
Aorta - Annulus: *3.3 cm <= 3.0 cm
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *4.2 cm <= 3.0 cm
Aorta - Ascending: *4.5 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Findings
LEFT ATRIUM: Normal LA size. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the body of the RA. A catheter or pacing wire
is seen in the RA and extending into the RV. No spontaneous echo
contrast in the RAA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Mild global LV hypokinesis. False LV tendon (normal
variant). Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Dilated sinuses of
Valsalva. Moderately dilated ascending aorta. Mildly dilated
aortic arch. Mildly dilated descending aorta.
AORTIC VALVE: Bicuspid aortic valve. No masses or vegetations on
aortic valve. No AS. Severe (4+) AR. Eccentric AR jet directed
toward the anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR. Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
Conclusions
PRE-CPB:1. The left atrium is normal in size. No thrombus is
seen in the left atrial appendage.
2. No spontaneous echo contrast is seen in the body of the right
atrium. There is a thebesian valve seen at the entrance to the
coronary sinus.No atrial septal defect is seen by 2D or color
Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. There is mild global
left ventricular hypokinesis (LVEF = 45 %). Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
5. Right ventricular chamber size and free wall motion are
normal.
6. The aortic root is moderately dilated at the sinus level. The
sinuses of Valsalva are dilated. There is effacement of the
sinotubular junction. The ascending aorta is moderately dilated.
The aortic arch is mildly dilated. The descending thoracic aorta
is mildly dilated.
7. The aortic valve is bicuspid. No masses or vegetations are
seen on the aortic valve. There is no aortic valve stenosis.
Severe (4+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet.
8. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
POST-CPB: On infusion of phenylephrine. Well-seated homograft in
the aortic position with normal leaflet excursion. No AI. Small
hematoma at proximal end of homograft at [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] of neoaorta.
Distal anastomosis has normal contour. LVEF 45%.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2194-1-14**] 11:54
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2194-1-7**] for pre-operative
evaluation and intravenous heparin. On [**1-14**] he was brought to
the operating room and underwent a Homograft Bentall procedure
using a 28mm LifeNet prosthesis. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Within 24 hours, Mr. [**Known lastname **] had awoke
neurologically intact and was extubated. On postoperative day
one, he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. He
developed atrial fibrillation for which amiodarone was started
with good rate control. Coumadin was resumed for
anticoagulation. Mr. [**Known lastname **] continued to make steady progress
and was discharged home on postoperative day five. Dr. [**Last Name (STitle) **]
will manage his coumadin dosing as an outpatient for a goal INR
of 2.0-2.5. He will follow-up with Dr. [**Last Name (STitle) 1290**], his
cardiologist and his primary care physician as an outpatient.
Medications on Admission:
Spirinolactone 25mg Daily
Lisinopril 20mg Daily
Amiodarone 200mg Daily
Lopressor 25mg Twice daily
Ativan
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every four (4) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
please take 400mg daily for 7 days then decrease to 200mg daily
and follow up with Dr [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*0*
5. Warfarin 5 mg Tablet Sig: 0.5 Tablet PO once a day: please
take 2.5mg sunday [**1-19**] and have [**Month/Day (4) **] draw [**1-20**] for further
dosing .
Disp:*60 Tablet(s)* Refills:*2*
6. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing draws Mon-Wed-Fri with results to Dr
[**Last Name (STitle) **] office [**Telephone/Fax (1) 3183**] for further dosing goal INR 2-2.5 for
atrial fibrillation
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three
times a day: pleae take 75mg three times a day .
Disp:*135 Tablet(s)* Refills:*0*
8. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing draws Mon-Wed-Fri with results to Dr
[**Last Name (STitle) **] office [**Telephone/Fax (1) 3183**] for further dosing goal INR 2-2.5 for
atrial fibrillation
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
AI s/p bentall
Ascending aortic aneurysm
Post op atrial fibrillation
Hypertension
Cardiomyopathy
Hypertension
Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
PT/INR for coumadin dosing draws Mon-Wed-Fri with results to Dr
[**Last Name (STitle) **] office [**Telephone/Fax (1) 3183**] for further dosing goal INR 2-2.5 for
atrial fibrillation
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) 16004**] in 1 week [**Telephone/Fax (1) 3183**]
Dr [**Last Name (STitle) **] in [**3-16**] weeks [**Telephone/Fax (1) 3183**]
Dr [**Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
2 weeks wound clinic - please schedule with RN
PT/INR for coumadin dosing draws Mon-Wed-Fri with results to Dr
[**Last Name (STitle) **] office [**Telephone/Fax (1) 3183**] for further dosing goal INR 2-2.5 for
atrial fibrillation
Completed by:[**2194-1-20**] Name: [**Known lastname 12343**],[**Known firstname 33**] Unit No: [**Numeric Identifier 12344**]
Admission Date: [**2194-1-14**] Discharge Date: [**2194-1-19**]
Date of Birth: [**2148-5-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
Addendum:
Spoke with [**Location (un) 102**] at Dr [**Last Name (STitle) **] [**1-20**] and he will continue to follow
him for coumadin dosing, first lab draw done at Dr [**Last Name (STitle) **] office
today [**1-20**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 50**] VNA
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2194-1-20**]
|
[
"428.0",
"425.4",
"427.31",
"401.9",
"300.00",
"424.1",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.45",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
12841, 13034
|
8028, 9194
|
403, 448
|
10994, 11001
|
1765, 2515
|
11697, 12818
|
1075, 1118
|
9349, 10739
|
2552, 2588
|
10841, 10973
|
9220, 9326
|
11025, 11674
|
1133, 1746
|
282, 365
|
2617, 8005
|
476, 769
|
791, 879
|
895, 1043
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,035
| 184,671
|
17988+56906
|
Discharge summary
|
report+addendum
|
Unit No: [**Numeric Identifier 49794**]
Admission Date: [**2153-11-22**]
Discharge Date: [**2153-11-22**]
Date of Birth: [**2089-12-13**]
Sex: F
Service:
CHIEF COMPLAINT: Right pleural effusion.
For complete history and physical, please refer to the notes
written by Dr. [**Last Name (STitle) **] on [**2153-11-25**].
In brief, the patient is a 63-year-old woman who has
undergone a combined liver, kidney transplant who has had
recurrent right pleural effusions that had been managed by
repeat thoracenteses. She is currently in the hospital for
management for urinary tract infection and has planned to
undergo an umbilical hernia repair by the transplant service.
They have asked if we would consider performing a talc
pleurodesis in the same setting.
I discussed with the patient the anticipated procedure. We
reviewed the possibility that lung may not expand and a
decortication may be required. We also discussed the
possibility that the effusion may recur despite pleurodesis.
We also discussed other risks of the operation and include
bleeding, infection, pneumonia, and death. She is willing to
proceed and we will schedule for surgery for tomorrow [**2153-11-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 32450**]
Dictated By:[**Last Name (NamePattern4) 49795**]
MEDQUIST36
D: [**2153-11-27**] 16:05:13
T: [**2153-11-27**] 16:43:50
Job#: [**Job Number 49796**]
Name: [**Known lastname 400**],[**Known firstname 634**] M Unit No: [**Numeric Identifier 9233**]
Admission Date: [**2153-11-22**] Discharge Date: [**2153-12-8**]
Date of Birth: [**2089-12-13**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan
Attending:[**First Name3 (LF) 2648**]
Addendum:
Appears that the intial discharge summary was done as a
procedure note. The full d/c summary is now complete.
Chief Complaint:
fevers/chills
Major Surgical or Invasive Procedure:
[**2153-11-28**]: Liver Biopsy
[**2153-11-28**]: Bronchoscopy
[**2153-11-28**]:Right thoracoscopy; drainage of pleural effusion;
decortication of right lung; talc pleurodesis.
[**2153-12-1**]: Hepatic artery angiogram
History of Present Illness:
63F s/p liver/kidney transplant [**7-17**] requiring multiple
courses of plasmapheresis for desensitization, c/b splenic
venous
thrombus, recurrent MDR UTI (ESBL Klebsiella) s/p course of
ertapenem, right pleural effusion requiring thoracentesis. Now
p/w 3 day history of dysuria, 1 day history of abdominal and
flank pain, nausea, vomiting and chills. She denies diarrhea,
states she has been eating normally, and states her urine output
has decreased over the last several days. She also complains of
a
worsening cough.
Past Medical History:
PMH: NASH, esophageal varices, ascites, aenmia,
thrombocytopenia,
ESRD, T2DM, CDiff, seizures, meningioma, HTN, GERD, OSA, ?RLS,
nekc DJD, dermoid cyst, R adrenal mass
PSH: OLT + CRT ([**7-17**]), CCY, tubal ligation, oopherectomy,
appendectomy, thoracentesis
Social History:
SOCIAL HISTORY:
Widowed, lived in [**Hospital3 2065**] although most recently has
been at rehab. Has 4 children, several in MA. Smoking: None;
EtOH: Never; Illicits: None
Family History:
NC
Physical Exam:
98.1 72 169/62 24 98 (T 101.1 on arrival)
uncomfortable
RRR, diminished R sided lung sounds scattered left basal
crackles, abdomen + RUQ tenderness and tenderness over graft
site, incisions c/d/i, non peritoneal, reducible abdominal
hernia, 1+ edema bilateral lower extremities.
Pertinent Results:
Imaging:
Renal Scan [**11-22**]: No significant change from [**2153-9-5**], normal
blood flow and renogram, normal blood flow with minimal to no
excretion in native kidneys.
Liver dupplex: focal area of turbulent flow in MPV with focally
elevated velocity possibly indicating stenosis. No pv thrombus.
pt s/p splenectomy, no flow seen in splenic vein. SMV is patent.
CXR: recurrent small R pleural effusion, significant volume
overload
Labs:
Trop-T: 0.02
137 97 29
--------------<101 AGap=18 (baseline Cr 0.7-1.1)
5.0 27 *1.2*
estGFR: 45/55 (click for details)
CK: 51 MB: Notdone
Ca: 9.7 Mg: 1.8 P: 5.0
ALT AST AP TBili
[**2153-11-22**] 05:15PM 304* 438* 356* 1.2
[**2153-11-10**] 07:00AM 22 30 125* 0.2
[**2153-11-9**] 05:45AM 22 21 131* 0.2
17.6>12.3/37.8<380
PT: 24.5 PTT: 26.0 INR: 2.3
UA: nitrite +, leuk +, bacteria & WBCs ([**11-9**] shows nit(-),
leuk(-))
Brief Hospital Course:
SEPSIS:
-Pt was admitted to the surgical service and placed in the SICU
for presumed sepsis. She was started on linezolid and meropenem
for her UTI and possible PNA. She was also very volume
overloaded so she was started on lasix and diuresed. She had
ESBL Klebsiella growing out of her urine culture. ID consult
was obtained as well as a nephrology consult. Linezolid was
stopped per ID recommendations, and meropenem was continued. She
was placed on a course of vancomycin to cover PNA, but this was
stopped prior to discharge as her levels remained high, and
there was no strong feeling to continue her course beyond 2
weeks. She would be continued on the course of meropenem which
would end on [**2153-12-9**].
RECURRENT EFFUSION:
-She also had a large right sided pleural effusion that she had
chronically and was follwed with daily CXRs. She was
transferred out of the ICU on [**2153-11-25**]. Thoracic surgery was
consulted regarding her effusion and need for possible drainage
and/or decortication. This was performed on [**2153-11-28**] in
addition to simultaneous ventral hernia repair. Post-op she had
respiratory distress and had to be reintubated and transferred
to the SICU. Bronch/BAL was performed the following day which
demonstrated no lesions, and a BAL was done. Chest tube
remained in place. However, her chest tube did fall out several
days later. She continued to improve with PT, chest PT,
diuresis.
ELEVATED LFTS:
-She had a persistent elev of her AP. A transjugular biopsy was
done which demonstrated concern for venous congestion and
ischemia. This prompted a hepatic angiogram once she was stable
which demonstrated no evidence of hepatic artery thrombosis.
Her diet was advanced which she tolerated well.
SPLENIC VEIN THROMBOSIS
She has a history of this since her splenectomy and was
anticoagulated with heparin and then transitioned to coumadin.
AFIB
-This was controlled with beta blocker. She had a repeat echo
that showed worsenign mitral regurg. Cardiology recommended
outpatient cardiology followup.
Medications on Admission:
Medications - Prescription
AMLODIPINE - (Dose adjustment - no new Rx; recording) - 5 mg
Tablet - 2 Tablet(s) by mouth once a day
CITALOPRAM - 20 mg Tablet - 3 Tablet(s) by mouth daily
FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth once a day
HYDROCODONE-ACETAMINOPHEN - (discharge med) - 5 mg-500 mg
Tablet
- [**2-9**] Tablet(s) by mouth every four (4) hours as needed for
abdominal pain given # 20 on [**11-10**]
LEVETIRACETAM - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
LORAZEPAM - (discharge med) - 0.5 mg Tablet - 1 Tablet(s) by
mouth HS (at bedtime) as needed for anxiety
METOPROLOL TARTRATE - (Dose adjustment - no new Rx; discharge
med) - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
MYCOPHENOLATE MOFETIL - 250 mg Capsule - 1 Capsule(s) by mouth
twice a day
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
PREDNISONE - 5 mg Tablet - 1.5 Tablet(s) by mouth DAILY (Daily)
TACROLIMUS [PROGRAF] - (Dose adjustment - no new Rx; d/c meds)
-
1 mg Capsule - 3 Capsule(s) by mouth twice a day
TRAZODONE - 50 mg Tablet - 0.5 Tablet(s) by mouth twice a day as
needed for anxiety
TRIMETHOPRIM-SULFAMETHOXAZOLE - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
WARFARIN - (Prescribed by Other Provider) - 3 mg Tablet - 1
Tablet(s) by mouth daily
Medications - OTC
DOCUSATE SODIUM - (d/c med) - 100 mg Capsule - 1 Capsule(s) by
mouth twice a day
INSULIN REGULAR HUMAN [NOVOLIN R] - 100 unit/mL Solution - per
sliding scale four times a day
NPH INSULIN HUMAN RECOMB [NOVOLIN N] - (Dose adjustment - no
new
Rx; d/c meds) - 100 unit/mL Suspension - 30 units at 7am once a
day
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: as dir
Injection ASDIR (AS DIRECTED).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain .
15. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours): check daily prograf levels.
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
18. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for anxiety.
19. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
20. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for htn.
21. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
s/p kidney/liver transplant [**7-17**]
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 242**] for fever,
chills, increased oxygen demands, chest pain, shortness of
breath, nausea, vomiting, diarrhea.
Labwork every Monday and Thursday
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2153-12-18**] 2:00
Needs a follow up appt scheduled with a cardiologist to evaluate
her new worsening mitral regurgitation # [**Telephone/Fax (1) 337**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2153-12-8**]
|
[
"401.9",
"250.50",
"V42.7",
"530.81",
"293.0",
"428.0",
"276.2",
"362.01",
"038.9",
"327.23",
"V58.61",
"486",
"995.91",
"424.0",
"553.21",
"357.2",
"285.21",
"250.60",
"296.24",
"590.10",
"V42.0",
"427.31",
"345.90",
"518.81",
"250.40",
"041.3",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.14",
"88.47",
"34.04",
"33.24",
"50.11",
"38.93",
"96.71",
"34.52",
"34.92",
"53.51",
"34.06"
] |
icd9pcs
|
[
[
[]
]
] |
10182, 10263
|
4582, 6643
|
2031, 2251
|
10346, 10360
|
3613, 4559
|
10614, 11013
|
3293, 3297
|
8328, 10159
|
10284, 10325
|
6669, 8305
|
10384, 10591
|
3312, 3594
|
1978, 1993
|
2279, 2803
|
2825, 3088
|
3120, 3277
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,192
| 184,281
|
49594
|
Discharge summary
|
report
|
Admission Date: [**2132-3-22**] Discharge Date: [**2132-4-3**]
Service: MEDICINE
Allergies:
Penicillins / Macrodantin / Amiodarone
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
dizziness at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a [**Age over 90 **] y/o female with CAD, A fib, HTN, restless leg
syndrome, with recent [**Hospital1 18**] admissions in [**2-11**]-25 for
viral gastroenteritis. and most recently from [**3-4**] to [**3-6**] for
exacerbation of RLS. During this admission, she presented with
worsening symptoms of her restless legs; subsequently started on
ropinorale (Requip). Was then seen again in the ED on [**3-10**] with
worsening of restless leg syndrome. Subsequently seen by
Neurology in th ED who recommended rapidly uptitrating her
Requip. Negative LENIs [**2132-3-10**]. Pt not great historian, most
history is obtain through records and geriatrics CM.
.
Now presents after a presyncopal episode while sitting on the
toilet (with the lid down). She remembers the entire episode.
HHA found slumped on the seat, but conscious and talking. She
was just distressed because she was weak and could not get up.
Yesterday pt had what sounded like a mechanical fall, while
attempting to walk without her walker. CT head done and was
negative. When EMTs arrived to site, pt was found to be in NAD,
pale, breathing normally, c/o urticaria both hands, no NVD, no
fevers, no chills, no cough. + dizziness. BP was 88/50, hr 68;
bg 101. Apparently, pt had an extensive w/u of her LE weakness
that has been ongoing for at least 1yr. Dr. [**Last Name (STitle) 31464**], the pt's
neurologist recently ordered MRI LS spine and EMG, which were
abnormal. MRI was concering for lesions consistent either with
MM or metastatic lesions (this information was passed on from
the geriatric case manager, not known to patient or PCP). We
don't have the records of those tests.
.
Regarding her hypoxia, she was reportedly found by PT 2 days ago
to be hypoxic with sats in the 80s, but apparently no decision
has been made to send the patient to the ED. Upon the
presentation to the ED, the patient was satting 94% on 5L NC.
Initial VS in the ED: 965, 70; 104/54; 14; 94%5L. Diffuse
maculopapular, pruritic rash all over trunk and extremities was
noted, that the patient states was 2 days old. The 2 new
medication started in the beginning of [**Month (only) **] were her
ropirinole for RLS and amlodipine for HTN.
.
Pt is a poor historian but on ROS, denied CP, SOB, stated that
she has "spastic stomach" , no GU discomfort, no dizziness, no
lightheadedness, no palpiations, no weakness, no back pain. She
complained of diffuse itching.
MICU COURSE:
[**3-23**]: Diuresed. Derm and Rheum consulted; consensus being
hypersensitivity reaction, possibly to drug.
[**3-24**]: Lasix gtt discontinued, started on nitro gtt.
[**3-25**]: Continued nitro drip. Added hydral for BPs. Attempting to
wean O2. Hyponatremia continues. Rash improved.
[**3-26**]: Gently diuresed. Returned hard copies of CT spine to Ms.
[**Known lastname **].
[**3-27**]: Changed steroids to prednisone 60 daily. Increased
hydralazine.
[**3-28**]: Increased hydral to 75 Q6H. D/c topical steroids.
[**3-29**]: Prednisone lowered to 30 daily.
Past Medical History:
1. CAD s/p PTCA [**Month/Year (2) **] to LCX, RCA, PDA (last cath [**8-20**])
2. Afib with pacemaker 2 yrs ago for tachy-brady syndrome
3. HTN
4. CRI, baseline Cr 1.3 (as of [**2130**])
5. Anemia
6. GERD
7. Bladder spasms
8. s/p appy
9. s/p TKR [**2128**]
10. Chronic low back pain from "ruptured disc" 30 yrs ago
11. Breast Ca, [**2126**], T1N0M0, LN neg, ER pos, Her2/Neu neg, on
Arimidex
12. Hiatal hernia
13. RLS: following medication regimen: [x]neurology recs -
ropinrole to have been titrated up rapidly over several days.
0.5 mg for days [**3-26**]; 1 mg for week 2; 1.5 mg for week 3; 2 mg
for week 4; 2.5 mg for week 5; 3 mg for week 6; 4 mg for week 7
Social History:
lives at home w/ health aide, works in antique store, no
tobacco/alcohol use, no IVDA, performs most ADLs independently
at home.
Family History:
mother died of CVA
Physical Exam:
Vital signs: 95.8; 132/52; 16; HR 75 (apaced); 62-94% O2 sat on
1.0 FIO2 by venti mask.
Gen: laying in bed, non-toxic, well-appearing, diffuse
maculopapular rash
HEENT: erythematous upper eyelids, no periorb edema; pupils
equal and reactive; EOMI
Neck: supple, JVD 8cm up at 90% , no carotid bruits
Chest: dry crackles [**1-22**] way up, bulateral lower half expiratory
wheezes.
CVS: rrr, no m/r/g
Abd: soft, slightly protruberant, +tympanic, NABS, NT, ND, no
rebound/gaurding
Extrem: cool to touch, mottled. pulses are dopplerable. diffuse
petechial rash over posterior LE's, blanching.
SKIN: diffuse maculopapular pruritic rash over trunk, head and
extremities, more confluent over trunk
Neuro: CN II-XII grossly intact. MS: pt is alert and oriented x
3, but at times inappropriate and tangential with her responses.
MSK: no joint effusions, normal ROM
Pertinent Results:
Labs on admission:
.
Imaging:
CXR ([**3-22**]): A single AP view of the chest is obtained on [**2132-3-22**]
at 2240 hours and compared with the prior radiograph performed
the same day at 1155 hours. There appears to be some increased
prominence of the interstitial markings bilaterally above what
has been seen as chronic findings in this patient suggesting
that the patient is developing some interstitial edema
superimposed on chronic interstitial disease. No other changes
noted since the prior examination.
.
CT head ([**3-22**]): No intracranial hemorrhage or mass effect.
.
EKG ([**3-22**]): Atrial pacing. Prolonged QT interval. Left
ventricular hypertrophy. Since previous tracing, no significant
change.
.
CXR ([**3-23**]): A single AP view of the chest is obtained [**2132-3-23**] at
0530 hours and is compared with the prior evening's radiograph.
There is further worsening of the interstitial [**Doctor Last Name 5926**] since the
prior examination together with patchy alveolar opacities
consistent with developing failure or fluid overload
superimposed on the chronic interstitial changes. There is also
likely a new small right- sided pleural effusion and a possible
small left pleural effusion.
.
CXR ([**3-24**]): Mild-to-moderate pulmonary edema has improved since
[**3-23**]. Small right pleural effusion persists. Borderline heart
size is stable. Transvenous right atrial and right ventricular
pacer leads are unchanged in their respective positions. The
atrial lead is lower in the right atrium than generally seen. No
pneumothorax.
.
ECHO ([**3-24**]): The left atrium is mildly dilated. The interatrial
septum is mildly aneurysmal. The estimated right atrial pressure
is 11-15mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-11-30**],
the estimated pulmonary artery systolic pressure is higher. The
severity of aortic regurgitation is reduced (likely mild on
review of the prior study) and the blood pressure is lower.
CLINICAL IMPLICATIONS:
Based on [**2122**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a low risk (prophylaxis not recommended).
Clinical decisions regarding the need for prophylaxis should be
based on clinical and echocardiographic data.
.
CXR ([**3-26**]): The heart is moderately enlarged. There are no overt
pleural effusions. There is no pneumothorax. Diffuse
interstitial and airspace disease consistent with pulmonary
edema is stable since [**3-25**], but improved since [**3-23**]. Left
pacemaker leads end in the right atrium and right ventricle.
.
Microbiology:
ASO negative
Blood culture ([**3-22**]): no growth
Urine culture ([**3-22**]): GNR ~ [**2125**]/mL
Repeat urine culture ([**3-22**]): no growth
.
CT scan chest, non contrast: FINDINGS: The airways are patent
through the segmental level. Chronic interstitial lung
abnormality consisting of interlobular septal thickening,
subpleural honeycombing, traction bronchiectasis, and traction
bronchiolectasis is predominantly subpleural, basal and more
extensive on the right. Associated extensive diffuse
ground-glass opacity is new. In comparison to the prior study,
the degree and extent of fibrosis has mildly progressed.
Nonenlarged right upper and left lower paratracheal lymph nodes
are stable. Right lower paratracheal lymph node and right
paraesophageal mildly enlarged lymph nodes have increased in
size from 7 to 10 mm and 10 to 11 mm respectively. There has
been interval mild increase in cardiac size. Cardiac size is
mildly enlarged. Moderate calcifications are in LAD, left
circumflex, and right coronary artery. Multiple coronary stents
are in place. Left pacemaker lead ends in standard position in
the right atrium and right ventricle. Dilatation of the
ascending aorta is stable at 45 mm AP. There is no pleural or
pericardial effusion.
There are no bone findings of malignancy.
The upper abdomen is unremarkable.
IMPRESSION:
- From reviewing several chest x-rays from [**2132-3-20**], the
findings are consistent with pulmonary edema.
- Mild progression of fibrosing interstitial lung disease. In
the presence of pulmonary edema, a component of acute alveolitis
cannot be excluded.
- Coronary calcifications.
- Stable ascending aortic dilatation
- Enlarging mild cardiomegaly.
Brief Hospital Course:
This is a [**Age over 90 **]F with MMP more recently complicated by increased
leg weakness, hypoxia and episode of pre-syncope admitted to the
ICU with ongoing hypoxia
.
# Hypoxia: Unclear etiology, though likely a combination of
underlying interstitial lung disease with overlying pulmonary
edema. Seems to have been present several days prior to
admission, when PT at home noted them to be in the 80s. Upon
admission to the [**Name (NI) **], pt saturating 94% on 5L NC. sats in the ED
range from 95% on 5L to 87% on NRB, without any significant
changes in status to 70% on 5L. BNP was elevated on admission.
Patient aggressively diuresed in the MICU and continued with
transfer to floor. LENIs neg in [**2-27**]. CT scan chest showed
diffuse interstitial changes c/w pneumonitis as well. Seen by
pulmonary consult who rec swallow eval (no overt aspirations
when eating slowly), ANCA sent (pending at time of discharge,
pls follow up), diuresis, and attempt at slower prednisone
taper. Patient doing better at time of discharge needing only
1L NC. Can continue attempt taper as outpatient and if persists
patient can be referred to pulmonary clinic for more
investigation. Continue low dose lasix as well.
.
#renal failure: Improved to 2 from high of 3.2. Initial UA dirty
and pt had a few gram negative rods in urine so got 3 days
cipro. Repeat urine culture had yeast. Foley discontinued. No
urine eos seen. This may be element of ATN or new baseline.
Patient should get repeat chem 7 checked in next week and uring
output followed. Good urine output here.
.
# Hyponatremia: Appears to have element SIADH. Does better with
fluid restriction. [**Month (only) 116**] be related to lung disease. Again
repeat chem 7 in week and follow. Fluid restrict to 1200cc per
day. Complicated by lasix dependence so follow as outpatient.
.
# Leukocytosis: Developed with starting of steroids. 18 on day
of discharge. No infection found. Need to follow as
outpatient.
.
# rash: Started 2 days prior to admission. papular with
petechial areas on the lower legs. more confluent on trunk.
Evaluated by Derm who felt it was likely drug reaction but no
mucosal involvement so can treat through with topical and oral
steroids. ESR and CRP very elevated initially but trended down.
[**Doctor First Name **] negative. Should repeat ESR/CRP again as outpatient.
Believe offending drug was ropirinole.
Second possibility was amlodipine. Should avoid both in future.
.
# leg weakness/? malignancy: Under care of Dr. [**Last Name (STitle) 31464**] of
neurology (at [**Hospital1 **]) who has most records and has been ordering
the workup. In conjunction with rash and new renal failure, ?
unifying vasculitic process. CT scan from outside was read of
lucency in L spine and sacrum. Per report radiologist here felt
c/w Paget's disease, L spine changes likely secondary to
degenerative disease. Seen by neurology here who felt exam most
consistent with peripheral neuropathy and rec attempt at low
dose neurontin. Appeared to give some relief.
- spep/upep negative
- CT has been scanned in here at [**Hospital1 18**], continue to look for
read of this
.
# presyncopal episode: main complaint for admission to the ED
was weakness/dizziness. does not seem to be neurologic in
origin; likely orthostasis/vasovagal given low BPs on admission.
.
# HTN: On many medications on admit. Tried to narrow here.
.
# CAD: There is no evidence of myocardial ischemia in the
setting her desats. There were no EKG changes suggestive of
ischemia and she had 2 sets of negative CE. patient is not
diabetic
- cont ASA, Plavix, sotalol, statin (question if needs statin
still at this age; can decide as outpatient)
.
# Afib: h/o Afib and tachy/brady s/p pacer, now A-paced with
PACs
.
# anemia: chronic per outpt records and currently at baseline
29-32. on aranesp.
.
# h/o Breast CA: on arimidex as oupt.
.
# Thrush: Developed after starting on steroids. Nystatin swish
and spit as needed.
.
# Hyperglycemia: While on steroids. Continue sliding scale
insulin as needed.
.
# Dementia: Pt seen by geriatrics while here. Found to have
MMSE 20/30. Might consider repeat as outpatient. Also can
continue to address polypharmacy in this older patient.
.
#CODE: DNR/DNI per daughter, [**Name (NI) **] [**Name (NI) 103733**], [**0-0-**], but
central lines are ok, pressors are OK.
#communication: [**Doctor First Name **]: case manager: [**Telephone/Fax (1) 103734**]
daugher,=HCP [**0-0-**]
Medications on Admission:
1. Amlodipine 10 mg qd
2. Ropinirole 0.25 mg qhs
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
12. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)).
14. Lasix 40 TIW
15. HCTZ 50 qhs
last two meds per dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] recs, not clear if the
patient has been taking the medications or not.
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO qd ().
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Please check fingersticks qid
and apply sliding scale insulin as needed.
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
15. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours): Hold for sedation.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
19. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush: Will likely need while
still taking steroids.
21. Prednisone 5 mg Tablet Sig: See taper below. Tablet PO once
a day for 20 days: Take 4 tabs daily for 5 days, then 3 tabs
daily for 5 days, then 2 tabs daily for 5 days, then 1 tab daily
for 5 days then stop.
22. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
23. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Hypersensitivity reaction (rash) to requip
Diastolic congestive heart failure
SIADH
Peripheral neuropathy
Urinary tract infection
Thrush secondary to steroids
Dementia
Discharge Condition:
Good
Discharge Instructions:
You were admitted after a presyncopal episode at home and you
were found to be profoundly hypoxic and with worsening kidney
function. The presyncope did not appear to have a cardiac
cause. It may have been a combination of general weakness and
medications.
.
Your hypoxia appears to have been from volume overload (heart
failure) and an ongoing underlying fibrosis. This now appears
to be improving but you may have chronic lung disease that at
some point may require oxygen. You will be sent out on a
steroid taper to help with the inflammation. You can decide
with your physician whether you want this further followed.
.
You have been concerned previously about "restless leg syndrome"
and had been started on requip. You appeared to have an
allergic reaction this medication (including rash). Discussing
with our neurologists here you may have a peripheral neuropathy.
You were restarted on low dose neurontin which can be adjusted
as necessary as an outpatient.
.
You have worsening kidney function. This may be chronic now but
should be rechecked in the next few weeks.
.
You also were found to have a low sodium level. Your body may
now have difficulty regulating sodium. You should stay on a
fluid restriction (1200cc daily) and get this followed as an
outpatient.
.
You were also seen by our geriatrics group and are concerned for
some mild dementia that you may have. Consider arranging repeat
testing as an outpatient.
.
You were also treated for a urinary tract infection while you
were here.
Followup Instructions:
Follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 103735**]) on
[**2132-4-22**] at 130pm.
.
Please schedule a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31464**]
([**Telephone/Fax (1) 94156**]) in 4 weeks.
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Discharge summary
|
report+addendum
|
Admission Date: [**2200-11-15**] Discharge Date: [**2200-12-22**]
Date of Birth: [**2143-6-15**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 112389**] is a 57 yo male from [**Country 3396**] with stage III
esophageal squamous cell diagnosed [**9-/2200**] currently receiving
chemo/radiation s/p 2 cycles of cisplatin/5-FU, CAD, and was
discharged today after polymicrobial bacteremia believed to be
secondary to esophageal mass s/p esophageal stent currently on 1
month course of zosyn via new placed PICC who presented with
shortness of breath and hypotension with concern for sepsis.
Patient reports cough for past 4 days. He had 4 episodes of
diarrhea today and 2 episodes of vomiting. He is having pain in
midline of upper chest which is similar to prior pain. Once
arriving outside ED, daughter reports he lost consciousness
while seated. Denies trauma, incontinence, limb flailing or
tongue biting. Today he also complains of shoulder pain. He does
have orthopnea. Last chemo was [**2200-11-10**]. In [**Month (only) 216**] had strep
viridans bacteremia for which finished 1 month course of
ceftriaxone.
In the ED, initial VS were: 102 rectally HR 177 90/50 99% on RA
Hypotensive down to 63 systolic, lactate of 9, was given 4L NS
and started emperically on vanc/zosyn (slow vanco and benadryl
w/ dexamethasone 10mg given prior redman syndrome). For access
he has 2 18G PIVs and a PICC
On arrival to MICU, patient's VS: 98.5 127/87 HR 119 sat 100% 4L
NC.
Review of systems: no chest pain, myalgias, constipation,
rashes.
Past Medical History:
- Esophageal squamous cell carcinoma stage III: dx [**9-/2200**]
- CAD
- Mitral regurgitation: last echo [**2200-10-11**]: moderate/severe MVP
- BPH
- Strep Viridans bacteremia ([**9-/2200**] s/p 1 month course of
ceftriaxone)
- Extensive alcohol/tobacco use: no current use
- Hx SIADH
PAST ONCOLOGIC HISTORY:
Mr. [**Known lastname 112389**] initially presented to clinic on [**2200-9-10**], at
which time he had five to seven months of pain in his throat and
difficulty swallowing. He had undergone a CT
scan in [**Country 3396**] and was told that he had throat narrowing,
which was causing him that difficulty. According to his report,
he had an endoscopy there, but no biopsy. Following my visit, he
was hyponatremic and thus was admitted to the hospital for this
and for workup of his new malignancy. He underwent a CT neck on
[**2200-9-10**], which showed some question of a mass-like lesion
within the esophagus, but no neck abnormalities. He underwent a
CT torso on [**2200-9-11**], which showed proximal dilation of the
esophagus with thickening of the esophagus distal to the level
of the carina as well as some small pulmonary nodules. He had a
barium swallow on [**2200-9-12**], which showed a mid esophageal
lesion concerning for esophageal carcinoma. He went on to
undergo an endoscopy on [**2200-9-16**]. Biopsy of the esophageal
mass revealed an invasive squamous cell carcinoma. He underwent
a PET scan on [**2200-9-23**], which showed high-level FDG avidity at
the site of the biopsy-proven squamous cell carcinoma as well as
scattered subcentimeter mediastinal and bilateral hilar lymph
nodes limited FDG avidity with an SUV mass of 3.7.
Social History:
Moved from [**Country 3396**] in [**Month (only) 205**], where he is living with his
daughter and son-in-law. [**Name (NI) **] used to run a business in [**Country 3396**],
but is not currently working here. He does not currently smoke
cigarettes. He stopped smoking three years ago after smoking
very heavily. Quit drinking 2y ago. With hx of drinking very
heavily. His family notes that he would start drinking first
thing in the morning and drinks throughout the day.
Family History:
No history of cancer. Both his parents have passed away. Mother
with diabetes.
Father: Murdered
Mother: Diabetes
Physical Exam:
ADMISSION:
Vitals: 98.5 127/87 HR 119 sat 100% 4L NC
Gen: NAD, cachectic
CV: tachycardic, RR, holosystolic murmur w/ radiation to axilla
Pulm: bibasilar crackles, ronchi bilaterally, decreased air
movement
Abd: NT, ND, soft
Back: no spinal tenderness
Skin: diffuse erythema and erosions on mid upper back and mid
upper chest
Ext: no peripheral edema
Neuro: alert, no gross deficit
DISCHARGE:
Vitals - 98.1 100/70 p102 R18 99% RA
Gen: NAD, cachectic
CV: tachycardic, RR, holosystolic III-IV/VI murmur
Pulm: Clear to auscultation b/l. No wheezes or crackles
Abd: NT, ND, soft. G-tube site with stable 2-3mm surrounding
erythema and induration, minimal tenderness
Ext: Distal pulse 2+ and all extrems warm, well perfused.
Neuro: AAOx3. CN II-XII intact. no gross deficit.
Pertinent Results:
Admission labs:
[**2200-11-16**] 12:51AM BLOOD WBC-15.6* RBC-2.55* Hgb-7.5* Hct-22.1*#
MCV-87 MCH-29.5 MCHC-34.1 RDW-16.2* Plt Ct-124*
[**2200-11-16**] 12:51AM BLOOD Neuts-98.8* Lymphs-0.2* Monos-0.7*
Eos-0.1 Baso-0.1
[**2200-11-16**] 12:51AM BLOOD PT-12.4 PTT-30.2 INR(PT)-1.1
[**2200-11-16**] 12:08PM BLOOD Fibrino-364
[**2200-11-16**] 12:51AM BLOOD Glucose-115* UreaN-16 Creat-1.0 Na-133
K-4.4 Cl-105 HCO3-20* AnGap-12
[**2200-11-16**] 12:08PM BLOOD LD(LDH)-164 CK(CPK)-98 TotBili-0.4
[**2200-11-15**] 09:30PM BLOOD Lipase-22
[**2200-11-16**] 12:51AM BLOOD CK-MB-3 cTropnT-0.04*
[**2200-11-16**] 12:51AM BLOOD Calcium-7.2* Phos-2.0* Mg-1.4*
[**2200-11-16**] 01:04AM BLOOD freeCa-1.07*
Micro:
[**2200-11-16**] STOOL C. difficile DNA amplification
assay-FINAL
**FINAL REPORT [**2200-11-16**]**
C. difficile DNA amplification assay (Final [**2200-11-16**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
[**2200-11-16**] URINE Legionella Urinary Antigen -FINAL
**FINAL REPORT [**2200-11-16**]**
Legionella Urinary Antigen (Final [**2200-11-16**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
CT NECK AND CHEST W/O CONTRAST [**11-16**]:
IMPRESSION:
1. No evidence of perforation or mediastinitis.
2. Esophageal stent appears in satisfactory position, unchanged
from
previously. Thick walled esophagus corresponding to known
malignancy.
3. Slight increased atelectasis at the left base. Otherwise,
CT appearance of the chest is little changed from [**2200-11-4**].
Studies:
[**2200-11-16**] CXR: FINDINGS: The right PICC is in stable position
terminating in the mid SVC. Again seen is an esophageal stent.
The lungs are clear. There is left pleural thickening vs less
likely small pleural fluid, unchanged from [**2200-11-7**]. There is
no pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION: No acute cardiopulmonary process.
CXR [**11-25**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The right-sided PICC line and the esophageal stent are
in unchanged position. Appearance of the lung parenchyma is
constant, with known apical scars, left more than right.
Very subtle basal parenchymal changes documented on the CT
examination from [**2200-11-16**] and likely reflecting the
sequela of chronic aspiration are not clearly seen on the chest
x-ray.
CT CHEST, ABDOMEN, AND PELVIS W/ CONTRAST:
IMPRESSION:
1. No evidence of abnormal fluid collection to suggest an
abscess within the thorax, abdomen or pelvis.
2. Stable thoracic esophageal stent with distal esophageal
fullness
consistent with history of esophageal carcinoma.
3. Stable left apical scaring. No new lymph nodes.
4. Sigmoid diverticulosis without diverticulosis.
ECHO [**11-28**]:
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 diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is posterior leaflet
mitral valve prolapse suggested. No definite masses or
vegetations are seen on the mitral valve (there may be partial
posterior leaflet flail), but cannot be fully excluded due to
suboptimal image quality. An eccentric, anteriorly directed jet
of moderate to severe ([**3-14**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. The pulmonary artery
systolic pressure could not be determined. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2200-10-15**], no
clear change. If clinically indicated, a TEE is suggested to
exclude endocardits and to better assess mitral/tricuspid
anatomy and degrees of valve regurgitation.
[**2200-12-4**] Radiology FDG TUMOR IMAGING (PET)
INTERPRETATION:
Comparison is made to a prior PET-CT from [**2200-9-23**] and a CT of
the torso from [**2200-11-26**].
HEAD/NECK: There is no abnormal FDG-avidity in the head or neck.
There is no cervical lymphadenopathy. The visualized paranasal
sinuses are clear.
CHEST: Since the prior PET-CT, a stent has been placed in the
esophagus over the site of the known squamous cell cancer. It
is unchanged in position since the most recent CT on [**2200-11-26**]. There is circumfrential FDG-avidity around the stent.
Additionally, there is a focus with slightly higher activity
continguous with the lateral aspect of the esophagus with the
SUV max of 6.87 (image 66). Just distal to the stent, there is
mild esophageal fullness and FDG-avidity with an SUV max of
4.58. In comparison to the prior PET-CT, the SUV max of the
esophageal lesion was 17.12.
Multiple sub-centimeter mediastinal and hilar lymph nodes are
present and not significantly changed from the prior exam. A
right hilar node measures 9 mm with an SUV max of 3.96 (image
65). It previously measured 9 mm with an SUV max of 3.59. A
second right hilar node measures 5 mm with an SUV max of 3.65
(image 71). It is unchanged in size and previously had an SUV
max of 3.58. A right paratracheal node measures 8 mm with an
SUV max of 3.22 (image 60). It previously measures 6 mm with an
SUV max of 2.95. A precarinal node measures 4 mm with an SUV
max of 2.47 (image 64). It previously measured 9 mm with an SUV
max of 3.30. Finally, a right hilar node measures 5 mm with an
SUV max of 3.19
(image 69). It previously measured 6 mm with an SUV max of 3.7.
There are no new FDG-avid lymph nodes.
Mild FDG-avidity in the right base with some ill-defined ground
glass has an SUV max of 2.10 and is new from the prior exam. No
discrete nodule is identified.
Left apical pulmonary scarring is stable. A punctate nodule in
the right lung is stable (image 77). Centrilobular emphysema is
unchanged. There is bibasilar atelectasis. There is mild left
pleural thickening with calcifications, unchanged.
ABDOMEN/PELVIS: There is no abnormal FDG-uptake in the abdomen
or pelvis. A G-tube shows surrounding FDG-avidity, which is a
normal finding. There is no abdominal, mesenteric or pelvic
lymphadenopathy.
MUSCULOSKELETAL: There is no abnormal FDG-uptake in the bones or
muscles.
Radiation changes are noted in the thoracic spine.
Physiologic uptake is seen in the brain, myocardium, salivary
glands, GI and GU tracts, liver and spleen.
IMPRESSION: 1. Residual FDG-avidity around the esophageal stent
may be due to residual disease, particularly the focus in the
mid stent region with an SUV max of 6.87. Alternatively, the
FDG-activity could be related to inflammation around the stent.
2. Stable small FDG-avid mediastinal and hilar lymph nodes.
3. Small focus of low-level FDG-activity at the right lung base
is likely
aspiration or inflammation.
DISCHARGE LABS:
[**2200-12-22**] 01:48AM BLOOD WBC-13.5* RBC-2.46* Hgb-7.4* Hct-21.9*
MCV-89 MCH-30.1 MCHC-33.7 RDW-17.8* Plt Ct-252
[**2200-12-22**] 01:48AM BLOOD Glucose-156* UreaN-21* Creat-0.7 Na-127*
K-4.1 Cl-91* HCO3-29 AnGap-11
[**2200-12-22**] 01:48AM BLOOD ALT-28 AST-34 AlkPhos-120 TotBili-0.3
[**2200-12-22**] 01:48AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 112389**] is a 57 yo male from [**Country 3396**] with stage III
esophageal squamous cell diagnosed [**9-/2200**] receiving
chemo/radiation s/p 2 cycles of cisplatin/5-FU, who was
discharged on IV Zosyn after polymicrobial bacteremia believed
to be secondary to esophageal mass s/p esophageal stent
re-admitted due after his discharge [**11-15**] for shortness of breath
and hypotension with concern for sepsis. He remained in the
hospital for a prolonged period due to recurrent fevers without
discovering a source and despite antibiotics. He also had
electrolyte abnormalities, notably hyponatremia that had to be
monitored until we were comfortable it would remain stable. He
was deemed to not be a surgical candidate for his cancer by
Thoracic Surgery Tumor board so was started on cycle 3 of
chemotherapy.
ACTIVE ISSUES:
# Stage III-IV SCC of the esophagus: S/p 2 cycles of cisplatin
and 5-FU as well as 28-day cycle of radiation.. Subsequent PET
scan shows FDG avid area mid-stent as well as stable small
FDG-avid mediastinal and hilar lymph nodes. Patient having
persistent odynophagia and dysphagia limiting PO intake and
resulting in weight loss. After the repeat PET scan, thoracic
surgery reconsulted and discussed his case at tumor board. They
determined he was not a surgical candidate at this time. Patient
then proceeded to cycle 3 of cicplatin/5-FU. His pain regimen
was been titrated with standing oxycodone po, since his
difficulty swallowing pills has prevented MSContin and his
cachectic body habitus and intermittent fevers prevented
fentanyl. Further oncologic management per Dr. [**Last Name (STitle) **], with
likely readmission for cycle 4.
# Sepsis: Fevers, altered mental status, and hypotension
required ICU admission on his presentation. Hypotension was
responsive to fluids in ICU and did not require pressors. No
definitive source, however suspicion for seeding from esophageal
lesion. Patient has history of multiple organisms found on blood
culture during last admission, but none were isolated on current
admission. Diarrhea raised concern for C-diff but assays were
negative. Stable, dry cough with unchanged CXR making pulmonary
source unlikely. Recent echo showed possible tricuspid
vegetation vs. leaflet thickening, but unable to have TEE due to
esophageal mass.He was treated at various times during his long
admission with vancomycin, meropenem, or zosyn. He continued to
have low-grade fever spikes through some antibiotics, so unclear
whether infectious or due to tumor fever. PICC line was at one
point removed (later replaced). Final regimen chosen was
vanc/[**Last Name (un) 2830**]/fluc on [**11-25**] without true fever since then. 1 week
course completed [**12-1**]. Per ID no current evidence to suggest
possible hidden source such as recurrent endocarditis or
abscess. Possibly necrotic source from mass. Fever after failed
PICC placement (see below) may have been due to hematoma
inflammatory reaction. No need to start antibiotics unless
patient presents with overt infection, a concerning culture, or
is very sick.
# Failed Right PICC placement on [**12-5**]: In advance of planned
discharge, during bedside PICC placement patient's artery was
punctured and he developed a large hematoma in his right arm.
H/H remained stable, and the hematoma size gradually decreased.
He went for IR guided PICC line in his left arm subsequently
without complications.
# Hyponatremia: Secondary to SIADH. Initially fluid-responsive,
likely due to hypovolemia, but once euvolemic managed with salt
tabs, free-water restriction with encouraged high electrolyte
diet,and concentrated tube feeds with TwoCal HN.
# Likely Adjustment Disorder with depressed mood - Difficult to
fully assess given translation issues, but patient now
well-known to staff here and is understandably showing the above
mentioned symptoms. Noted by nursing to be much less interactive
through his stay. Patient also had depressed mood, poor
appetite, loss of interest secondary to his situation. Was
started on Paroxetine for his symptoms. TSH/B12/RPR unrevealing
for other contributors to depression.
# Diarrhea, chronic: Nonbloody with multiple negative C diff
assays. Attributed to his chemotherapy. Controlled with banana
flakes in his tube feeds.
# Tachycardia, possibly related to tumor burden: Sinus per EKG
[**11-3**] and [**11-15**], however old EKG with SVT and lack of p waves
suggesting possible re-entrant arrythmia. Stable, asymptomatic,
related to urination, vomiting, and exertion. Started on low
dose verapimil however had to be stopped due to hypotension. He
remained tachycardic and asymptomatic without intervention due
to his generall tenuous status.
# G-tube site: Starting [**11-13**], skin site developed minor 2-3mm
erythema, induration, and some thin white-yellow discharge.
Non-tender. Provided wound care with cleanses and dressing
changes. Tube was then clogged, replaced by Thoracic surgery
[**11-21**]. No evidence of true cellulitis.
# MVP/MVR: per [**9-11**] TTE Myxomatous mitral valve leaflets,
moderate/severe MVP. eccentric MR jet, moderate (2+) MR.
Recently seen by cardiology and felt there is no indication for
medications at this time given normal LV function. He is
considered to be stable for surgery and chemo as needed. No e/o
worsening on exam or imaging.
# Hypomagnesmia, likely secondary to cisplatin-induced renal
wasting - With persistent repletions. Pischarged patient on
daily magnesium oxide 400mg crushable for G-tube delivery and
outpatient lab followup. Family and patient to be cautioned
about possible loose stool side effects.
CHRONIC ISSUES
# BPH: No urinary issues off doxazosin, held earlier in the
setting of hypotension
Continued tamsulosin
TRANSITIONAL ISSUES:
1) Esophageal carcinoma: Further outpatient management per Dr.
[**Last Name (STitle) **].
2) Hyponatremia secondary to SIADH: Intermittent labs checked
advised.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aquaphor Ointment 1 Appl TP TID:PRN skin rash
2. Nystatin Oral Suspension 10 mL PO QID:PRN mucositis
3. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
4. Metoclopramide 20 mg PO QIDACHS
5. Filgrastim 300 mcg SC Q24H
6. multivitamin *NF* Oral daily
7. Acetaminophen 1000 mg PO Q8H:PRN fever
may crush up to put through G-tube.
8. Cepacol (Menthol) 1 LOZ PO PRN throat dryness
9. DiphenhydrAMINE 25-50 mg PO Q8H:PRN pruritis or insomnia
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
through G-tube.
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Piperacillin-Tazobactam 4.5 g IV Q8H
End [**12-7**]
13. Sodium Chloride 2 gm PO BID
may take with or without food. take with food if upset stomach
with these salt tabs.
14. Senna 1 TAB PO BID:PRN constipation
15. Temazepam 15 mg PO HS
patient may refuse
16. 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.
17. Tamsulosin 0.4 mg PO HS
hold for sbp<90
Discharge Medications:
1. Metoclopramide 20 mg PO QIDACHS
2. OxycoDONE Liquid 10-15 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 10-15 mg(s) by mouth every four (4)
hours Disp #*1 Bottle Refills:*1
3. OxycoDONE Liquid 10 mg PO Q8H
4. Simethicone 40-80 mg PO QID:PRN gas pains
RX *simethicone 40 mg/0.6 mL 40-80 mg by mouth four times a day
Disp #*1 Bottle Refills:*0
5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
RX *docusate sodium 50 mg/5 mL 10 mL by mouth twice a day Disp
#*1 Bottle Refills:*2
6. Outpatient Lab Work
On Thursday, [**12-25**] please check Labs (Chem-10).
Fax results to Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] - Fax ([**Telephone/Fax (1) 11708**], Phone
([**Telephone/Fax (1) 3280**].
7. Mag-Oxide *NF* (magnesium oxide) 400 mg Oral Daily
Please dispense form that can be crushed for G-Tube.
RX *magnesium oxide 400 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*3
8. Aquaphor Ointment 1 Appl TP TID:PRN skin rash
9. Cepacol (Menthol) 1 LOZ PO PRN throat dryness
10. 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.
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
through G-tube.
12. ZOFRAN ODT *NF* (ondansetron) 8 mg Oral Q8H:PRN If cannot
take regular PO zofran Reason for Ordering: Cannot tolerate pill
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*50 Tablet Refills:*3
13. Senna 1 TAB PO BID:PRN constipation
14. Sodium Chloride 2 gm PO TID
may take with or without food. take with food if upset stomach
with these salt tabs.
15. Paroxetine 20 mg PO DAILY
RX *paroxetine HCl 20 mg 1 tablet(s) by mouth once a day Disp
#*90 Tablet Refills:*3
16. Acetaminophen 1000 mg PO Q8H:PRN fever
may crush up to put through G-tube.
17. DiphenhydrAMINE 25-50 mg PO Q8H:PRN pruritis or insomnia
18. multivitamin *NF* 0 tablet ORAL DAILY
19. Tamsulosin 0.4 mg PO HS
hold for sbp<90
20. Tube Feeds
Tubefeeding: Two Cal HN Full strength; Additives: Banana flakes,
3 packets per day
Start/Goal rate: 40 ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 50 ml water q4h
Discharge Disposition:
Home with Service
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Sepsis
Secondary Diagnosis:
Intermittent fevers
Esophageal carcinoma
Acute Kidney Injury, mild
Tachycardia
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 112389**],
It was a pleasure to care for you during your hospitalization.
You were admitted on [**11-15**] after becoming unresponsive and
developing fevers. You were treated in the Intensive Care Unit
temporarily until you were stable. You underwent an extensive
work-up which included blood tests and imaging studies. Based on
these results, you most likely had an infection that caused your
symptoms.
You were treated with several strong antibiotics through your
IV. After adjusting these antibiotics, you have remained without
a fever for a week. You also received fluids through your IV to
help support your kidney function. We have adjusted your tube
feeding and meals to maintain your sodium. Please AVOID liquids
that do not have electrolytes (for example, try to drink plain
water). Food and drinks with high protein and electrolytes are
better to make sure you do not have a low sodium.
Please be sure to follow-up at the appointments listed below. If
you develop any of the symptoms listed below, please call your
doctor, 911, or go to the Emergency Department immediately.
Please review the medication list carefully.
Followup Instructions:
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]. You
will be called at home with the appointment. If you have not
heard within 2 business days or have questions, please call
[**Telephone/Fax (1) 15512**].
Completed by:[**2200-12-28**] Name: [**Known lastname 18438**],[**Known firstname 18439**] Unit No: [**Numeric Identifier 18440**]
Admission Date: [**2200-11-15**] Discharge Date: [**2200-12-22**]
Date of Birth: [**2143-6-15**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 11713**]
Addendum:
Additional Transitional Issue
#) Thoracic surgery was requested to document their tumor board
discussion and/or impressions to clarify why he is not a
surgical candidate, given the implications for the patient.
Pending at time of discharge
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6331**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9495**] MD [**MD Number(1) 11715**]
Completed by:[**2200-12-28**]
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
359, 365
|
22224, 22224
|
4917, 4917
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,754
| 173,899
|
47602+59016
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-4-17**] Discharge Date: [**2116-5-1**]
Date of Birth: [**2048-7-15**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Aldactone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
intubation
tracheostomy
PEG
History of Present Illness:
67 yo F with COPD, CHF, MVR, CRI secondary to renovascular
disease was reffered to ED for abnormal labs.
.
She came in today for routine labs and hct noted to be 18.8
(from 31.7 one month ago). Has noted increased fatigue and SOB.
She says that she noted BRBPR on toilet paper few days ago that
she attributed to hemorrhoids. She says that when she walked in
triage RN noted that she had bright red blood running down her
leg (not documented). She denies melena but says that her stools
are dark at baseline due to iron.
.
She had EGD and colonoscopy done [**5-16**] which showed gastritis and
duodenitis, and 3 small colonic polyps (felt to be hyperplastic)
which were not biopsied due to her need for anticoagulation and
f/u colonscopy was recommended. She was treated with protonix,
and clarithro/amox/protonix for positive Hpylori.
.
In ED VS 98.1, 72, 112/25, 13, 100%2LNC--> Hct noted to be 18.8.
Rectal: black guaiac positive stool. NG lavage was clear but
without bilious return. Her sBP dropped down to 60s and she was
admitted to the ICU for further w/u and treatment.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. Rheumatic heart disease status post mitral valve prolapse
x2 with a mechanical valve.
2. COPD with a FEV1 of 0.6.
3. CHF with an EF of 20-30% by echocardiogram [**2114-5-15**].
4. History of AFib status post ablation/pacer.
5. Peripheral vascular disease, history of aortofemoral
bypass.
6. CAD with a previous one-vessel disease by cath in '[**06**].
7. History of pulmonary hypertension.
8. History of bilateral renal artery stenosis.
9. Chronic renal insufficiency with baseline creatinine of
1.6-2.4.
10. History of secondary hyperparathyroidism.
11. Status post cholecystectomy
.MEDS:
Coumadin 5
Digoxin 0.0625qd
Colace 100bid
Lasix 40qd
Lisinopril 2.5qd
Toprol XL 25qd
Advair
Spiniva
Lipitor 10
Protonix 40BID
FeSo4
Epogen
.
All: Bactrim, Aldactone
Social History:
Patient quit smoking 1 month ago, prior half pack per day, 50
pack year history. Denies any alcohol use. She lives with her
husband and son in a single floor apartment.
Family History:
Noncontributory.
Physical Exam:
PE VS 77/56 70
GEN: NAD
HEENT:PERRL, EOMI, Dry MMM
LUNGS:CTAB
COR:RRR, deformed surgical chest
ABD:S, NT/ ND +BS
EXT:WWP, no edema, +1 DP
RECTAL: black stool, OB positive, external hemorrhoids,
non-bleeding
Pertinent Results:
Labs on admission to ICU
[**2116-4-17**] 12:20AM BLOOD WBC-4.7 RBC-1.89* Hgb-5.8* Hct-18.8*
MCV-100* MCH-31.0 MCHC-31.1 RDW-17.6* Plt Ct-184
[**2116-4-16**] 02:17PM BLOOD WBC-5.0 RBC-1.97*# Hgb-5.9*# Hct-19.6*#
MCV-100* MCH-29.8 MCHC-29.9* RDW-17.4* Plt Ct-192
[**2116-4-17**] 12:20AM BLOOD Neuts-71.2* Bands-0 Lymphs-18.7 Monos-6.9
Eos-2.9 Baso-0.4
[**2116-4-17**] 12:20AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2116-4-17**] 12:20AM BLOOD PT-23.3* PTT-34.8 INR(PT)-3.4
[**2116-4-17**] 12:20AM BLOOD Plt Smr-NORMAL Plt Ct-184
[**2116-4-16**] 02:17PM BLOOD Plt Ct-192
[**2116-4-16**] 02:17PM BLOOD PT-21.5* INR(PT)-2.9
[**2116-4-17**] 12:20AM BLOOD Glucose-96 UreaN-91* Creat-3.5* Na-143
K-4.9 Cl-110* HCO3-23 AnGap-15
[**2116-4-16**] 02:17PM BLOOD UreaN-94* Creat-3.7*# Na-140 K-4.6 Cl-106
HCO3-24 AnGap-15
[**2116-4-16**] 02:17PM BLOOD ALT-11 AST-15
[**2116-4-17**] 04:40AM BLOOD CK(CPK)-58
[**2116-4-17**] 04:40AM BLOOD CK-MB-NotDone cTropnT-0.33*
[**2116-4-17**] 01:25PM BLOOD CK-MB-NotDone cTropnT-0.24*
[**2116-4-17**] 09:44PM BLOOD CK-MB-NotDone cTropnT-0.27*
[**2116-4-17**] 04:40AM BLOOD Calcium-7.8* Phos-5.6*# Mg-1.8
[**2116-4-16**] 02:17PM BLOOD TSH-4.9*
[**2116-4-18**] 01:58AM BLOOD Triglyc-133 HDL-34 CHOL/HD-3.7 LDLcalc-64
[**2116-4-22**] 01:50AM BLOOD PTH-183*
[**2116-4-17**] 04:40AM BLOOD Cortsol-20.4*
[**2116-4-17**] 04:41AM BLOOD Type-ART Temp-35.4 Rates-16/ Tidal V-500
PEEP-5 FiO2-100 pO2-190* pCO2-46* pH-7.22* calHCO3-20* Base
XS--8 AADO2-485 REQ O2-81 -ASSIST/CON Intubat-INTUBATED
[**2116-4-17**] 05:50AM BLOOD Type-ART Temp-36.0 pO2-228* pCO2-43
pH-7.25* calHCO3-20* Base XS--8 Intubat-INTUBATED
[**2116-4-17**] 04:41AM BLOOD Lactate-1.4
[**2116-4-17**] 10:12AM BLOOD Lactate-1.0
[**2116-4-17**] 04:41AM BLOOD freeCa-1.03*
[**2116-4-17**] 01:30PM BLOOD freeCa-1.10*
Labs on discharge
[**2116-4-30**] 11:59AM BLOOD Hct-32.3*
[**2116-4-30**] 04:05AM BLOOD WBC-6.9 RBC-3.56* Hgb-10.4* Hct-32.0*
MCV-90 MCH-29.1 MCHC-32.3 RDW-16.2* Plt Ct-180
[**2116-4-29**] 03:32PM BLOOD WBC-6.2 RBC-3.23* Hgb-9.4* Hct-28.8*
MCV-89 MCH-29.1 MCHC-32.6 RDW-16.1* Plt Ct-192
[**2116-4-27**] 03:18AM BLOOD WBC-7.1 RBC-3.36* Hgb-9.7* Hct-30.4*
MCV-90 MCH-28.8 MCHC-31.9 RDW-16.5* Plt Ct-151
[**2116-4-30**] 11:59AM BLOOD PT-16.1* PTT-92.1* INR(PT)-1.6
[**2116-4-30**] 06:30AM BLOOD PTT-91.7*
[**2116-4-30**] 04:05AM BLOOD Plt Ct-180
[**2116-4-30**] 04:05AM BLOOD Glucose-109* UreaN-85* Creat-2.9* Na-139
K-4.4 Cl-112* HCO3-17* AnGap-14
[**2116-4-29**] 03:32PM BLOOD Glucose-117* UreaN-87* Creat-2.8* Na-140
K-4.5 Cl-113* HCO3-19* AnGap-13
[**2116-4-30**] 04:05AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.4
[**2116-4-29**] 03:32PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.3
[**2116-4-30**] 04:18AM BLOOD Type-ART Temp-36.3 Rates-20/ Tidal V-500
PEEP-5 FiO2-50 pO2-175* pCO2-29* pH-7.39 calHCO3-18* Base XS--5
-ASSIST/CON Intubat-INTUBATED
Brief Hospital Course:
1. GIbleed: The initial concern was of upper GI (pylorus) vs.
lower GI source. SHe underwent EGD that did not reveal a source
of bleed. on [**4-17**]-5. Surgery and interventional readiology was
consulted. She was intubated initially for airway protection as
she had COPD and required sedation for comfort. She continued to
have bleeding and required numerous (around 6 units of pRBC and
6 units of FFP for coumadin reversal). She subsequently
underwent angiography to find the source of bleeding that
revealed 1) an irregular abdominal aorta with a patent
aorto-bifemoral bypass graft. There is complete occlusion of the
left renal artery.2)cclusion of the inferior mesenteric artery.
3) Selective celiac arteriogram revealed irregularity within the
gastroduodenal artery and tortuosity of the splenic artery. No
vascular abnormality or pseudoaneurysm was identified.4)
Selective superior mesenteric arteriography revealed a focal
moderate stenosis just distal to its origin with collateral
filling of the left colic and superior hemorrhoidal arteries via
the middle colic and SMA branches. There was no evidence of
active extravasation nor vascular abnormality identified.THe SMA
stenosis was stented but no evidence of bleed was found. Over
the next day (3/5-6), She continued to experience dropping Hct
and underwent abdominal CT to rule out retroperitoneal bleed.
The abdominal Ct was negative for any such bleed. As her
hematocrit stabilized on [**4-14**]. She was restarted on heparin
for her mitral valve replacement. She has had continued trace
guiac positive stool throughout her hospital stay, but she never
had another episode of new GI bleed.
2. MVR: She underwent emergent reversal of anticoagulation with
FFP given acute GI bleed and hypotension on admission. She was
restarted on heparin on [**4-21**] after her hematocrit stabilized. Her
heparin was held again on [**4-28**] briefly for tracheostomy and PEG
tube placement. Her heparin was restarted on [**4-28**]. Her coumadin
was restarted on [**4-30**].
.
3. Respiratory: Severe COPD (FEV1 0.6) and CHF (EF 20%). She was
initally intubated for airway protection and given need for
aggresive volume resuscitation and EGD.
She was attempted to wean from the ventilator on [**2122-4-23**], but
this was unsuccessful as she was likely to experience
respiratory muscle deconditioning, fluid overload and baseline
severe COPD. Disucssion was made with the family. She was tried
briefly on BiPAP and given lasix and nebulizer but she failed to
respond and was reintubated on [**4-24**] and given her likely need
for slow wean from ventilation . She underwent tracheostomy
placement on [**4-29**]. She is deemed to need slow wean from vent.
She will go to a vent rehab facility for weaning.
.
4. Renal: She experienced acute on chronic renal failure likely
due to volume depletion on admission with creatine bump to
3.5-3.7. This was improved with aggresive volume resuscitation
and blood transfusion. Her lisinopril was held. She was also
started on dopamine drip briefly during her hospital stay along
with lasix drip to help her mobilized her fluid given her CHF
status. Her kidney responded by increasing urine outpt and
decreasing creatine. She was followed by renal consult on this
admission. She was deemed to be not hemodilaysis candidate on
this admission as her kidney suffered an acute event. However,
if her renal function does not improve in the near future, she
will need an evaluation for hemodialysis. She is also to
continued on regular epogen shot for chronic renal insuffiency
.
5. CHF: EF 20%. Monitor volume status with fluid resusciation.
Her lasix was held this admission
.
6. CAD: h/o 1vd by cath in 95. Her aspiring was held given her
GI bleed. Her beta-blocker was held given hypotension.
Transfuse for hct >28.
7. Infectious disease- She developed fever and grew gram
negative rod that speciated to be pan-sensitive serratia during
this admission . SHe was treated with 10 day course of
ceftazidime. She also grew MRSA from her sputum at the same
time. She was also treated with 10 day course of vancomycin. She
was placed on MRSA precaution during this hospitalization.
.
8. FEN. She was initially held on po diet given her GI bleed and
procedures. She was later started on Tube feed during
intubation. She is getting tube feed through her PEG tube on
discharge.
.
8. Access:She received an right IJ and Left a-line during this
admission for fluid resucitation and intensive blood pressure
monitoring.
.
.
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-16**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO
DAILY (Daily) for 7 days.
14. Metoclopramide 5 mg IV Q6H
15. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED): please aim for
PTT goal of 60-80 while pt is being transitioned to coumadin.
16. Fentanyl Citrate 25-100 mcg IV Q4H:PRN
17. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
please check INR daily and adjust to goal INR 2.5-3.5.
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
19. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): 2 unit for FS 150-200: 4 unit for
FS 201-250; 6 unit for FS 251-300; 8 unit for FS 301-350; 10
unit for FS 351-400; 10 unit for FS 410 or greater and call
house officer.
20. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed.
21. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CHF
Chronic renal insuffiency
COPD
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1.5L
PLease check INR daily and adjust coumadin to INR 2.5-3.5.
Coumadin to start on [**5-1**] with 2mg coumadin. Please stop heparin
once INR is therapeutic for a couple of days.
Please do continous bladder irrigation and decrease frequency as
needed to q2 then q4 and monitor for signs of blood clots and
urine output. PLease call hospital if much increased hematuria,
but hematuria should resolved over next several days.
Please check patient creatine daily and forward to facility
doctor as pt may need hemodialysis in the future (no indication
for hemodilaysis right now) stable creat @ 2.9. PLease have
facility doctor arrange for renal clinic followup at [**Hospital1 18**] if
persistent high creatine as they may need to start hemodialysis
in the future
Pt is adrenal insuffient. Pt will need to be on 10 prednisone
and 0.1 fludrocortisone indefinitely.
Followup Instructions:
please make appointment to see you primary doctor in 2 weeks
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname 16162**],[**Known firstname 2243**] Unit No: [**Numeric Identifier 16163**]
Admission Date: [**2116-4-17**] Discharge Date: [**2116-5-1**]
Date of Birth: [**2048-7-15**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Aldactone
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Pt was noted to have hematuria on [**4-30**] after foley reinsertion
trauma and PTT of 144. Her hematuria was resolving on [**5-1**]. She
was maintained on continuous bladder irrigation and had minimal
blood clots in her urine. She is deemed ok to go to vent
facility. SHe will initially require continous bladder
irrigation. THis can be titrated down in terms of frequency to
q2 then q4 then q6 as patient tolerates.
She will need outpatient urology followup with possible
cystoscopy in the future to rule out bladder malignancy.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2116-5-1**]
|
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"V09.0",
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icd9cm
|
[
[
[]
]
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[
"34.91",
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[
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295, 325
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12414, 12422
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2704, 5587
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|
2444, 2462
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10138, 12240
|
12356, 12393
|
12446, 13431
|
2477, 2685
|
247, 257
|
353, 1437
|
1481, 2241
|
2257, 2428
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,215
| 128,835
|
31612
|
Discharge summary
|
report
|
Admission Date: [**2120-3-12**] Discharge Date: [**2120-3-31**]
Date of Birth: [**2050-7-13**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Allopurinol And Derivatives /
Vancomycin / Ciprofloxacin / Augmentin / Azithromycin /
Linezolid / Cefepime / Iodine / Meropenem
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Febrile neutropenia and meropenem desensitization
Major Surgical or Invasive Procedure:
Cycle 13 of decitabine
History of Present Illness:
The patient is a 59-year-old gentleman with a history of
myelodysplastic syndrome with acceleration to AML s/p
clofarabine induction therapy with prolonged remission then
recurrence, s/p 12 cycles of decitabine, presenting with febrile
neutropenia for meropenem desensitization in the ICU.
.
The patient was recently discharged on [**2119-3-11**] after his 12th
cycle of decitabine, with hospitalization complicated by mild
tumor lysis. He was supported with pRBC and platelet
transfusions. Upon his return visits to clinic for the last 2
days, he has required further platelet/RBC transfusions for plt
counts of <10, Hct<30, with appropriate bumps to transfusions
(Plt 6 --> 50 this AM). He called the BMT fellow on-call to
report a fever to 101.4. He did not have any symptoms prior to
taking his temperature, and states that he normally measures his
temperature twice a day, per instructions from his oncologist.
His most recent ANC is 84 (on [**2119-3-12**]). He was instructed to
report to the ED for further work-up. He also states that he
has been having some nosebleeds recently that result in him
coughing up some blood, which he feels is definitely not from
his lungs. He has also noticed bruising all over his body.
Prior to transfusions, he has been receiving Benadryl and
Tylenol, which he did receive the morning prior to admission
before getting his platelets. He did remark that he has
occasional episodes where he feels like his "throat is closing",
which makes him panic and his blood pressures acutely rise.
This all resolves within 8-10 minutes. He has also been using
his home O2 more around the house within the past 1 month.
.
Of note, the patient has extensive antibiotic allergies and he
is being followed by Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] of Allergy/Immunology who
has made a number of recommendations. He is able to tolerate
Daptomycin and Clindamycin. However, if broader coverage is
needed (Aztreonam or Meropenem), he must undergo a
desensitization protocol in the ICU. In [**2119-10-4**], he
underwent a successful meropenem sensitization after developing
a drug-induced hypersensitivity rash while on Cefepime.
Linezolid desensitization has been unsuccessful in the past.
Cefepime and allopurinol should be completely avoided. He also
strongly recommended standing doses of H1 and H2 blockers
(diphenhydramine 25 mg q6h or hydroxyzine 25mg PO q6h +
famotidine 20 mg q12h) and to continue these agents through the
length of his antibiotics.
.
In the ED, VS: 96.4, 102, 140/68, 18, 2L 94% (home oxygen). The
patient does not endorse any localizing signs or symptoms.
Blood culture was drawn from his portacath, U/A and urine
culture done, but they were unable to draw peripheral cultures
prior to receiving his 1st dose of Daptomycin 450mg. Received
Tylenol 650mg and 1L NS. Labs are notable for WBC 1.6 with 4%
neutrophils and 5% blasts, Hct 25.5, Plt 25, Cr 1.2 (baseline
0.9-1.0), and lactate 0.9. U/A clear. CXR shows an infiltrate
in the posterior RLL, seen best in the lateral view.
.
In the ICU, he is quite comfortable on 2L O2 without any
complaints.
.
ROS: (+) per HPI, (-) for fevers, chills, nausea, vomiting,
diarrhea/constipation, chest pain, SOB (above baseline),
abdominal pain, dysuria, headaches, blurry vision, dizziness,
LOC.
Past Medical History:
Oncologic history:
Patient initially presented in [**2119**] with easy bruising
and dropping cell counts (pancytopenic) as well as some
SOB/fatigue. BMBx was consistent by report with myelodysplastic
syndrome with presence of a 15-20% immature cells consistent
with blasts; Dr. [**Last Name (STitle) **] felt the pathology was consistent with
MDS with excess blasts in transformation, suggesting
acceleration of the disease towards acute leukemia.
.
Pt underwent induction and reinduction with single [**Doctor Last Name 360**]
clofarabine per protocol 07-013, last treated in 09/[**2116**]. Since
that time, he showed signs of dysplasia was dropping cell lines
and bone marrow biopsy done in [**9-/2118**] showed blasts occurring
in small clusters occupying an estimated 20% of the marrow
cellularity. Cytogenetics showed deletion of the long arm of
chromosome 20 and he was treated on [**2118-9-19**] with his first
cycle of decitabine. He has completed 12 cycles of decitabine,
with the 8th cycle complicated by pneumonitis and deterioration
of lung function, requiring home oxygen use. He has previously
opted not to undergo allogeneic stem cell transplant due to
quality of life desires.
.
Other past medical history:
- COPD/emphysema
- GERD
- ? Angina (Last stress MIBI in [**12-11**] was grossly normal, most
recent TTE in [**10-12**] normal)
- Degenerative joint disease/arthritis of the spine
.
Past surgical history:
- Tonsillectomy as a child- age 5
- Appendectomy as a child - age 8
- Submucous resection - age 12
- Left meniscus repair of the knee - age 37
- Right meniscus repair of the knee - age 64
- Hernia repair left side - age 65
Social History:
Occupation: former veteran from [**Country 3992**], ? exposure to [**Doctor Last Name **]
[**Location (un) **]. Retired from food and beverage industry.
Drugs: none
Tobacco: smoked heavily [**3-7**] ppd x 40 years, quit [**2096**]
Alcohol: significant past alcohol intake, quit [**2091**]
Other: married 44 years; 4 children (2 sons, 2 daughters) -
lives with one son's family. Family involved in patient's care
Family History:
His mother is deceased at age [**Age over 90 **] from a bowel obstruction. His
father is deceased at age [**Age over 90 **] from prostate cancer. He has no
siblings.
Physical Exam:
VS: Temp: 97.5, BP: 108/67, HR: 104, RR: 16, O2sat: 92% on 2L NC
GEN: pleasant, comfortable, NAD
HEENT: NC/AT, PERRL, EOMI, anicteric, slightly pale
conjunctivae, MMM, OP without lesions or tonsilar swelling
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTAB, no wheezes/rales/rhonchi, no stridor
CV: RRR, quiet S1 and S2 wnl, no m/r/g
ABD: normoactive BS, soft, NT/ND, mild hepatomegaly percussed,
no detectable splenomegaly
EXT: no c/c/e, WWP
SKIN: no rashes/no jaundice/no splinters; skin around portacath
intact, without erythema or tenderness; mild bruising over arms
NEURO: AAOx3. CN II-XII intact. 5/5 strength and full sensation
to LT throughout. 2+ DTR's-patellar and biceps
Physical Exam on discharge
- please see daily progress note
Pertinent Results:
INITIAL LABS:
136 / 104 / 25
4.0 / 22 / 1.2
.
1.6 \ 25.5 (MCV 81) / 25
N:4 Band:0 L:57 M:33 E:0 Bas:1 Blasts: 5
.
PT: 14.0 PTT: 29.6 INR: 1.2
.
Lactate 0.9
.
U/A - leuk and nitrite neg, WBC 0-2, few bact, trace blood, prot
25
===============================================================
Pertinent Labs:
[**2120-3-28**] 06:05PM BLOOD WBC-11.9* RBC-3.96* Hgb-11.9* Hct-34.5*
MCV-87 MCH-30.0 MCHC-34.5 RDW-14.0 Plt Ct-15*
[**2120-3-27**] 12:00AM BLOOD Neuts-0 Bands-0 Lymphs-49* Monos-6 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* Other-44*
[**2120-3-28**] 06:05PM BLOOD Neuts-0 Bands-0 Lymphs-20 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-76* NRBC-2*
[**2120-3-21**] 12:00AM BLOOD IgG-1241 IgA-274 IgM-60
[**2120-3-14**] 04:46PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1
[**2120-3-14**] 04:46PM BLOOD B-GLUCAN- Test not performed due to lab
accident
===============================================================
Discharge Labs:
[**2120-3-31**] 12:00AM BLOOD WBC-1.6* RBC-3.89* Hgb-11.4* Hct-33.1*
MCV-85 MCH-29.2 MCHC-34.3 RDW-13.8 Plt Ct-25*
[**2120-3-31**] 12:00AM BLOOD Neuts-3* Bands-0 Lymphs-38 Monos-2 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 Blasts-56*
[**2120-3-31**] 12:00AM BLOOD PT-13.9* PTT-24.4 INR(PT)-1.2*
[**2120-3-31**] 11:57AM BLOOD Fibrino-246
[**2120-3-31**] 12:00AM BLOOD Gran Ct-48*
[**2120-3-31**] 11:57AM BLOOD Glucose-138* UreaN-33* Creat-1.1 Na-139
K-4.6 Cl-105 HCO3-25 AnGap-14
[**2120-3-31**] 12:00AM BLOOD ALT-14 AST-17 LD(LDH)-332* AlkPhos-69
TotBili-0.3
[**2120-3-31**] 12:00AM BLOOD Calcium-8.7 Phos-5.4* Mg-2.2
===============================================================
Microbiology:
[**2120-3-13**] 11:14 am URINE
Legionella Urinary Antigen (Final [**2120-3-14**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2120-3-22**] 11:32 am SPUTUM Source: Induced.
GRAM STAIN (Final [**2120-3-22**]):
<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 [**2120-3-22**]):
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2120-3-22**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
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.
===============================================================
Imaging:
CXR ([**3-12**]):
PA AND LATERAL VIEWS OF THE CHEST: Right-sided Port-A-Cath tip
terminates within the SVC. The cardiac silhouette is normal in
size. The mediastinal and hilar contours are unchanged. A new
focal consolidation is seen within the posterior aspect of the
right lower lobe concerning for pneumonia. Left lung is clear.
Probable trace pleural effusion on the right is present. There
are no acute osseous findings.
CT chest ([**3-17**]):
1. Right lower lobe, lateral-basal segment consolidation, new
from prior
study.
2. Near complete resolution of previously demonstrated left
upper lobe
consolidation with residual biopsy scar.
3. Emphysema.
LENIS ([**3-21**]):
Grayscale and color evaluation of the right common femoral vein,
superficial femoral veins, popliteal vein, and posterior tibial
vein
demonstrate normal color flow, augmentation, and
compressibility. The
peroneal veins were not seen.
IMPRESSION: No evidence of DVT in the right lower extremity.
Brief Hospital Course:
59M with hx of MDS with transformation to AML s/p clofarabine
and decitabine chemotherapy and multiple antibiotic allergies,
now admitted to the ICU with febrile neutropenia for meropenem
desensitization.
1. Febrile neutropenia and antibiotics hypersensitivity. ANC of
64 on admission, s/p recent decitabine infusion, with fever to
101.4. Afebrile on admission. No localizing signs of
infection, but patient is at high risk for infection and cannot
mount a proper immune response. CXR shows a developing RLL
consolidation, concerning for pneumonia (seen best on lateral
film). Due to the patient's numerous antibiotic allergies, he
cannot receive Cefepime for treatment. Instead he underwent
desensitized to Meropenem to properly cover GNs. He also has a
portacath and has been exposed to health-care associated
pathogens recently, so he needs covererage for GPs but cannot
receive Vancomycin due to allergy. He has tolerated Daptomycin
well in the past. In the ICU patient underwent Meropenem
desensitization per protocol and treated with Daptomycin for GP
coverage. Unfortunately, the patient developed a sensitivity
reaction to meropenem (see below). Given his extensive history
of allergy to antibiotics, and after extensive consultation with
both Allergy and ID, the patient was started on tigecycline. In
the two days following the administration of tigecycline, the
patient had worsening erythema and edema in his upper
extremities. It was unclear, according to Allergy, whether this
was a continuation of his established reaction to meropenem or a
new reaction to tigecycline. Again, antibiotic stopped. After
discussion with patient, BMT, Allergy, and ID, the patient was
started on oral levofloxacin, starting with a 10% dose and
progressing to a full dose. There has been conjecture about
patient allergy perhaps being to diluent or preservative in IV
antibiotics, since he denies ever having a reaction to oral
medications. He remained afebrile since [**3-17**] when the oral
levofloxacin was started (D1 = [**3-17**]) and tapering of prednisone
to 10 mg was started on [**3-18**] per Allergy recommendation given
his clinical improvement. However, by [**3-21**], intense
erythroderma again spread to include his face, which he reports
never had before with prior antibiotics hypersensitivity, his
body ached, and his LE became more swollen. Given that patient
had not spiked a fever since [**3-17**] and his hypersensitivity
appeared worsened, levofloxacin was discontinued (total 4 day
course) and prednisone was uptitrated to 20 mg daily on [**3-21**].
He was restarted on home doxycycline on [**3-22**]. His prednisone
was again tapered to 5 mg on [**3-28**]. However, his
hypersensitivity flared again, thought to be [**3-6**] rapid taper of
prednisone, so he received 15 mg on [**3-29**] and again 10 mg daily
starting [**3-30**]. Derm was consulted and agreed with the
assessment. He was discharged with home doxyycline and
voriconazole. He was given instruction on the prednisone taper
and petrolatum for protective barrier for his skin.
2. Meropenem desensitization: The patient had undergone a
successful desensitization to Meropenem previously, when a
decitabine cycle was complicated by a COPD exacerbation.
Cefepime is not tolerated well by the patient and he requires
Pseudomonal coverage for febrile neutropenia. Patient has
multiple allergies across all classes of antibiotics.
Aminoglycosides have not yet been tried as another option for GN
coverage. In the ICU pt initially underwent meropenem
desensitization per protocol including standing benadryl 25mg IV
Q6H and Q12 hour standing H2 blocker. B-blocker was held to
prevent blunting of allergic response. On the evening of
[**2120-3-14**], the patient began to experience fever and erythema on
his back. The erythema and pruritus spread to his arms and legs
over the course of the evening. Meropenem was stopped, and the
patient was given an additional dose of diphenhydramine and
started on low-dose (20mg) prednisone. See above for the
remaining of his neutropenia and associated antibiotics
hypersensitivity.
3. MDS --> AML with chronic anemia/thrombocytopenia. At
admission, he was s/p 12 cycles of decitabine with persistent,
transfusion-dependent anemia and thrombocytopenia. He was
transfused with pRBC and platelet frequently to maintain Hct of
about 30 and plt > 10. He was started on hydroxyurea on
[**2120-3-28**] and cycle 13 of decitabine on [**2120-3-29**] because of
increased WBC (~11,000) and blast counts (~75%). Hydroxyurea
was discontinued on [**3-30**] as his WBC improved. Upon discharge,
his blast counts were in the 50%. He will need to return to
outpatient clinic for last dose of decitabine.
4. Acute kidney injury: Initially, his creatinine was 1.2, which
is slightly elevated above his baseline. It was thought to be
pre-renal since he was on no new medication. His UA was neg and
there was no evidence of active sediment. His creatinine
improved to 0.9. However, with the chemo, his creatinine
increased again. This has been observed in the past where his
creatinine rises with the chemotherapy. This will need to be
followed closely in the outpatient setting.
5. Multifocal lung opacities and COPD/emphysema: This was
thought to be the major limiting factor to his functional
status. It was noted that the past LUL biopsy did not appear to
be infectious etiology and past bronchial washings were negative
for malignancy on cytology. Patient continued with home O2 at
night. Because of his symptomatic SOB from Hct < 30, he got
frequent blood transfusion. Home tiotropium and albuterol were
continued. He was also started on monteleukast. See above for
the pnuemonia and antibiotics.
6. GERD: patient was on Omeprazole 20mg daily at home. Describes
long-standing transient episodes of swelling sensation in
throat, which do not have any identifiable trigger but do worsen
when lying down. They are sometimes associated with heartburn.
Episodes always resolve within 10-15 minutes of sitting up. This
was thought to be possibly caused by acid reflux. We increased
his Omeprazole dose to 40mg. In the ICU, famotidine was
started, but it was subsequently discontinued as patient did not
notice significant change.
7: DJD: pain control with oxycodone PRN
Medications on Admission:
1. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H
2. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB or
wheeze.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain. (rarely uses this medication)
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
Discharge Medications:
1. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
2. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
10. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
11. prednisone 5 mg tab
Take 10 mg (2 tabs) once a day for 5 days, then 5 mg (1 tab)
once a day for 5 days, then 5 mg (1 tab) once EVERY OTHER DAY
for 5 days.
Dispense: 20 tabs.
Refill: 0.
12. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for desquamating skin.
Disp:*1 bottle* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- AML, Cycle 13 of decitabine
- Healthcare associated pneumonia
- Hypersensitivity reaction
Secondary diagnoses:
- Acute renal failure, resolved.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 22130**],
It was a pleasure to take care of you at [**Hospital1 827**].
You were admitted for neutropenic fever (fever in the setting of
low white blood cell count) which was thought to be the result
of a pneumonia. Because of the extensive antibiotics allergies
that you had in the past, you required desensitization to the
antibiotics of choice. You underwent this process initially
with meropenem and developed allergic reaction. Subsequently,
tigecycline was tried, but you continued to have significant
skin reaction. Therefore, you were started on levofloxacin
because you tolerated similar medicine in the past. Your
reaction initially improved, which could be the natural course
of the meropenem and possible tigecycline, but then spread to
your face. Therefore, we stopped the levofloxacin. We switched
you back to your home doxycycline, which you tolerated well.
You did not have a fever since [**2120-3-17**].
While you experienced the allergic effect from the failed
desensitization, you were started on medicine to help relieve
your symptoms. You are currently on a prednisone taper as your
skin reaction improves.
Your white blood cells and blasts begin to rise during this
hospital stay. You were started on hydroxyurea and the 13th
cycle of decitabine. Hydroxyurea was stopped before your
discharge.
Please note the following changes in your medications:
- Please START diphenhydramine 25 mg (Benadryl) tab, 1 tab, by
mouth, every 6 hours as needed for itching skin. You can get
this medicine from over the counter.
- Please START prednisone taper. Take 10 mg (2 tabs) once a day
for 5 days, then 5 mg (1 tab) once a day for 5 days, then 5 mg
(1 tab) once EVERY OTHER DAY for 5 days.
It will be VERY IMPORTANT for you to follow up with your doctors
as [**Name5 (PTitle) 1988**] below.
Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: MONDAY [**2120-4-1**] at 9:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: BMT/ONCOLOGY UNIT
When: TUESDAY [**2120-4-2**] at 9:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: BMT/ONCOLOGY UNIT
When: WEDNESDAY [**2120-4-3**] at 9:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Completed by:[**2120-3-31**]
|
[
"E933.1",
"584.9",
"486",
"E930.8",
"492.8",
"284.1",
"782.3",
"276.52",
"721.90",
"205.02",
"693.0",
"288.03",
"530.81",
"780.61",
"285.22",
"V07.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
19386, 19392
|
10653, 16961
|
475, 500
|
19602, 19602
|
7004, 7301
|
21623, 22521
|
5979, 6146
|
17904, 19363
|
19413, 19525
|
16987, 17881
|
19753, 21600
|
7959, 9340
|
5308, 5533
|
6161, 6985
|
19546, 19581
|
9376, 10630
|
383, 437
|
528, 3859
|
19617, 19729
|
7317, 7943
|
5104, 5285
|
5549, 5963
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,631
| 138,094
|
37717
|
Discharge summary
|
report
|
Admission Date: [**2193-9-12**] Discharge Date: [**2193-9-18**]
Date of Birth: [**2109-8-15**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Pedestrian struck by auto
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84F pedestrian on coumadin struck by car reportedly at 40MPH;
GCS 14->15 at scene. She was taken to an area hospital where
found to have subdural hemorrhage and was then transferred to
[**Hospital1 18**] for further care.
Past Medical History:
Afib (on coumadin), CHF, h/o stroke
PSH: ulcer surgery years ago, C-1 surgery 10yrs ago
Family History:
Noncontributory
Physical Exam:
Upon exam:
T:97.1 BP:171/114 HR: 68 R:22 O2Sats:96% NC
Gen: WD/WN, comfortable, NAD.
HEENT: R head laceration, edema and ecchymosis over R eye
Pupils:L 4-3mm, R difficult to appreciate due to edema
EOMs: intact
Neck: no point tenderness over cervical spine
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-5**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils L [**3-8**] reactive to light, R difficult to appreciate
due
to edema. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength antigravity in upper extremities and [**4-9**] in
lower extremities. Unable to access pronator drift due to pain
in
upper extremities.
Sensation: Intact to light touch
Toes downgoing bilaterally
Pertinent Results:
[**2193-9-12**] 11:06PM GLUCOSE-132* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-32 ANION GAP-15
[**2193-9-12**] 11:06PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.9
[**2193-9-12**] 11:06PM WBC-12.0* RBC-3.47* HGB-10.5* HCT-31.9*
MCV-92 MCH-30.3 MCHC-33.0 RDW-14.3
[**2193-9-12**] 11:06PM PLT COUNT-195
[**2193-9-12**] 11:06PM PT-19.3* PTT-25.3 INR(PT)-1.8*
[**2193-9-12**] 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Micro/Imaging:
[**2193-9-16**] MRI CSpine Severe spinal canal compression on the cord
at C3-4 level
[**2193-9-15**] MRI Cspine increased C7 signal, C3/4 spinal stenosis,
cord compression, DJD
[**2193-9-13**] MRI [**First Name8 (NamePattern2) **] [**Doctor First Name **]
[**2193-9-13**] MRI cspine partial study- anterolisthesis of C4 over C5
[**2193-9-12**] CT [**Last Name (un) **] No facial bone fractures
[**2193-9-12**] CT cspine degenerative changes, old fx
[**2193-9-12**] CT torso No acute thoracic/abdominal injury, mod L
pleural eff, no fx
[**2193-9-12**] CT head Thin right frontal subdural hematoma
[**2193-9-12**] repeat CTH stable 3mm SDH, small L parietal [**Last Name (LF) **], [**First Name3 (LF) 30272**] R
frontal IPH
[**2193-9-12**] MRI cspine:
1. Obliquely oriented linear focus of increased STIR signal in
the
anterosuperior aspect of the C7 vertebral body which may
represent a fracture cleft.
2. Extensive degenerative changes, with anterolisthesis at
multiple levels as described above.
3. Severe spinal canal stenosis, with compression on the cord at
C3-4 level.
Small focus of increased signal intensity at C4 level in the
cord, can relate to myelomalacic changes.
Brief Hospital Course:
She was admitted to the Trauma service; Neurosurgery was
consulted for her subdural and cervical spine injuries. These
were managed non operatively. Serial head CT scans were followed
and remained stable, her Coumadin was withheld and should not be
restarted until her repeat head CT scan in 4 weeks. She was
maintained in a hard cervical collar and underwent an MRI which
revealed a severe spinal canal stenosis, with compression on the
cord at C3-4 level. It is being recommended that she remain in a
hard collar and will follow up in 1 month with Dr. [**Last Name (STitle) 548**] for
repeat head and spine imaging.
A Geriatric Medicine consult was obtained given her age and
mechanism of injury. several recommendations were made
pertaining to her medications and for maintaining adequate
sleep/wake cycle to minimize delirium. Of note she was not found
to be delirious during her hospital stay.
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
dilt xr 300', atenolol 50', coumadin 2.5', lasix 20'.
.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Oxycodone 5 mg/5 mL Solution Sig: Five (5) MG PO Q4H (every 4
hours) as needed for pain.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 3 days.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 56223**]
Discharge Diagnosis:
s/p Pedestrian struck by auto
Right frontal subdural hematoma
Cervical spine canal stenosis at C3-4 level
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
You are required to wear your cervical collar at all times, you
may remove briefly to shower daily per neurosurgery without
moving your neck. Someone will need to assist you with replacinf
the collar properly.
DO NOT resume your coumadin for at least 4 weeks until follow up
with Dr. [**Last Name (STitle) 548**].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**], Neurourgery in 4 weeks for your
head and spine, you will need head CT prior to appt - please
call [**Telephone/Fax (1) 2992**] to arrange.
Completed by:[**2193-9-24**]
|
[
"852.26",
"839.03",
"285.9",
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"839.04",
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"952.04",
"V45.4",
"427.31",
"799.02",
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] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
5848, 5896
|
3758, 4765
|
300, 306
|
6045, 6125
|
2051, 3735
|
6488, 6713
|
686, 703
|
4872, 5825
|
5917, 6024
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|
6149, 6465
|
718, 994
|
231, 262
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334, 558
|
1286, 2032
|
1009, 1270
|
580, 670
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,555
| 172,991
|
49130
|
Discharge summary
|
report
|
Admission Date: [**2106-8-18**] Discharge Date: [**2106-8-27**]
Date of Birth: [**2050-11-12**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
woman who presents with three weeks of constant occipital
headache. The headache began three weeks ago with an episode
where the patient reported feeling like she had the flu. She
sensitivity to noise. She went to see her primary care
physician who prescribed Fiorinal. She states that this
resolved most of her symptoms but the occipital headache
remained. She went to see her primary care physician again
who sent her for an MRI and a subsequent MRA 1?????? weeks later.
The MRA demonstrated an aneurysm. The patient denies any
visual changes, no dizziness, no gait disturbances, and no
PAST MEDICAL HISTORY: The past medical history includes
lupus; type 2 diabetes, diet controlled;
hypercholesterolemia; hysterectomy; and appendectomy.
MEDICATIONS: Procardia XL 30 mg p.o. q. day, Premarin 0.625
mg p.o. q. day, Prilosec 20 mg p.o. q. day, Plaquenil 400 mg
p.o. q. day.
ALLERGIES: Bactrim, Tetracycline, Augmentin, paper tape,
catgut sutures.
PHYSICAL EXAMINATION: On physical examination, the patient
was awake, alert, and oriented times three. Speech was
fluent, normal content. Extraocular movements were full, no
nystagmus. Pupils were equal and reactive to light, 3 mm
down to 2 mm bilaterally. Sensation of the face was intact.
Muscles of mastication were intact. Face was symmetric,
tongue midline. Hearing was intact to finger rub on the
left, decreased on the right which was old. Shoulder shrug
was [**3-27**]. Motor strength was [**3-27**] in all muscle groups. She
had no drift. Finger-to-nose was intact. Reflexes were 2+
throughout.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for close monitoring. A lumbar puncture was done
which showed no evidence of xanthochromia. The patient had
an angiogram which showed a right middle cerebral artery
aneurysm. On [**2106-8-21**], the patient underwent a right pterional
craniotomy with clipping of aneurysm. Postoperative vital
signs were stable. The patient was awake, alert, and
oriented times three with some right periorbital edema. Face
was symmetric, no drift. The dressing was with
serosanguinous drainage. The patient's vital signs remained
stable, she remained neurologically intact. The patient was
transferred to the regular floor on [**2106-8-23**]. She underwent
repeat angiogram on [**2106-8-26**] which showed aneurysm
completely clipped with no residual and no evidence of
vasospasm. Vital signs had been stable, the patient remained
afebrile, and she was discharged to home in stable condition.
DISCHARGE MEDICATIONS: Percocet 1-2 tablets p.o. q. 4 hours
p.r.n., Procardia XL 30 mg p.o. q. 12 hours, Prilosec 20 mg
p.o. q.a.m., Premarin 0.625 mg p.o. q. day, Plaquenil 400 mg
p.o. q. day, Erythromycin ophthalmic ointment to the right
eye ?????? inch q. 4 hours x 5 days.
CONDITION ON DISCHARGE: Vital signs were stable and the
patient was afebrile. The patient was discharged home with
followup with Dr. [**Last Name (STitle) 1132**] in two to three weeks time.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2106-8-27**] 09:20
T: [**2106-8-29**] 13:55
JOB#: [**Job Number 92888**]
|
[
"250.00",
"710.0",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
2738, 2993
|
1772, 2714
|
1160, 1754
|
148, 773
|
796, 1137
|
3018, 3446
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,263
| 173,396
|
26177
|
Discharge summary
|
report
|
Admission Date: [**2159-1-11**] Discharge Date: [**2159-1-12**]
Date of Birth: [**2094-11-5**] Sex: M
Service: SURGERY
Allergies:
Percocet / Ranitidine
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
fevers, back pain, confusion
Major Surgical or Invasive Procedure:
IR upsizing of PTC catheter [**1-11**]
History of Present Illness:
64yo man with a history of large lipsosarcoma s/p multiple
resections with large residual tumor despite trials of
chemotherapy who recently had PTC catheter placed at [**Hospital1 112**],
internal and external drainage, for obstructing jaundice
secondary to tumor. ERCP was attempted and not able to access
biliary tree. He was dischared 6 days ago with bilirubin down
to 2, afebrile, with PTC capped. On the day prior to
presentation he devoloped low grade fevers and the catheter was
flushed easily. On the day of presentation he continued to have
low grade fevers, and the PTC was placed to bag drainage without
output. He then developed confusion and severe back pain, and
he was brought from home by family to [**Hospital **] Hospital where his
temp was 102, he was tachycardic to the 150s and hypotensive,
with elevated bilirubin. Treated for sepsis with Vancomycin and
started on Levophed. Attempts were made to transfer him to [**Hospital1 112**],
because his prior care had been there, however no ICU beds were
available and therefore he was transferred to [**Hospital1 18**]. On arrival
he was tachycardic with blood pressures in low 100s on levophed,
alert and oriented, with fevers to 103. Treated with Zosyn.
Currently denies abdominal pain, no nausea or vomiting.
Tolerating less and less POs, mostly liquids. Decreased
appetite. Regular BMs, no blood, no diarrhea. No dysuria. No
chest pain or shortness or breath, no cough.
Past Medical History:
- liposarcoma s/p 50lb tumor excision [**2155**] with several more
smaller exvisions, residual tumor s/p chemo (last [**11-20**])
followed at [**Hospital3 328**]
- obstructive jaundice with PTC placed [**2159-1-4**] at [**Hospital1 112**]
- hypothyroid
Social History:
no ETOH, no smoking
Family History:
NC
Physical Exam:
0.4 mcg/kg/min Levophed
98.9 110 100/73 16 96% 4L NC
Gen: pleasant man in NAD, A+Ox 3
HEENT: +scleral icterus, MMdry
CV: tachycardic
Lungs: decreased bases
Abd: soft, obese NT/ND, palpable mass right abdomen
ext: no c/c/e
Pertinent Results:
[**2159-1-10**] 11:20PM WBC-8.6 RBC-3.73* HGB-11.4* HCT-35.3* MCV-95
MCH-30.5 MCHC-32.3 RDW-14.7
[**2159-1-10**] 11:20PM NEUTS-92* BANDS-3 LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2159-1-10**] 11:20PM PLT COUNT-302
[**2159-1-10**] 11:20PM PT-16.3* PTT-33.2 INR(PT)-1.4*
[**2159-1-10**] 11:20PM GLUCOSE-133* UREA N-14 CREAT-1.6* SODIUM-134
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15
[**2159-1-10**] 11:20PM ALT(SGPT)-94* AST(SGOT)-124* ALK PHOS-578*
TOT BILI-4.0* DIR BILI-3.4* INDIR BIL-0.6
[**2159-1-10**] 11:20PM LIPASE-29
[**2159-1-10**] 11:20PM CALCIUM-7.3* PHOSPHATE-1.9* MAGNESIUM-1.4*
[**2159-1-10**] 11:28PM LACTATE-3.2*
[**2159-1-11**] 05:02AM WBC-21.8*# RBC-3.45* HGB-11.1* HCT-33.0*
MCV-96 MCH-32.2* MCHC-33.6 RDW-14.8
[**2159-1-11**] 05:02AM PLT COUNT-330
[**2159-1-11**] 05:02AM PT-16.1* PTT-48.2* INR(PT)-1.4*
[**2159-1-11**] 05:02AM GLUCOSE-116* UREA N-17 CREAT-1.6* SODIUM-132*
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-19* ANION GAP-14
[**2159-1-11**] 05:02AM ALT(SGPT)-118* AST(SGOT)-161* ALK PHOS-555*
AMYLASE-25 TOT BILI-5.2*
[**2159-1-11**] 05:02AM CALCIUM-7.2* PHOSPHATE-3.3 MAGNESIUM-1.4*
[**2159-1-11**] 05:02AM LIPASE-22
[**2159-1-11**] 05:02AM CRP-117.8*
[**2159-1-11**] 05:16AM LACTATE-2.5*
[**2159-1-11**] 01:13PM HCT-32.5*
Brief Hospital Course:
Pt was admitted to surgical ICU under Red/West3 service, placed
on broad-spectrum Abx (Vanco Zosyn), and provided IVF
resuscitation for presumptive dx of cholangitis and biliary
obstruction, possibly from obstructed PTC drain. He remained
stable and underwent upsizing of the PTC cathether on [**1-11**] by
interventional radiology from 8Fr to 10Fr, a pullback
cholangiogram demonstrated severe common ductal
narrowing/occlusion, and moderate amount of blood coming from
drain as well as puncture site (most likely source is
intraductal tumor infiltration at the level of the common duct).
Subsequent Hct was stable at 32.5. Blood cultures obtained at
time of admission were [**4-15**] positive for GNR, and Zosyn was
changed to Meropenem. After completing the procedure an ICU bed
became available at [**Hospital1 112**] and he accordingly was transferred there
to resume his prior care.
Medications on Admission:
Dilaudid 4mg q4hrs
Fentynyl patch 25 mcg q 72hrs
Remeron 15mg qHS
Synthroid 25 mcg qAM
MVI
1000 Tums daily
Laxative/stool softener
Discharge Medications:
Levothyroxine Sodium 25 mcg PO/NG DAILY
LR at 100 ml/hr
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP>65
Famotidine 20 mg IV Q24H
Ondansetron 4 mg IV Q8H:PRN nausea
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Pantoprazole 40 mg IV Q24H
HYDROmorphone (Dilaudid) 0.5 mg IV Q2H PRN pain
Insulin SC (per Insulin Flowsheet) Sliding Scale
Vancomycin 1000 mg IV Q 12H
Meropenem 1000 mg IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1708**]
Discharge Diagnosis:
cholangitis
liposarcoma
hypothyroid
Discharge Condition:
fair
Discharge Instructions:
pt transferring to [**Hospital1 112**] for further care
Followup Instructions:
Can follow-up with Dr. [**Last Name (STitle) **] as necessary, ([**Telephone/Fax (1) 2537**].
Otherwise remaining follow-up will be via his primary caretakers
at the [**Name (NI) 112**] and [**Name (NI) 2860**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"041.85",
"V45.89",
"244.9",
"V10.89",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.98",
"87.54",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5375, 5422
|
3767, 4662
|
309, 349
|
5501, 5507
|
2427, 3744
|
5611, 5932
|
2161, 2165
|
4843, 5352
|
5443, 5480
|
4688, 4820
|
5531, 5588
|
2180, 2408
|
241, 271
|
377, 1831
|
1853, 2108
|
2124, 2145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,243
| 173,494
|
26199
|
Discharge summary
|
report
|
Admission Date: [**2190-7-24**] Discharge Date: [**2190-7-28**]
Date of Birth: [**2153-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
alcohol intoxication/withdrawl
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 37yo m with PMH significant for alcohol abuse and
depression who was brought to the ED after being found
intoxicated and unresponsive under a bench at the T stop. Pupils
were noted to be small but not pinpoint.
In the ED, initial vitals were T 97.9 BP 140/84 AR 102 RR 10 O2
sat 96% RA. He was initially placed in the observation unit with
plan for discharge this morning. When he stood up he was noted
to be unsteady and his BP and HR increased. He was also noted to
have auditory hallucinations. He received a total of Ativan 6mg,
Valium 15mg, MV, thiamine, folate, and was placed on a CIWA
scale.
On further questioning, the patient admits to drinking 2 pints
of Vodka yesterday and does not remember the course of events
thereafter. Of note, he was recently admitted to the MICU from
[**Date range (1) 64929**] for alcohol withdrawal and left AMA. He denies suicidal
ideations.
Past Medical History:
1)Alcohol abuse and dependence: At [**Hospital1 **] for detox about
3-4 months prior. He completed the detox program and then began
drinking again soon afterwards.
2)Suicide attempt in [**12-3**], requiring inpt psych admisison
3)Depression: He has a counselor/therapist that he used to see
at the [**Hospital3 33953**] Community Center. He had been on prozac and
seroquel until he stopped going to his therapy sessions a few
months ago.
Social History:
Born in [**Location (un) 3678**], MA. Lives alone, 1PPD x 20 years, denies
illict drugs.
Family History:
Mother with alcohol abuse
Physical Exam:
vitals T 97.5 BP 141/90 AR 108 RR 20 O2 sat 100% RA
Gen: Lying in bed, tired, difficult to arouse
HEENT: MMM
Heart: Sinus tachycardia; no m,r,g
Lungs: CTAB
Abdomen: Soft, NT/ND, +BS
Extremities: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
==================
ADMISSION LABS
==================
[**2190-7-23**] 10:30PM BLOOD WBC-10.8# RBC-4.32* Hgb-14.2 Hct-40.2
MCV-93 MCH-32.8* MCHC-35.3* RDW-14.1 Plt Ct-609*#
[**2190-7-23**] 10:30PM BLOOD Neuts-66.2 Lymphs-25.3 Monos-3.6 Eos-3.5
Baso-1.4
[**2190-7-23**] 10:30PM BLOOD Plt Ct-609*#
[**2190-7-23**] 10:30PM BLOOD Glucose-103 UreaN-16 Creat-0.8 Na-149*
K-4.0 Cl-110* HCO3-25 AnGap-18
[**2190-7-23**] 10:30PM BLOOD ASA-NEG Ethanol-385* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Mr. [**Known lastname **] is a 37yo m was admitted to the MICU for alcohol
withdrawal. He was recieving almost hourly valium. Eventually
symptoms began to subside and valium could be space out. CIWA
scores were zero for almost 24 hours before discharge. He was
seen by psych who recommended outpatient alcohol and depression
treatment.
1)Alcohol withdrawal: Patient presented with alcohol
intoxication with an elevated EtOH level~385. He presented
similarly a few weeks ago to the MICU but left AMA. He does have
some evidence of withdrawal including tachycardia, hypertension,
and hallucinations. Upon transfer to the MICU, he was placed on
a CIWA scale and 1:1 sitter. Psychiatry was consulted and given
his mental status on transfer, he was not able to leave AMA (has
he had during his last admission).
2)Depression: Patient has history of inpatient hospitalization
and suicide attempt. No active suicidal ideations during this
stay. Was put on section 12 because he was thought to be a
danger to himself and others. They followed him after transfer
to the floor and recommend outpatient treatment.
3)Hypernatremia: Likely due to poor free water intake. Resolved
after receiving IVFs. No recurrences while on the floor.
Monitored electrolytes daily.
4) Social support - has supportive family to help with with his
goal of becoming sober. His contact was [**Name2 (NI) **] [**Name (NI) **] (uncle)
[**Telephone/Fax (1) 64930**].
# Patient was monitored on the floor for two days. He did well
and required no benzodiazepines for withdrawal syndromes. He
did appear anxious at times, but calmed down when talked to by
his family members. Was discharged home with numbers for day
programs for alcohol abuse. Patient works in the evenings and
was looking for a morning program.
Medications on Admission:
none
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Etoh abuse
2. Etoh withdrawl
3. Depression
4. Suicidal ideation
Discharge Condition:
vital signs stable, afebrile, no tremor, tolerating PO foods
without nausea or vomitting, ambulating without difficulty
Discharge Instructions:
You were admitted to the hospital after being found intoxicated.
While in the emergency room, you started to exhibit withdrawl
symptoms and were admitted to the intensive care unit for
management. You were monitored and given valium as needed.
Eventually you were stable enough to be transferred to the floor
where your valium wean was continued. You stopped requiring it
and felt much better.
.
Psychiatry also saw you because you made statements about
suicide. They thought you were a danger to yourself. You also
have a history of depression. After your withdrawl symptoms
ended, they talked about inpatient vs. outpatient management of
your alcohol use and depression and decided outpatient was the
best.
.
You should return to the hospital if you have chest pain,
shortness of breath, fainting, nausea or vomitting, feelings of
suicide or any other concerns. Call 911 if it is an emergency.
Followup Instructions:
Please follow up in your treatment program tomorrow as
scheduled.
.
Please follow up wiht Dr. [**Last Name (STitle) 64931**] as within 1-2 weeks for
medical follow up. Call [**Telephone/Fax (1) 17826**] to make an appointment
that fits into your schedule.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2190-8-15**]
|
[
"291.81",
"311",
"303.01",
"305.1",
"V62.84",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
4952, 4958
|
2694, 4488
|
344, 351
|
5088, 5211
|
2174, 2671
|
6162, 6571
|
1879, 1906
|
4543, 4929
|
4979, 4979
|
4514, 4520
|
5235, 6139
|
1921, 2155
|
274, 306
|
379, 1293
|
4998, 5067
|
1315, 1756
|
1772, 1863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,734
| 182,938
|
9931
|
Discharge summary
|
report
|
Admission Date: [**2131-4-9**] Discharge Date: [**2131-4-17**]
Date of Birth: [**2063-12-22**] Sex: F
Service: CARDIOTHORCIC
HISTORY OF PRESENT ILLNESS: This is a 67 year-old female
with unstable angina transferred from [**Hospital 1474**] Hospital to
[**Hospital1 69**] on [**2131-4-9**] for
cardiac [**Year (4 digits) 29817**]. The patient was evaluated in her
primary care physician for evaluation of increasing angina.
She was admitted to [**Hospital 1474**] Hospital Emergency Room due to
electrocardiogram changes, which were discovered in his
office. The patient was started on Aggrastat and heparin and
was subsequently pain free and she was transferred to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 29817**].
PAST MEDICAL HISTORY: Significant for known coronary artery
disease. She has had an angioplasty previously in [**2115**]. She
has noninsulin dependent diabetes mellitus. She has
hypercholesterolemia, hypertension and former history of
smoking, but quit twenty years ago.
MEDICATIONS ON ADMISSION: Aspirin 325 mg q.d., Isosorbide 10
mg b.i.d., Plendil 5 mg q.d., Glucophage 500 mg b.i.d.,
Lipitor 40 mg q.d., Atenolol 50 mg q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married and retired and lives
with her husband.
PHYSICAL EXAMINATION: The patient arrived in no acute
distress. Lungs were clear to auscultation bilaterally.
Heart was normal S1 S2. Abdomen was soft, nontender with
positive bowel sounds.
ADMISSION LABORATORIES: Hematocrit 38.2, INR 1.1, BUN 23,
creatinine 1.1, potassium 3.9. Electrocardiogram revealed
normal sinus rhythm with ST sloping in lead 1.
The patient was admitted to the Cardiology Medicine Service.
The patient was taken to the cardiac [**Year (4 digits) 29817**]
laboratory on [**2131-4-10**] and underwent coronary
[**Year (4 digits) 29817**] where it was revealed that the patient had
severe three vessel coronary artery disease and normal left
ventricular function. Cardiothoracic surgery consult was
obtained later in the day and it was felt that the patient
was an appropriate surgical candidate for revascularization.
The patient was taken to the Operating Room on [**2131-4-12**]
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and underwent coronary artery bypass
graft times four with a LIMA to the LAD, saphenous vein to
OM1, saphenous vein to OM2, saphenous vein to the right
coronary artery. Postoperatively, the patient was
transferred from the Operating Room to the Cardiothoracic
Intensive Care Unit on nitroglycerin and propofol drips and
was also placed on nitroprusside and insulin infusions. The
patient was weaned and extubated from the ventilator on [**4-13**], which is postoperative day one. Her chest tube was
removed later in the day. The patient also on postoperative
day one, [**4-13**] went into rapid atrial fibrillation, which
was treated with Lopressor intravenously and she was placed
eon Procainamide at that time and was transferred out of the
Cardiothoracic Intensive Care Unit later that day on
postoperative day one to the Telemetry Floor. On
postoperative day two the patient remained in normal sinus
rhythm. She had been hemodynamically stable and was
progressing with cardiac rehabilitation. She continued with
diuresis.
On postoperative day four [**2131-4-16**] the patient went
back into atrial fibrillation and she was again treated with
increasing doses of Lopressor, but was changed from
Procainamide to Amiodarone due to GI upset, which was
attributed to the Pocainimide. The patient had converted
back to normal sinus rhythm and has remained in normal sinus
rhythm since that time. The patient is hemodynamically
stable and ready to be discharged to a rehabilitation
facility to progress with cardiac rehabilitation and
increasing mobility.
Condition today [**2131-4-17**] is stable. Vital signs are
temperature 98.9. Blood pressure 108/64. Heart rate 58
sinus rhythm. Respiratory rate 20. Her room air saturation
ranges from 93 to 95%. On 2 liter nasal canula, she is [**Age over 90 **]%
saturating. Her lungs have bibasilar crackles. She is in
normal sinus rhythm with a regular rate and rhythm. Her
right lower extremity does have an ecchymotic area around the
incision and some serous drainage as well. Her chest
incision sternum is clean, dry and intact.
DISCHARGE MEDICATIONS: Aspirin 81 mg po q.d., Percocet one
to two tablets po q 3 to 4 hours prn pain, Colace 200 mg po
b.i.d. times four weeks, Glucophage 500 mg po b.i.d., Lipitor
40 mg po q.h.s., Lopressor 50 mg po b.i.d., Miconazole powder
under the breasts and skin folds b.i.d. and prn, Niferex 150
mg po b.i.d. times four weeks, Amiodarone 400 mg po t.i.d.
through [**4-23**] and then she is to decrease to 400 mg po
b.i.d. through [**4-30**] and then her maintenance dose will be
400 mg po q.d.
Postoperatively, the patient is to follow up with her primary
care physician in three to four weeks for medical management
as well as continuation of amiodarone. The patient is to
follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in three to four weeks for
postoperative evaluation examination.
DISCHARGE DIAGNOSIS:
Coronary artery disease status post coronary artery bypass
graft and postoperative atrial fibrillation.
She is being discharged to a rehabilitation facility to
increase her cardiac rehab.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2131-4-17**] 12:39
T: [**2131-4-17**] 12:39
JOB#: [**Job Number 33288**]
|
[
"401.9",
"411.1",
"V45.82",
"272.0",
"997.1",
"250.00",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.15",
"88.53",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
4424, 5237
|
5258, 5714
|
1069, 1239
|
1343, 4400
|
175, 766
|
789, 1042
|
1256, 1320
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,427
| 142,727
|
41399
|
Discharge summary
|
report
|
Admission Date: [**2121-2-15**] Discharge Date: [**2121-3-2**]
Date of Birth: [**2070-10-20**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
intercranial Hemorrhage
Major Surgical or Invasive Procedure:
PEG tube placement [**2121-3-1**]
History of Present Illness:
50 yo, F, p/w headache. On the morning of admission the
patient was complaining of pain in the lower right arm. The
patients boyfriend notes that it wasnt swollen and the patient
continued her day. After dinner the patient was noted to
complain of a severe headache. The patients boyfriend noted that
the patients words were not making sense and the speach appeared
garbled. At that point the boyfriedn picked up the patient amd
lied her on the bed. The patient continued to be conscious
throughout, but continued to have word problems. The EMS
arrived. The boyfriend next saw the patient intubated at an
outside hospital.
At the outside hospital the patient was noted to receive a
total of 10 mg of Ativan and 250 mcg of Fentanyl. The exam from
the notes show that the patient had a flaccid left arm and no
grasp. BP noted to be 170/90, hr 100, RR 12. A Ct scan was
performed.
The CT showed a 7 x 4 cm right sided intraparenchymal hemorhage
with an 8 mm midline shift.
At that point the patient was transferred to [**Hospital1 18**] and Neurology
was called. Upon presentation to the ED the patient was
receiving 80 g of Mannitol.
The patients boyfriend noted that she had a history of
hypertension for which she was on triamterene and HCTZ(37.5
mg/25mg). He also noted that she took a baby aspirin
approximately 3 days earlier. There were no recent fever,
chills,
cough, runny nose or evidence of illness.
Past Medical History:
Hypertension.
Social History:
Has one son, [**Name (NI) **] a boyfriend that she lives with, not married
Family History:
Not obtained.
Physical Exam:
Neurologic:
Alert, oriented to hospital and [**Location (un) 86**] and year.
Hypophonic, fluent language, able to repeat and name objects.
There is a right gaze preference and neglect of the left side of
the body.
The left side is hemiplegic and the right side is full strength.
Pulmonary: Lungs are clear to auscultation
CV: RRR no murmurs appreciaed
Ext: No edema
Skin: No rashes
Pertinent Results:
[**2121-2-15**] 05:00AM GLUCOSE-136* UREA N-10 CREAT-0.6 SODIUM-134
POTASSIUM-3.1* CHLORIDE-95* TOTAL CO2-25 ANION GAP-17
CT head:
FINDINGS: The large right basal ganglia hemorrhage is stable in
size. There
is persistent mass effect on the adjacent sulci and effacement
of the frontal
[**Doctor Last Name 534**] of the right lateral ventricle, with 5-mm leftward shift of
the normally
midline structures. Blood products are also again noted layering
in the
bilateral posterior horns, right greater than left, stable in
extent. The
shifted third ventricle is compressed. The temporal [**Doctor Last Name 534**] of the
left lateral
ventricle remains prominent, suggesting mild trapping. There is
no new
hemorrhage or evidence of an acute major vascular territorial
infarct. The
visualized paranasal sinuses and mastoid air cells are well
aerated. No
osseous abnormality is identified.
Brief Hospital Course:
Patient [**Name (NI) **] was admitted as an OSH transfer because there was
demonstration of a right BG bleed. The bleed was secondary to
hypertension. She had develloped a VAP and was treated with
cefepime prior to sidcharge. She was controlled with amlodipine
and transferred to the wards after the bleed was shown to be
stable on CT scan with a stable neurologic examination. Because
of continued failed swallow evaluation a PEG tube was placed.
She was also started on sertraline prior to discharge. There
were no other complicating infections or incidences. She was
transferred to rehab for further care.
Medications on Admission:
Triamterene/HCTZ(37.5 mg/25mg).
Discharge Medications:
1. 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.
2. 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.
3. Metoprolol Tartrate 5 mg IV Q6H:PRN SBP>180, HR>120
4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. acetaminophen-codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for headache.
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
16. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day) as needed for Muscle spasm.
17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
18. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
19. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
New
- Right basal ganglia Bleed
Old
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to [**Hospital1 18**] because you had a large bleed on the
right side of your brain. The bleed was likely caused by high
blood pressure. We controlled your blood pressure to prevent
future bleeds. You were unable to swallow safely and you had a
feeding tube placed. Once you are able to safely swallow you may
have the feeding tube taken out. You went to a rehab hospital in
for further care.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2121-4-15**] 11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"729.81",
"997.31",
"599.70",
"342.90",
"790.01",
"781.94",
"401.9",
"431",
"348.4",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"43.11",
"96.04",
"96.6",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5768, 5811
|
3309, 3919
|
329, 365
|
5906, 5906
|
2399, 2524
|
6476, 6712
|
1963, 1978
|
4002, 5745
|
5832, 5885
|
3945, 3979
|
6041, 6453
|
1993, 2380
|
265, 291
|
394, 1817
|
2533, 3286
|
5921, 6017
|
1839, 1855
|
1871, 1947
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,263
| 154,633
|
3585
|
Discharge summary
|
report
|
Admission Date: [**2124-1-16**] Discharge Date: [**2124-1-21**]
Date of Birth: [**2055-6-13**] Sex: M
Service: MEDICINE
Allergies:
Methotrexate
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
C3-C4 spinal cord compression
Major Surgical or Invasive Procedure:
C4 corpectomy with allograft and plate
intubation and mechanical ventilation
History of Present Illness:
This is a 68 year old man, with a PMH significant for A. FIB
with RVR, Lower GI bleed 3 weeks prior to admission, severe lung
disease including idiopathic pulmonary fibrosis, believed to be
[**3-15**] rheumatoid arthritis, pulmonary hypertension, and COPD
admitted to [**Hospital 1562**] Hospital on [**2124-1-7**] after 1 day of
moderate shortness of breath and cough productive of yellow
sputum as well as two weeks of progressive difficulty walking.
He was treated for HAP with levofloxacin, pip/tazo, and
vancomycin. A blood culture was positive for Ecoli x 1,
sensitive to pip/tazo and ceftriaxone. He improved
symptomatically, and his antibiotics were narrowed to pip/tazo
alone for unclear reasons. His pulmonary status returned to
baseline by report, but then he went into atrial fibrillation
with RVR to the 180s. He was started on digoxin in addition to
his home dronaderone and diltiazem, and returned to sinus. While
working with PT in anticipation of discharge he was found to be
increasingly weak. He also complained of escalating neck pain. A
spinal MRI was obtained which showed severe c3-c4 spinal
compression with cord edema. He was transferred to [**Hospital1 18**] for
Neurosurgical eval by Dr. [**Last Name (STitle) 548**].
.
On the floor here at [**Hospital1 **] he was comfortable on 4L NC, and by
report was at his baseline from a pulmonary standpoint. He was
taken to surgery the following day. His surgical course was
uncomplicated.
.
In the MICU he was intubated and sedated. He was transferred to
the MICU to remain intubated due to his underlying pulmonary
issues and concern from his pulmonologist that if he were
extubated too early and needed to be reintubate, it would be
very risky given his underlying spinal pathology. He was
extubated successfully on [**1-18**], but had difficulty swallowing
pills so speech and swallow was consulted. On [**1-19**] he converted
from normal sinus rhythm to Afib with rates in the 90s-100s, but
was asymptomatic and hemodynamically stable.
Past Medical History:
- Extensive emphysema, especially of the upper lungs
- Asthma since childhood
- Rheumatoid arthritis (diagnosed [**2118**]; "rheumatoid lung" may
contribute to interstitial lung disease)
- Coronary artery disease, s/p large anterior wall MI [**2111-8-11**],
s/p BMS to LAD with ~50% restenosis noted in [**2122**]
- Sleep apnea - off CPAP
- UIP interstitial lung disease s/p wedge resections in [**2118**]
- Interstitial lung disease
- Chronic renal insufficiency (estimated GFR = 47 ml/min/1.73
m2)
- Ischemic cardiomyopathy
- Systolic CHF with LVEF of 35-40%, hypokinesis of the anterior
septum, anterior free wall,lateral wall and apex
- Pulmonary hypertension
- PERCUTANEOUS CORONARY INTERVENTIONS: AMI in [**2111**] and underwent
cardiac catheterization here where he subsequently had a stent
to his mid LAD. He returned for cardiac catheterization on [**7-17**], [**2120**] where he was noted to have two-vessel CAD, mild MR,
moderate LV dysfunction, mild pulmonary HTN. None of the
lesions was > than 50% so he was medically managed. Most recent
cath from [**2122**] showed ~50% restenosis of stent in LAD, but no
intervention undertaken.
Social History:
Lives with wife [**Name (NI) **] (she has not completed HCP [**Name (NI) 16353**], but pt
intends her to serve as his proxy). He has 4 children and 8
grandchildren. Semi-retired (this is his first semester out of
work) as a foreign language teacher, most recently at [**Hospital1 498**]
[**Location (un) 86**].
-Tobacco history: 30-40 pack-year history; quit 25 years ago
-ETOH: None recently
Family History:
Father died age 37 of "asthma" - family was later told that
studies done at [**Hospital3 **] showed evidence that he may have had
mild cystic fibrosis. Mother died age 59 of complications of
breast cancer including heart failure. One sister has breast
cancer, another sister has COPD, a living brother has a valve
replacement (patient does not know circumstances),
recently-deceased brother died of heart-related illness; he also
had RA. One daughter with [**Name2 (NI) **] (age 33), another daughter with
angioedema. Patient has been tested for genetics related to
hereditary angioedema but was negative.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
On admission:
Vitals: T: 97.8 BP: 130/74 P: 72 R: 24 O2: 90 in 4 L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Diffusely rhonchorous to anterior auscultation
CV: Regular rate and rhythm, distant heart sounds, no murmurs
appreciated
Abdomen: soft, non-tender, non-distended, hyperactive bowel
sounds, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema in ankles
and hands. Diffuse ecchymoses on both arms.
Neuro: A & O x3, appropriately conversant
CN grossly intact.
Motor: 3 in lower extremities and R deltoid. 4 in all other
upper extremity muscles bilaterally.
Sensation: Intact to light touch in upper and lower extremities.
Position sense impaired in both upper and lower extremities.
DTR: 3+ throughout. Several beats of clonus in R foot.
Withdrawal to babinski bilaterally.
On admission to MICU:
GEN: Intubated and sedated, NAD
HEENT: Dry MM, L IJ, anterior surgical scar with serosanguinous
exudate
CV: RR, NL S1 S2, possible S4, no MRG
PULM: Coarse breath sounds throughout
ABD: BS+ NTND, no masses or HSM
EXTREMITIES: Clubbing, 2+ upper and lower extremity edema
NEURO: Pupils are 2mm and minimally responsive, reflexes are 3+
on the L patella and achilles tendons, 2+ on the L biceps
tendons, and 1+ on the R achilles, patellar, and biceps tendons.
SKIN: Stage 2 sacral decubitous ulcer, chronic hyperpigmentation
of the upper extremities, ecchymosis of the L hip
Pertinent Results:
On admission:
135 98 16 AGap=7
------------ 96
4.2 34 0.7
estGFR: >75 (click for details)
Ca: 7.9 Mg: 2.1 P: 2.3
Dig: 1.2
9.8
10.2 ----- 286
30.2
Vit-B12:502 Folate:8.5
Other Blood Chemistry:
Iron: 115
calTIBC: 274
Ferritn: 117
TRF: 211
On discharge:
WBC-9.2 RHgb-8.8* Hct-28.7* MCV-98 MCH-30.0 MCHC-30.7* RDW-18.4*
Plt Ct-287
Glucose-81 UreaN-23* Creat-0.6 Na-141 K-4.1 Cl-100 HCO3-35*
AnGap-10
IMAGING:
MRI C-spine [**2124-1-17**]:
Multilevel degenerative disc disease versus calcification of the
left aspect of the posterior longitudinal ligament, worse from
C3-C4 through C5-6, with severe spinal canal narrowing at C3-C4
and moderate spinal canal narrowing at C4-5 and C5-C6. There is
increased signal within the cervical cord at C3-C4, which may
represent cord edema versus myelomalacia. If differentiating
between disc disease and calcified ligament is of clinical
importance, cervical spine CT may be helpful.
CT C-spine [**2124-1-19**]:
1. No evidence of immediate hardware complication or change in
hardware
alignment since the radiographs done this AM, with persistent
angulation of
the anterior cervical bracket plate. Expected post-operative
changes including
marked edema and emphysema of the prevertebral and deep cervical
soft tissues.
2. C5-6: Residual marked spinal canal narrowing, largely due to
segmental
ossification of the posterior longitudinal ligament.
3. Multilevel neural foraminal narrowing with likely exiting
nerve root
impingement, unchanged from the pre-op MR study.
Speech/swallow exam [**2124-1-20**]: Penetration with thin liquid
consistency.
Brief Hospital Course:
68 year old man, with a PMH significant for AFIB with RVR, Lower
GI bleed 3 weeks prior to admission, severe lung disease
including IPF, pulmonary HTN, and [**Hospital 2182**] transfered to the MICU
for observation after C3-4 laminectomy for cord compression.
.
# C3-C4 Cord compression s/p laminectomy: The patient was
admitted to [**Hospital1 18**] for neurosurgical consultation, due to his
severe c3-c4 spinal compression with cord edema as above. He
underwent laminectomy and was extubated after sugery in the MICU
without incident. Per the surgery team, there are no
restrictions on the pt's activity; however, he should wear the
C-spine collar until he follows up with neurosurgery. PT was
consulted, who recommended that he be discharged to a rehab
facility.
.
# Pulmonary Disease: The patient is known to have COPD, ILD, and
pulmonary hypertension, which was recently complicated by
pneumonia. By report, he had been started ABx for this infection
on [**2124-1-7**]. He was additionally continued on his home regimen
of Bactrim (for PCP [**Name Initial (PRE) 1102**]), home nebulizers, and
fluticasone. As the patient had been receiving
MethylPREDNISolone Sodium Succ 20 mg IV Q24H, he was given
stress dose steroids for the 2 days following surgery with
MethylPREDNISolone Sodium Succ 40 mg IV Q6H and before being
returned to his home dose of prednisone.
.
#Bacteremia: Upon transfer to the [**Hospital1 **], the patient was continued
on CeftriaXONE 1 gm IV Q24H (in place of pip/tazo) for his Ecoli
bactermia.
.
# AFib w/ RVR: The patient was monitored on telemetry and
continued on his home regimen of diltiazem, dronedarone, and
digoxin. He entered afib with normal ventricular rate several
times while in the MICU. At discharge, the patient was in --
rhythm.
.
# Dysphagia: Patient was having difficulty swallowing pills and
was choking on food, so speech and swallow was consulted. His
difficulties are thought to be secondary to edema from surgery.
Speech and swallow recommends that he continue on a dysphagia
diet with 1:1 assist until his swallowing improves. They predict
full recovery of swallowing function.
.
# CAD and CHF: The patient is s/p anterior wall MI [**2111-8-11**],
s/p BMS to LAD with ~50% restenosis noted in [**2122**]. Known EF of
30-40%. His aspirin was held, pending Nsurg clearance. He was
continued on his home statin. Lasix was held.
.
# History of GI Bleed: CBC stable this admission so far. -
- Continue pantoprazole 40mg daily
- Continue PO iron
- Iron studies pending
.
# Hyperglycemia: Caused by ongoing steroids.
- Continue HISS if blood sugars remain elevated.
.
Medications on Admission:
2L oxygen
Lipitor 10mg qd
Symbicort 80/4.5
Atrovent Nasal [**Hospital1 **]
Leflunomide 20mg PO QD
Xopenex 1.25mg per .5ml neb q 4 hours prn for SOB
Protonix 40mg po QD
Triamcinolone acetonide .1% [**Hospital1 **] to cracked skin
Bactrim 160/800
Dronaderone 400mg po BID
Ferrous Sulfate 825mg PO BID
Aspirin 325mg QD
Diltiazem 30mg po TID
Lasix 20mg QD
Methylprednisone 8mg po QD
Senna 1 tab PO BID
Colace 100mg PO BID
Erythromycin 500mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24HR () as needed for
neck pain.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO Daily () as
needed for RA.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
19. Xopenex 1.25 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
20. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-12**]
Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
21. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QHS (once a day (at bedtime)) as needed for constipation.
23. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
24. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
25. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
26. supplemental oxygen
supplemental oxygen to keep O2 90-94
27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Cervical spondylotic myelopathy
Discharge Condition:
Stable. Alert, oriented, limited mobility
Discharge Instructions:
You have been seen for a spinal cord compression caused by an
outgrowth of bone from your vertebra. We have made the following
changes to your medications:
Please follow up with your PCP, [**Name10 (NameIs) **] rheumatologist, and with
your neurosurgeon as outlined below.
Followup Instructions:
Please follow up with Dr.[**Name (NI) 2845**] office in 2 weeks.
[**2124-2-1**] 10:45am [**Hospital Ward Name 23**] [**Location (un) **] spine center
Please follow up with Dr [**Last Name (STitle) 548**] in 6 weeks, you will need xrays
at this appt - please call [**Telephone/Fax (1) 2992**] to schedule.
[**2124-2-29**] 10:45 am [**Hospital Ward Name 23**] [**Location (un) **] spine center
Rheumatology
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2124-1-27**] 2:00
Completed by:[**2124-1-21**]
|
[
"416.8",
"721.1",
"327.23",
"412",
"112.0",
"428.0",
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"714.0",
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"285.9",
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"276.2",
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"707.22",
"707.03",
"722.71",
"424.0",
"492.0",
"714.81",
"414.01",
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"V45.82",
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"427.31",
"041.4",
"428.22",
"790.29",
"996.72",
"E932.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"81.62",
"81.02",
"80.51"
] |
icd9pcs
|
[
[
[]
]
] |
13454, 13566
|
7896, 10514
|
303, 382
|
13642, 13686
|
6266, 6266
|
14009, 14591
|
4021, 4715
|
11009, 13431
|
13587, 13621
|
10540, 10986
|
13710, 13837
|
4730, 4730
|
6540, 7873
|
13867, 13986
|
234, 265
|
410, 2421
|
6280, 6526
|
2443, 3594
|
3610, 4005
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,208
| 181,914
|
15539
|
Discharge summary
|
report
|
Admission Date: [**2181-12-7**] Discharge Date: [**2181-12-10**]
Date of Birth: [**2106-6-16**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Left carotid pseudoaneurysm.
HISTORY OF PRESENT ILLNESS: This 75-year-old white male with
diabetes, hypertension, arthritis, underwent a left carotid
endarterectomy for asymptomatic left carotid stenosis in
[**State 108**] approximately 18 months prior to admission.
Postoperatively, patient did well. He remembered he had some
drainage from his neck wound for a day or two following
surgery.
In mid [**Month (only) **], patient noted a pulsatile mass in his left
neck which had slowly enlarged over the past month.
Patient was seen by his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 44989**] [**Name (STitle) **] and had MRA
done at the [**Hospital1 1474**] Regional MRI Center on [**2181-11-15**]. The
MRA showed a 4 x 3 cm wide pseudoaneurysm of the left carotid
artery. A 50% stenosis of the right internal carotid artery
was noted.
After Dr. [**Last Name (STitle) **] reviewed the operative report and
obtained a CT scan of patient's neck, the patient was
scheduled for an elective left carotid pseudoaneurysm repair.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Hypertension.
3. Arthritis.
4. Chronic renal insufficiency.
PAST SURGICAL HISTORY:
1. Left carotid endarterectomy [**2180**] in [**State 108**].
2. Right inguinal hernia repair.
3. Right inguinal lymph node excision.
4. Left hip surgery about [**2178**].
5. Appendectomy.
6. Toe amputations [**2177**].
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Patient lives alone. He is a retired
corrections officer. He does not smoke cigarettes. He does
not use alcohol.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Glyburide 5 mg po q day.
2. Metformin 500 mg po q day.
3. Cardizem CD 180 mg po q day.
4. Enalapril 5 mg po q day.
5. Atenolol 25 mg po q day.
6. Clonidine 0.1 mg po q day.
7. Diovan 160 mg po q day.
8. Proscar 5 mg po q day.
PHYSICAL EXAMINATION: Vital signs: Pulse 68, respirations
12, blood pressure 168/90. General: Alert, well appearing
white male in no acute distress. Neck: Carotids palpable.
Right carotid bruit present. Left neck incision well healed.
Mid scar pulsating 2.5-3 cm pulsatile, nontender mass
present. Faintly palpable thrill distal to the mass present.
Chest: Lungs clear. Heart: Regular, rate, and rhythm.
Abdomen is obese. No aneurysm appreciated. Extremities:
Feet equally warm. Status post two toe amputations of the
right foot. Pulse examination: Femoral and popliteal pulses
palpable bilaterally. Pedal pulses nonpalpable.
Admission laboratories on [**2181-11-29**]: White blood cells 7.8,
hemoglobin 12.2, hematocrit 37.9, platelets 254,000, PT 12.6,
PTT 26.6, INR 1.1. Sodium 139, potassium 4.8, chloride 104,
CO2 25, BUN 35, creatinine 1.7, glucose 235,000.
Chest x-ray showed no acute pulmonary disease.
Electrocardiogram on [**2181-11-29**] showed a normal sinus rhythm at
a rate of 67. Left axis deviation. Possible old inferior
infarct.
HOSPITAL COURSE: Patient was admitted to the hospital on
[**2181-12-7**] following a left neck exploration and left common
carotid artery to internal carotid artery interposition graft
with 6 mm PTFE. Postoperatively, patient was neurologically
intact. However, his heart rate decreased to the 30's, and
the patient was hypotensive. He was treated with the usual
supportive measures, and returned to baseline. Cardiac
enzymes were cycled. He ruled out for a myocardial
infarction.
The patient's subsequent postoperative course was uneventful.
He was discharged home on postoperative day #3. At the time
of discharge, his left neck incision was clean, dry, and
intact. His tongue was in midline. He had no swallowing
difficulty. No hoarseness. No facial droop.
Patient was instructed to followup with Dr. [**Last Name (STitle) **] in the
office for staple removal.
DISCHARGE MEDICATIONS: The patient is to resume preadmission
medications.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Home.
DIAGNOSES:
1. Left carotid artery pseudoaneurysm following left carotid
endarterectomy at OSH.
2. Repair of left carotid pseudoaneurysm with left common
carotid to internal carotid interposition graft, 6 mm PTFE on
[**2181-12-7**].
SECONDARY DIAGNOSES:
1. Type 2 diabetes.
2. Hypertension.
3. Chronic renal insufficiency.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2182-3-28**] 21:24
T: [**2182-3-29**] 04:00
JOB#: [**Job Number 44990**]
|
[
"442.81",
"458.2",
"401.9",
"250.00",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"38.42"
] |
icd9pcs
|
[
[
[]
]
] |
1591, 1609
|
4008, 4060
|
3124, 3984
|
1804, 2034
|
1353, 1574
|
4375, 4728
|
2057, 3106
|
168, 198
|
227, 1224
|
1246, 1330
|
1626, 1781
|
4085, 4354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,712
| 198,426
|
7133
|
Discharge summary
|
report
|
Admission Date: [**2163-10-24**] Discharge Date: [**2163-10-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fever, hypotension, chest congestion
Major Surgical or Invasive Procedure:
L subclavian central venous catheter
History of Present Illness:
83yo woman h/o aspiration PNA in setting of vomiting, recent e.
coli bacteremia + p. mirabilis UTI, DM2, PAfib, s/p R CVA, p/w
fever and chest congestion. Recent history significant for
admission in [**8-20**] for aspiration PNA in setting of vomiting.
Hospital course on that admission notable for melanotic stools
[**1-17**] erosive gastritis; h. pylori + and in setting of ASA use.
Treated w/ 2wk course of flagyl, tetracycline, bismuth,
protonix. Also, pt w/ UTI in setting of nephrolithiasis. Found
to have atrophic L kidney w/ multiple stones in collecting
system. Finished 14d course of ceftriaxone for proteus UTI,
however, immediately after finishing, pt spiked fevers. Thought
that w/ nidus for infection, pt required additional 7d course of
keflex, w/ suppressive keflex daily thereafter. Pt w/
EGD/colonoscopy 4d PTA for follow-up of erosive gastritis/GIB.
In terms of present illness, pt was in USOH until DOA when pt
spiked fever to 105F, and was complaining of increased chest
congestion. Pt??????s sats were 95% on 2L O2. Pt did have a change
in mental status, unclear if this preceded or followed PNA
symptoms.
Past Medical History:
multiple L renal stones w/ atrophic L kidney
Hypothyroidism
Osteoarthritis
Osteoporosis with h/o compression fracture
CVA x 2
L hemiparesis from CVAs
HTN
NIDDM
Hypercholesteremia
Social History:
Lives in [**Hospital3 1186**] nursing facility. Healthcare proxy is
sister [**Name (NI) **].
no etoh use
no tobacco use
no drug use
Family History:
non-contributory
Physical Exam:
GEN: expired
HEENT: pupils unreactive
PULM: no breath sounds, no respiratory movements of chest.
CARDS: no heart sounds.
Pertinent Results:
[**2163-10-24**] 11:42PM CORTISOL-52.5*
[**2163-10-24**] 10:58PM COMMENTS-TRIPLE [**Last Name (un) **]
[**2163-10-24**] 10:58PM LACTATE-2.7*
[**2163-10-24**] 09:18PM TYPE-ART PO2-67* PCO2-37 PH-7.29* TOTAL
CO2-19* BASE XS--7
[**2163-10-24**] 09:04PM TYPE-MIX PO2-39* PCO2-43 PH-7.24* TOTAL
CO2-19* BASE XS--8
[**2163-10-24**] 09:04PM LACTATE-2.0
[**2163-10-24**] 09:04PM HGB-9.3* calcHCT-28 O2 SAT-69
[**2163-10-24**] 08:39PM GLUCOSE-120* UREA N-17 CREAT-1.6* SODIUM-150*
POTASSIUM-2.1* CHLORIDE-120* TOTAL CO2-19* ANION GAP-13
[**2163-10-24**] 08:39PM CK-MB-4 cTropnT-0.07*
[**2163-10-24**] 08:39PM CALCIUM-5.2* PHOSPHATE-1.5* MAGNESIUM-1.0*
[**2163-10-24**] 08:39PM CK(CPK)-193*
[**2163-10-24**] 08:39PM WBC-17.8*# RBC-3.64* HGB-11.2* HCT-34.2*
MCV-94 MCH-30.8 MCHC-32.7 RDW-16.0*
[**2163-10-24**] 08:39PM NEUTS-75* BANDS-20* LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2163-10-24**] 08:39PM PLT COUNT-173
Brief Hospital Course:
In the [**Name (NI) **], pt was febrile w/ SBPs 70s; started on sepsis
protocol. Pt was intubated and placed on neosynephrine. CXR
showed LLL opacity, blood and urine cultures grew out
Enterobacter cloacae. Pt was initially started on
vanco/levo/zosyn; switched to levofloxacin alone after
sensitivities were final. Flagyl started for possible C. diff.
Patient since admission virtually anuric. CT scan showed an
atrophic L kidney w/ multiple stones, nl R kidney. Renal
ultrasound demonstrated no evidence of obstruction on R side.
Scant urine samples demonstrated packed WBCs despite appropriate
antibiotic coverage. Urology consult did not believe it was
necessary to intervene on stones currently. Renal consult
believed anuria/renal failure likely ATN vs renal artery
thrombosis. Given persistence of anuria/oliguria and worsening
renal failure, impending longterm if not lifelong hemodialysis
likely. Multiple discussions w/ family, prognosis described was
poor, with the likelihood of prolonged intubation/hemodialysis,
small likelihood of recovery. The healthcare proxy believed
that patient would not wish to have such interventions and on
[**10-30**], pt was extubated and placed on CMO. Patient expired on
[**2163-10-31**].
Medications on Admission:
Zofran 4mg po tid
Fentanyl patch 25mcg q72h
Tylenol 650mg po tid
Auralgun ear drops 2 drops R ear
Debrox ear drops [**Hospital1 **]
Crestor 20mg po qd
Levothyroxine 175mcg qd
Lopressor 25mg [**Hospital1 **]
Prilosec 20mg po bid
Heparin 5000mg sc tid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
urosepsis, multiple L renal stones, aspiration pneumonia
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"599.0",
"584.5",
"038.49",
"427.31",
"995.92",
"401.9",
"244.9",
"276.8",
"112.89",
"443.9",
"261",
"438.20",
"276.2",
"592.1",
"276.3",
"276.0",
"518.81",
"785.52",
"250.00",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"38.93",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
4611, 4620
|
3032, 4281
|
308, 346
|
4720, 4729
|
2056, 3009
|
4781, 4923
|
1881, 1899
|
4582, 4588
|
4641, 4699
|
4307, 4559
|
4753, 4758
|
1914, 2037
|
232, 270
|
374, 1511
|
1533, 1714
|
1730, 1865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,772
| 113,585
|
9684
|
Discharge summary
|
report
|
Admission Date: [**2105-10-15**] Discharge Date: [**2105-10-26**]
Date of Birth: [**2021-10-31**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p MVA
Major Surgical or Invasive Procedure:
[**2105-10-16**] Thoracic epidural placement for pain control
[**2105-10-20**] Placement of PICC line
History of Present Illness:
This is an 84-year-old female involved in a collision. She was
the restrained driver involved in an accident. Extensive damage
to the car including bending of the steering wheel. The patient
was complaining of pain in her chest as well as in her right
lower extremity. Hit her head on steering wheel. Patient does
recall loss of consciousness. In the ED, CT pan-scan was
performed, showing injuries as below. A pigtail catheter was
placed for the left pneumothrorax.
Past Medical History:
PMH: A-fib, renal artery stenosis, s/p L renal a stent placement
[**2097**], HTN, dyslipidemia, COPD (per [**2097**] d/c summary, pt denies),
bowel obstructions s/p ex-lap (details unclear) c/b mesh
infections, frequent falls.
PSH: AAA repair and ABI [**2093**], b/l TKA, L3/L4 laminectomy, remote
appendectomy, remote ovarian cystectomy, R THR [**2101**], mult bowel
obstructions s/p ex-lap (details unclear) c/b mesh infections
Social History:
denies ETOH, denies tobacco
Family History:
Non-contributory
Physical Exam:
HR: 90 BP: 150/100 Resp: 20 O(2)Sat: 100% on 2 L Normal
Constitutional: General appearance: The patient arrives
boarded and collared and is in no acute distress. The GCS is
15.
Head: The scalp is nontender and shows a laceration at the
left forehead near the hairline.
HEENT: The extraocular muscles are intact and the pupils
both constrict to light, [**2-11**]. The midface is stable.
Neck: There is no C-spine tenderness or step off.
Upper extremities: The upper extremities a extensive
abrasion over the left arm near the elbow.
Thorax: The chest wall is tender on the left side.
Lungs: The lungs are clear and symmetrical.
Heart: The heart sounds are crisp.
Abdomen: soft, scaphoid, and mildly tender in the right
abdomen.
Spine: There is no thoracic or lumbar spine tenderness.
Hips and pelvis: The pelvis is stable and the hips are
nontender.
Lower extremities: no long bone signs; there is a large deep
12 cm laceration of the left leg below the knee.
Neurovascular function distally is normal. There is an
abrasion on the right knee.
She has dopplerable pulses in both legs.
Neurological: The patient moves all 4 extremities equally.
Pertinent Results:
[**2105-10-15**] CT CHEST W/CONTRAST:
1. Displaced fractures of the left anterolateral 3rd through 6th
ribs with
small left pneumothorax.
2. Nondisplaced sternal fracture without significant hematoma or
vascular
injury.
3. Trace left-sided pleural effusion measuring simple fluid
density.
4. Significant subcutaneous emphysema over the left anterior
chest wall.
[**2105-10-15**] CT C-SPINE W/O CONTRAST:
Possible nondisplaced fracture of the left transverse process of
T1. No other fractures identified. Mild anterolisthesis of C6 on
C7, age
indeterminate, may be due to degenerative change.
[**2105-10-16**] ANKLE (AP, MORTISE & LAT) BILAT PORT:
Right distal fibular fracture.
[**2105-10-16**] Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation. Moderate pulmonary
hypertension.
[**2105-10-15**] 04:10PM WBC-14.9* RBC-4.10* HGB-12.8 HCT-38.6 MCV-94
MCH-31.1 MCHC-33.1 RDW-14.1
[**2105-10-15**] 04:10PM PT-12.8 PTT-27.5 INR(PT)-1.1
[**2105-10-15**] 04:10PM PLT COUNT-432
[**2105-10-15**] 04:10PM FIBRINOGE-347
[**2105-10-15**] 04:10PM LIPASE-21
[**2105-10-15**] 04:10PM UREA N-26* CREAT-1.5*
[**2105-10-15**] 04:20PM LACTATE-1.5
[**2105-10-15**] 04:20PM PO2-44* PCO2-54* PH-7.37 TOTAL CO2-32* BASE
XS-3 COMMENTS-GREEN
Brief Hospital Course:
Ms. [**Known lastname 32734**] was admitted on [**2105-10-15**] under the acute care
surgery service to the trauma ICU for further evaluation and
management of her injuries. She remained hemodynamically stable
on [**2105-10-18**] and was transferred to the surgical floor.
She had a significant forehead laceration was sutured on
admission. Sutures were removed prior to discharge and site
remained clean and dry at the time of discharge.
Neuro: A thoracic epidural was placed on [**2105-10-16**] for pain
management given her rib fractures, which was removed on
[**2105-10-19**]. She was transitioned from IV to PO analgesics. By the
day of discharge on [**2105-10-26**], her pain was well-controlled with
scheduled tylenol and prn tramadol and low dose oxycodone. On
[**2105-10-21**], Ms. [**Known lastname 32734**] was triggered for a transient episode of
altered mental status. Urine cultures were sent which were
negative. A chest xray was obtained which stable showed
bibasilar atelectasis and no evidence of infiltrate. She
remained hemodynamically stable during this episode, which
resolved quickly without intervention. She remained alert and
oriented at her baseline mental status upon discharge.
Cardiac: Her vital signs were monitored routinely throughout her
hospitalization. On arrival to the ED, her ECG showed rapid
atrial fibrillation with RVR (history of known atrial
fibrillation). She was rate controlled initially with IV beta
blockers in the ICU, and was then transitioned to her home
cardiac medications. She remained in atrial fibrillation at her
baseline throughout her floor course, with adequate rate control
in the 60s and 70s. A bedside echo was performed to evaluate her
cardiac function on [**2105-10-16**] (see pertinent results section). On
[**10-24**], she became slighly hypotensive down to a systolic BP of
80 with diuresis. On [**10-25**] albumin was given and her systolic BP
remained > 100 thereafter.
Pulm: A pigtail CT was placed on admission given her left sided
pneumothorax. It was removed on [**10-18**], with the post-pull chest
xray showing no evidence of pneumothorax. Subsequent chest xrays
showed bibasilar pleural effesions, and aggressive pulmonary
toileting and incentive spirometry were encouraged. A chest xray
on [**10-25**] revealed mild pulmonary edema, and gentle diuresis was
continued with lasix. She was also started on nebulizers as
needed. Her O2 therapy was weaned and her O2 sats remained in
the high 90's on 3L of NC at the time of discharge.
GI: On admission she was kept NPO and given IV fluids for
hydration. On [**10-16**] she was placed on a regular diet. On [**10-18**],
she began to develop nausea. She continued to have intermittent
episodes of nausea/vomiting, and a KUB on [**10-19**] showed evidence
of an ileus. She was given a 1X dose of methylnaltrexone as well
as a dulcolax suppository, and she subsequently had multiple
bowel movements. She subsequently had multiple episodes of
diarrhea, and stool samples were sent for c. diff and she was
empirically started on oral flagyl. She continued to be
intermittently nauseated and a repeat KUB was obtained on [**10-23**]
which showed continued evidence of an ileus with dilation of the
stomach, small, and large bowel. On [**10-25**] she was c. diff
negative x's 3 samples and flagyl was discontinued. On [**10-26**],
she denied any further nausea and vomiting, and was tolerating a
regular diet with no abdominal pain.
GU: U/A on admission was suspicious for a UTI and she was placed
on a 3 day course of oral ciprofloxacin. A repeat U/A [**10-18**] was
normal. A foley catheter was placed for urine output monitoring
on admission. It was removed on [**10-17**], however, she had an
episode of urinary incontinence and retention on [**10-18**] and the
catheter was replaced. Her I&O's were closely followed
throughout her admission. Her baseline Creatinine was 1.5, which
peaked at 1.9 and began to return to normal at 1.6 on
[**2105-10-24**]. Her urine output remained borderline at 20-25
mL/hour, with the return toward baseline kidney function and
adequate PO intake of fluids. She was discharged to rehab on
[**10-16**] with the foley in place for continued urine output
monitoring.
Heme/ID: Her electrolyes were routinely monitored and repleted
as needed. Continued hypocalcemia and hypophosphatemia were
noted at the time of discharge and she was discharged on 3 days
of neutra-phos as well as calcium supplements. Her initially
leukocytosis of 14.9 resolved quickly, and her WBC count
remained within normal limits throughout the remainder of her
hospitalization. Antibiotic courses were notable for cipro and
flagyl as discussed above. Her hgb and hct were routinely
checked and remained stable.
Musk: Orthopedics was consulted for her right distal fibula
fracture. The injury was determined to be nonoperable and she
remained weightbearing as tolerated in an aircast boot on her
RLE. Physical therapy was consulted to evaluated her mobility, a
discharge to an extended care facility when medically stable was
recommended. The patient was encouraged to mobilize out of bed
as tolerated. Follow up was scheduled in the orthopedic clinic
after discharge.
Prophyl: She was started SC heparin for DVT prophylaxis after
removal of the thoracic epidural. Her home dose of protonix was
continued during her hospitalization.
On [**2105-10-26**], Ms. [**Known lastname 32734**] remained afebrile and hemodynamically
stable. She expressed adequate pain control and was tolerating a
regular diet. She was discharged to rehab with plan for coninued
physical therapy, cardiopulmonary assessment, urine output
monitoring, and pain management. Follow up was scheduled with
orthopedics as well as the acute care service.
Medications on Admission:
advair diskus 250-50mcg'',
amytriptyline 25'HS,
amlodipine 5',
cardizem cd 180'
furosemide 60'
labetolol 300'HS
procrit solution [**Numeric Identifier 961**] unit/ml, 1ml subq/week
pantoprozole 40'
simvastatin 80'
Spiriva'
terazosin 5'
vesicare 10'
ezetimibe 10'
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. labetalol 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. terazosin 5 mg Capsule Sig: One (1) Capsule PO Q 24H (Every
24 Hours).
12. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO Q 24H (Every 24 Hours).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
17. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
18. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
19. ipratropium bromide 0.02 % Solution Sig: One (1) nib
Inhalation Q6H (every 6 hours) as needed for wheezing.
20. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
21. potassium & sodium phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
left [**2-15**] rib fractures, right [**3-18**] rib fractures, sternal
fracture, right distal fibular fracture, multiple lacerations,
and a left pnuemothorax
Secondary:
renal artery stenosis
Hypertension
dyslipidemia
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Needs assistance to transfer
Discharge Instructions:
You were admitted to the hospital after you were in a motor
vehicle accident. You sustained left [**2-15**] rib fractures, right
[**3-18**] rib fractures, sternal fracture, right distal fibular
fracture, multiple lacerations, and a collapse in your left
lung. The orthopedic service saw you for your fibula fracture
and recommended the aircast with weight bearing as tolerated
until you follow up with them in clinic in 2 weeks. The acute
pain service also was consulted to make sure you had adeuquate
pain control and placed an epidural. You were then transitioned
to pain medication by mouth after the epidural was removed. You
were requiring some oxygen to maintain appropriate oxygen
saturation levels. This was thought to be due to your rib
fractures and some extra fluid that we gave you diuretics for.
You were initially placed in the ICU for your rib fractures and
were brought to a regular hospital floor 3 days later. At the
time of discharge you had your forehead sutures removed, you
were having bowel movements, and your pain was well controlled.
Please follow up with the providers listed below.
General Instructions for Rib fractures:
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures.?????? In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake.?????? This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.??????
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.??????
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.??????
Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.??????Do not drive a vehicle or drink
alcohol while taking narcotics.
Do NOT smoke
Return to the Emergency Room right away for any acute shortness
of breath, increased pain or crackling sensation around your
ribs (crepitus).
You may bear weight as tolerated on your right leg while wearing
the air cast boot we have given you.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2105-11-10**] at 10:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2105-11-10**] at 10:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2105-11-12**] at 2:30 PM
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
Notes: You will need a chest x-ray prior to this appointment.
Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) 3202**] Radiology 30 minutes prior to your appointment.
Completed by:[**2105-10-26**]
|
[
"860.0",
"275.41",
"E812.0",
"599.0",
"891.0",
"805.2",
"405.91",
"338.11",
"787.91",
"440.1",
"873.42",
"416.8",
"807.2",
"493.20",
"427.31",
"824.8",
"807.08",
"854.02",
"V15.88",
"511.9",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
12568, 12665
|
4500, 10255
|
314, 418
|
12932, 12932
|
2629, 4477
|
15619, 16751
|
1430, 1448
|
10569, 12545
|
12686, 12911
|
10281, 10546
|
13086, 15596
|
1463, 2610
|
267, 276
|
446, 914
|
12947, 13062
|
936, 1368
|
1384, 1414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 142,176
|
22367
|
Discharge summary
|
report
|
Admission Date: [**2125-7-10**] Discharge Date: [**2125-7-11**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 20 yo female with Type I Diabetes (Dxd in 11/00) who was
found to be in DKA after an ambulance was called s/p sustaining
a mechanical fall on [**2125-7-9**] ~4 pm. Pt was at work folding
laundry when she felt her "back lock up", fell to the floor, hit
her head, and then went to her house. She threw up after hitting
her head and vomited 3-4 times that day. [**Name (NI) **] mother was
concerned about the fall and called an ambulance. In ED FS=497,
K = 6.8, Bicarbonate was 10, and AG was 33. She received 7 u
insulin subcutaneously and was started on Insulin gtt (7
units/hour) and received ~5 L NS.
Back pain has been constant since getting hit in a MVA in [**Month (only) **]
this year. The pain is sharp, and is localized to the right
lumbo-sacral region. She believes that this is why her back
locked up and it is not uncommon. The morning of the fall
patient said her FS was 138 and she had a slushy right after,
though she did not know the carbohydrate equivalents.
On ROS no diarrhea. No sick contacts. [**Name (NI) **] polyuria/ polydipsia/
polyphagia. No H/A or visual changes. No tremors. Does report "a
funny discharge" from her vagina which is yellow and started the
day of admission. No dyspareunia. Of note, patient had gonorrhea
in [**Month (only) 958**], when she was admitted to [**Hospital3 **] with DKA
and said that that was the tipoff that time. She says that she
is sexually active with her partner of 6 years and that they use
condoms "usually." In [**Month (only) 958**], patient's partner was also treated
for gonorrhea. There were a few months when they were not dating
and he had sexual relations with someone else. Otherwise, the
patient says that they are both monogomous.
Patient was diagnosed with DM I in 11/00 shortly after suffering
a miscarriage. She presented with H/A and went to [**Hospital1 2177**] and was
diagnosed. She has been in DKA ~5 times since that time, most
recently in [**Month (only) 958**] (as above). She reports having good recent
control since starting at [**Last Name (un) **] earlier this year. She takes
Novalog 1u/10 g of carbohydrates and takes 35 units of lantus at
night. She takes her FS ~3-4 times per day and reports a usual
range of 65-225.
Past Medical History:
1.Diabetes Type I as above.
2.Hyperlipidemia
3. S/P MVA [**5-4**]-Right lower back pain since then. + Back spasms
treated with tylenol.
4. Goiter
5. Depression
Social History:
Patient started work as a personalized care attendant on day of
admission. Completed high school in [**2122**]. She has a two-year-old
son with her current partner. Quit smoking two years ago. [**6-7**]
cigarettes per week for 3 years. No EtOH. No marijuana, cocaine,
heroin or other recreational drugs.
Family History:
GM with Type I diabetes. Otherwise non-contributory.
Physical Exam:
On admission to medicine floor from MICU:
VS: T: 98.6; BP: 116/55, P: 75; RR:15; O2: 99%; I/O 24
hour:[**Numeric Identifier **]/4775
FS: 0300 (214) 0400 (288) 1000 (92) 1300 (352)
Gen: Laying in bed in NAD
HEENT: PERRL, EOMI, OP clear no exudate, tongue-ring in place,
MMM
Neck: No JVD, No LAD. Painful to palpation left anterior
cervical area.
CV:RRR s1s2. No M/R/G.
Lungs: CTA b/l. good air entry.
Abd: + BS, soft, NT, ND.
Ext: 2+ DP. No C/C/E. No tremors.
Back: No pain to deep palpation. No CVA tenderness.
Neuro: Reflexes 3+ b/l patellar, biceps.
Pertinent Results:
Labs on Admission:
[**2125-7-9**] 08:52PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG COLOR-Straw
APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2125-7-9**] WBC-16.0* RBC-5.04 HGB-14.5 HCT-46.3 MCV-92 MCH-28.8
MCHC-31.3 RDW-13.3
PLT COUNT-232 HYPOCHROM-2+
NEUTS-86.0* LYMPHS-11.9* MONOS-1.4* EOS-0.2 BASOS-0.5
ALT(SGPT)-17 AST(SGOT)-40 ALK PHOS-116 AMYLASE-76 TOT BILI-0.4
GLUCOSE-489* UREA N-24* CREAT-1.2* SODIUM-132* POTASSIUM-6.8*
CHLORIDE-94* TOTAL CO2-5* ANION GAP-40*
[**2125-7-9**] 10:58PM GLUCOSE-457* NA+-136 K+-6.0* CL--99* TCO2-10*
[**2125-7-10**] 01:00AM GLUCOSE-202* UREA N-22* CREAT-1.1 SODIUM-138
POTASSIUM-6.8* CHLORIDE-106 TOTAL CO2-7* ANION GAP-32*
Chem 7s-
[**2125-7-9**] 10:40PM Glucose-489* UreaN-24* Creat-1.2* Na-132*
K-6.8* Cl-94* HCO3-5*
[**2125-7-10**] 01:00AM Glucose-202* UreaN-22* Creat-1.1 Na-138 K-6.8*
Cl-106 HCO3-7*
[**2125-7-10**] 04:00AM Glucose-219* UreaN-16 Creat-0.9 Na-138 K-3.9
Cl-112* HCO3-7*
[**2125-7-10**] 08:16AM Glucose-161* UreaN-10 Creat-0.7 Na-136 K-3.6
Cl-112* HCO3-12*
[**2125-7-10**] 02:30PM Glucose-130* UreaN-8 Creat-1.0 Na-136 K-3.7
Cl-113* HCO3-16*
[**2125-7-10**] 06:00PM Glucose-79 UreaN-9 Creat-0.6 Na-138 K-3.5
Cl-116* HCO3-15*
[**2125-7-11**] 06:09AM Glucose-164* UreaN-6 Creat-0.6 Na-137 K-3.4
Cl-111* HCO3-17* [**2125-7-11**] 05:20PM Glucose-120* UreaN-10
Creat-0.8 Na-138 K-3.6 Cl-104 HCO3-22
[**2125-7-11**] 06:09AM BLOOD WBC-5.5# RBC-3.90* Hgb-11.5* Hct-34.3*#
MCV-88 MCH-29.5 MCHC-33.7 RDW-13.6 Plt Ct-89*#
Last day of hospitalization
[**2125-7-11**] Glucose-120* UreaN-10 Creat-0.8 Na-138 K-3.6 Cl-104
HCO3-22
[**2125-7-11**] ALT-17 AST-25 AlkPhos-69 Amylase-86 TotBili-0.6
Calcium-8.5 Phos-1.9* Mg-1.8
WBC-5.5# RBC-3.90* Hgb-11.5* Hct-34.3*# MCV-88 MCH-29.5
MCHC-33.7 RDW-13.6 Plt Ct-89*#
EKG: [**2125-7-9**]- Sinus tachycardia at 105 bpm. Irregular rhythm with
premature atrial beats. T wave inversions in V1 and V2.
[**2125-7-10**]-Sinus rhythm at 95. Normal rate. Small ST depression in
V1. Less prominent than previous EKG.
Brief Hospital Course:
*** Pt left AMA on the night of [**2125-7-11**] secondary to childcare
issues. Attending and house staff both went over the risks of
leaving AMA, including but not limited to dehydration,
hyperglycemia, diabetic ketoacidosis, coma, and death. Also, the
patient was made aware that her plateletes had decreased
dramatically and leaving against medical advice could lead to
increased risk of bleeding.***
1. DKA
Patient was continued on insulin drip at 7cc/hour upon arrival
to the MICU. On [**7-11**] ~12:30 am insulin drip was d/cd and
patient had hypoglycemia to 52 (received amp D50). Anion gap
slowly closed by the morning of [**2125-7-11**], however with a
bicarbonate of 17. Patient was transferred to the floor and a
[**Last Name (un) **] fellow consulted on the case. The humalog insulin sliding
scale was changed to 4 units Humalog standing before each meal
and 1 unit of insulin for every 50 of glucose greater than 200.
We were also going to continue the patient on Lantus 30 units
qhs. Patient's blood sugars were in upper 100s-200s on day of
discharge with blood sugar going up to above 300 at times.
HgA1C was tested and found to be 11.6. Therefore usual glucose
is usually > 300 and indicates that patient is poorly
controlled.
2. Cause of DKA
Pt with vomiting upon arrival. Could have been from DKA
itself. No history in days prior to presentation of vomiting. On
transfer to the medicine floor from the MICU, the N/V had
resolved. Another possible etiology could be a vaginal infection
as patient says that she has a yellow discharge which is similar
to when she had gonorrhea in [**Month (only) 958**]. The plan was to perform a
gynecological exam. However, the patient left before being able
to do so.
3. Backpain
Ms. [**Known lastname **] has had backpain since being in an MVA in [**Month (only) **].
She takes tylenol for the pain and this was continued as an
inpatient.
4. F/E/N
On the day of leaving the hospital, Ms. [**Known lastname **] was tolerating
PO and was on a diabetic carbohydrate consistent diet.
5. Access: PVLs
6. Code Status: Full Code while in the hospital
Medications on Admission:
1. Lantus 35 units qhs
2. Novalog sliding scale-1 unit for every 10 grams of
carbohydrate
3. Lipitor 20 mg once a day
4. Trazadone 100 mg qhs
Discharge Medications:
Patient left AMA. She will continue her home medications.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Hyperlipidemia
Depression
Lower back pain
Discharge Condition:
Fair
Discharge Instructions:
Patient left AMA.
Followup Instructions:
Patient left AMA. She was urged to follow-up with her [**Last Name (un) **]
physician the day after discharge for an appointment within a
few days. Pt also said that she had an appointment with her PCP
two days after leaving the hospital.
|
[
"272.4",
"311",
"724.2",
"240.9",
"250.11",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8299, 8305
|
5909, 8024
|
331, 337
|
8413, 8419
|
3754, 3759
|
8485, 8726
|
3111, 3165
|
8217, 8276
|
8326, 8392
|
8050, 8194
|
8443, 8462
|
3180, 3735
|
270, 293
|
365, 2590
|
3774, 5886
|
2612, 2774
|
2790, 3095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,431
| 108,381
|
12381
|
Discharge summary
|
report
|
Admission Date: [**2121-2-27**] Discharge Date: [**2121-3-8**]
Date of Birth: [**2047-1-4**] Sex: F
Service: C MED
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female who
has a known history of aortic stenosis and mitral
regurgitation, as well as hypercholesterolemia and
hypothyroidism who is admitted with a syncopal episode. The
patient syncopized at the dentist and was found to have a
heart rate in the 200s and a blood pressure of 80. She was
transferred to the [**Hospital1 **] [**First Name (Titles) 2142**] [**Last Name (Titles) **],
where she had a regular supraventricular tachycardia at
approximately 180 beats per minute, which broke briefly with
vagal maneuvers, and then recurred. She was given adenosine
and Lopressor without effect and then spontaneously converted
to normal sinus rhythm, had a stable pulse and blood
pressure. During these episodes she denied chest pain,
shortness of breath, abdominal pain, nausea, vomiting,
diarrhea, bright red blood per rectum, melena or dysuria.
PAST MEDICAL HISTORY:
1. Mitral stenosis and mitral regurgitation.
2. Aortic stenosis.
3. Hypercholesterolemia.
4. Hypothyroidism on replacement.
5. Macular degeneration.
ALLERGIES: None.
MEDICATIONS ON ADMISSION:
1. Synthroid 0.088 mg po q.d.
2. Lipitor 10 mg po q.d.
SOCIAL HISTORY: The patient lives with her husband in [**Name (NI) 26532**]. No tobacco history, no alcohol history.
PHYSICAL EXAMINATION: Temperature 95.0. Blood pressure
110/70. Pulse 70. Respirations 20. Oxygen saturation 96%
on room air. In general, this is an elderly woman in no
acute distress. Her head, eyes, ears, nose and throat are
unremarkable. Her neck shows no elevation and jugular venous
pulsation. Her lungs have crackles a third of the way up at
the bases bilaterally. Her heart is regular with a normal
S1, S2. A 3/6 systolic crescendo-decrescendo murmur is heard
at the right upper sternal border. A holosystolic [**3-26**] murmur
is audible at the apex with a diastolic component. Her
abdomen has normal bowel sounds, is soft, nontender,
nondistended. No masses are palpable. Her extremities
reveal no cyanosis, clubbing or edema. Neurologically, she
is alert and oriented times three. Her cranial nerves are
grossly intact. Her strength is [**5-25**] in the upper and lower
extremities. Her sensation is intact.
LABORATORY DATA: Admission laboratories are significant for
a white blood cell count of 9.1 (differential: 75% polys,
17% lymphocytes). Potassium 4.1, BUN 20, creatinine 1.0.
Chest x-ray showed congestive heart failure, no
consolidations and no effusions.
Electrocardiogram: Regular supraventricular tachycardia with
right axis deviation, diffuse ST depressions.
HOSPITAL COURSE: This is a 74-year-old woman with known
aortic stenosis and mitral regurgitation and mitral stenosis
who presented with syncope in the setting of a
supraventricular tachycardia and hypotension.
1. Cardiovascular: The patient was initially evaluated for
a myocardial infarction. She had an enzyme leak with a peak
troponin of 16.3, and a peak CK of 145 with an MB of 16 for
an index of 11%. She therefore was taken to the coronary
catheterization laboratory where she was found to have clean
coronary arteries. However, the patient was found to have
severe mitral regurgitation and moderate aortic stenosis
(aortic valve gradient 10 mmHg, aortic valve area 0.9 square
cm, mitral valve gradient 19 mmHg, mitral valve area not
calculated). During the catheterization, hemodynamic testing
revealed improved cardiac output with dobutamine. The
patient was transferred to the Cardiac Intensive Care Unit on
dobutamine and nitroglycerin. These medications were quickly
weaned off as the dobutamine was found to put the patient
back into supraventricular tachycardia. Once she was weaned
off these medications, she was transferred again to the
floor. The patient was evaluated by the Cardiac Surgery
Team. It was felt that double valve replacement surgery on
this frail 74-year-old woman would present an intraoperative
mortality risk of up to 30% given the extensive aortic
calcification seen during the cardiac catheterization. It
was therefore recommended that the patient be managed
medically and that surgery be reserved only as a last ditch
effort if medical management should fail.
The patient was started on amiodarone, Lopressor, and an ACE
inhibitor. She was taken for an electrophysiology study in
an attempt to possibly ablate a arrhythmia focus. On further
consideration, as the patient was known to not tolerate her
supraventricular tachycardia, it was felt that a better
approach would be to insert a pacemaker and then ablate the
patient's AV node, thereby, ablating any possible tachycardic
foci. The pacemaker was inserted, however, the procedure was
complicated by hemopericardium, secondary to a right
ventricular leak. The patient was transferred back to the
Coronary Care Unit, where she was found to have tamponade
physiology. A pericardial drain was placed. The following
day, the pericardial drain was withdrawn after a repeat
echocardiogram showed no re-accumulation of the
hemopericardium. On the following day, another repeat
echocardiogram was also clear. After further consultation
with the Electrophysiology Team, it was decided that the
patient would be discharged home on medical management to
follow-up in the Electrophysiology Device Clinic and AV
nodule ablation would be considered at a later time.
The patient was also started on oral Lasix q.d. for a gentle
diuresis. She is to follow-up in the Electrophysiology
Clinic the week after discharge. The patient was discharged
home on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart's monitor to monitor her QT interval
during the amiodarone load. The results of this monitor will
be interpreted by her electrophysiologist, Dr. [**Last Name (STitle) **].
2. Infectious Disease: The patient was noted to have an
elevated white blood cell count and hypothermia during her
admission. She also had diarrhea. The diarrhea was negative
for C. difficile. The white blood cell count normalized on
its own. There is no consolidation on chest x-ray and the
patient had no clinical symptoms of infection. Urinalysis
and culture were also negative.
3. Endocrine: The patient's hypothyroidism was maintained
on her usual dose of Synthroid. Her TSH and T4 were within
normal limits.
4. Communication: The patient lives at home with her
husband, who is demented, however, friends of the family are
extremely involved in the patient's care. The [**Location (un) 38550**]
can be reached at area code [**Telephone/Fax (1) 38551**], or area code
[**Telephone/Fax (1) 38552**].
5. Code status: Full.
CONDITION OF DISCHARGE: The patient is discharged in stable
condition.
FOLLOW-UP: She is to follow-up in the Electrophysiology
Clinic next week with Dr. [**Last Name (STitle) **]. AV nodule ablation will
be considered at a later date.
DISCHARGE DIAGNOSES:
1. Syncope.
2. Supraventricular tachycardia.
3. Mitral regurgitation.
4. Aortic stenosis.
5. Status post pacer placement.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po q.d.
2. Amiodarone 400 mg po q.d.
3. Lisinopril 10 mg po q.d.
4. Synthroid 0.088 mg po q.d.
5. Atenolol 12.5 mg po q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2121-3-12**] 22:05
T: [**2121-3-12**] 22:05
JOB#: [**Job Number 38553**]
|
[
"244.9",
"398.91",
"427.89",
"423.0",
"285.9",
"780.2",
"998.2",
"396.2",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.26",
"37.72",
"37.23",
"37.83",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
7043, 7171
|
7194, 7621
|
1253, 1311
|
2756, 7022
|
1454, 2738
|
161, 1031
|
1053, 1227
|
1328, 1431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,028
| 159,748
|
25831
|
Discharge summary
|
report
|
Admission Date: [**2176-6-27**] Discharge Date: [**2176-7-13**]
Date of Birth: [**2108-1-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Avelox
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypotension to 70s
Major Surgical or Invasive Procedure:
-Tunnel catheter for HD
-Blood and FFP transfusions
-Hemodialysis
History of Present Illness:
68 yo F with tracheobronchomalacia, on heparin gtt for AVR, who
was transferred here from an OSH for IP evaluation and possible
Y stent who is transferred to the MICU for hypotension. She was
initially admitted here on [**6-27**] and had a CT of her airway done
revealing tracheobronchomalacia. She was scheduled for the OR on
Monday for rigid bronch. Her bp remained stable on admission,
and was in the 130s-140s/70s-80s throughout the day on [**6-27**] and
[**6-28**]. On [**6-29**], her bp was 100/80 at 8 am (pulse 92 from 82),
92/43 at noon, and 87/54 at 4 pm (pulse 104). Per thoracic
surgery she was mentating throughout all of this. No UOP
recorded as she was incontinent, but at 8:45 pm a Foley was
placed and drained 250 cc urine. The MICU team was called at 9
pm for hypotension. [**Name8 (MD) **] RN notes her bp was 62/palp (75/p
w/doppler), pulse 120, respirations 32, and 98% on 3L. They
attempted to give a 500 cc bolus but her last peripheral IV
stopped working. She was transferred to the MICU at this time
for CVL placement and further monitoring. Of note, her INR was
subtherapeutic on admission at 1.4, and she was begun on a
heparin drip (due to AVR). Her PTT was greater than 150 since 6
pm last night, and despite adjustments in the heparin gtt it was
last measured at 147.5. Her heparin gtt was shut off at the time
of her MICU transfer.
.
Currently, she is awake but drowsy and is mentating
appropriately. She is complaining of severe abdominal and back
pain which she states has been going on since yesterday. She
also feels very cold.
.
In terms of recent history, she was admitted to [**Hospital 28448**] Center on [**6-17**] with SOB and cough. Initial CXR
was clear. They felt she had a COPD exacerbation and treated her
with steroids, bronchodilators, and azithromycin. On [**6-20**], she
became acutely SOB and CXR showed LUL infiltrate. She was begun
on zosyn and cipro for possible pseudomonal pna (as had
reportedly grown this in past). Swallow study was negative for
aspiration. On [**6-27**] (day of transfer) she was on day 7 of
cipro/zosyn. Per their notes her SOB and cough were much
improved. Her creatinine fluctuated between 1.8 and 2, and was 3
on discharge from the OSH. Her lasix and enalapril were
discontinued there, and she was begun on IVF (total 500 cc).
Renal ultrasound showed R kidney 10.2 cm w/mult cysts, left
normal, no hydro. She had a negative C diff there, blood cx
negative x2, urine cx negative. ABG 7.40/40/77 on [**6-21**].
Past Medical History:
PMH:
1. Tracheobronchomalacia, s/p prolonged intubation/trach in [**2164**]
s/p CABG
2. Recurrent pneumonias, reported hx pseudomonas in sputum
3. Bronchiectasis
4. CAD s/p CABGX5 [**2165**]
5. COPD/restrictive lung disease FEV1 680 ml (39% pred) in [**2174**]
unchanged from [**2168**], TLC 63% pred
6. PVD
7. CHF (mild per notes)
8. Bell's Palsy
9. HTN
10. Hyperlipidemia
11. s/p AVR [**2165**]
12. DM
13. CKD, felt [**1-4**] diabetes, baseline Cr 1.4
14. GERD w/hiatal hernia
15. Esophageal stricture s/p dilatation x2
[**85**]. s/p R CEA [**4-/2169**]
Social History:
She lives alone in an [**Hospital3 **] facility. She is formerly
a suitcase manufacturer. She denies any alcohol use or ever
smoking cigarettes. She denies any asbestos exposure.
Family History:
father died from MI at age 60, mother died from MI at age 70
Physical Exam:
Physical Exam:
Vitals: 96.5F HR 99 BP 94/31 RR 40 100%/4Ln.c.
Gen: conversant, alert and oriented female, apppears pale and
uncomfortable
HEENT: anicteric, mucus membranes very dry
Neck: supple
CV: tachycardic, regular
Pulm: CTA anteriorly
Abd: obese, TTP RUQ/LUQ without rebound or guarding, +bs, guaiac
negative
Ext: [**1-5**]+ pitting edema bilaterally, skin cold, pulses 1+
bilaterally
Pertinent Results:
[**2176-6-27**] 09:21PM GLUCOSE-125* UREA N-70* CREAT-2.7* SODIUM-134
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18
[**2176-6-27**] 09:21PM CALCIUM-8.9 PHOSPHATE-5.3* MAGNESIUM-2.0
[**2176-6-27**] 09:21PM WBC-13.1* RBC-3.70* HGB-11.0* HCT-30.9*
MCV-84 MCH-29.7 MCHC-35.5* RDW-13.6
[**2176-6-27**] 09:21PM PLT COUNT-263
[**2176-6-27**] 09:21PM PT-15.4* PTT-20.9* INR(PT)-1.4*
.
CT Trachea [**2176-6-28**]
IMPRESSION:
1. Severe diffuse tracheobronchomalacia.
2. Cylindrical bronchiectasis, predominantly basal, and
scattered nodular
ground-glass opacities suggest chronic and ongoing aspiration.
3. Small bilateral pleural effusion.
4. Atherosclerosis, including coronaries.
5. Moderate size hiatus hernia.
.
CT Abd/Pelvix [**2176-6-30**]
IMPRESSION:
1. Large right pelvic side wall hematoma measuring 11.7 x 9.1
cm, with
extension into the right rectus muscle. There is no evidence of
intraperitoneal extension of hemorrhage. The possibility of
active
extravasation is not optimally assessed without intravenous
contrast.
2. There are again seen scattered areas of ill-defined ground
glass opacity
and bronchiectatic changes within the lungs bilaterally, which
are not
significantly changed in comparison to most recent study from
two days prior.
.
.
Echo [**2176-7-2**]:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue
velocity imaging E/e' is elevated (>15) suggesting increased
left ventricular
filling pressure (PCWP>18mmHg). A mid-cavitary gradient is
identified,
consistent with mild flow obstruction at rest. The patient was
unable to
cooperate with the Valsalva maneuver. Right ventricular chamber
size and free
wall motion are normal. A bileaflet aortic valve prosthesis is
present. The
transaortic gradient is normal for this prosthesis. No aortic
regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is an
anterior space which most likely represents a fat pad, though a
loculated
anterior pericardial effusion cannot be excluded.
IMPRESSION: Symmetric LVH with hyperdynamic systolic function,
and no regional
wall motion abnormalities. Mild resting mid-cavitary flow
obstruction.
Normally-functioning mechanical aortic valve prosthesis.
.
LENI [**2176-7-5**]
CONCLUSION:
No evidence of DVT.
.
CXR [**2176-7-4**]:
IMPRESSION:
1. Newly inserted two right central lines with no evidence of
complications.
2. Small new right pleural effusion.
Brief Hospital Course:
68 yo woman with tracheobronchomalacia, on heparin gtt for [**Hospital 64315**]
transferred to [**Hospital1 18**] from an OSH for IP evaluation and possible
Y stent who was transferred to the MICU for hypotension,
decreased Hct in the setting of retroperitoneal bleed.
.
1. Retroperitoneal Bleed - Pt had bleed and was hypovolemic in
setting of blood loss while supratherpeutic on heparin. She
received aggressive fluid resuscitation and PRBC transfusions
while in house as needed for bleeding. Her anticoagulation was
reversed with FFP. She did not require pressors. On CT scan,
she was found to have a large right pelvic side wall hematoma
with extension into the right rectus muscle. There was no
evidence of intraperitoneal extension of hemorrhage. We
monitored her Hct closely during the acute episodes q4.
Although her Hct stabilized, when we attempted to start
anticoagulation with warfarin again at low doses, she
subsequently developed a decreasing hematocrit which required
further transfusions of FFP and Hct. While attempting slow
increase of coumadin to reach therapeutic INR for her AVR, she
began further dropping her HCT with increase of her INR to 1.8.
We reversed this INR with Vit K. We decided that she was
currently not a candidate for anticoagulation in the setting of
her acute bleed and in the setting of increasing bleeds to even
low levels of anticoagulation.
.
2. ARF on CRI - After developing hypotension, she became anuric.
The most likely explination is that she developed ATN. She has
required hemodialysis/ultrafiltration during her stay in the
hospital, and she had a tunnel catheter placed to facilitate
this in the future. She was initially on CVVH. She was
converted to hemodialysis. She did experience two transient
episodes of desaturiation of hemodialysis. The diasylate was
changed to asili. She tolerated two additional dialysis
sessions without incident.
.
3. Elevated WBC count - She was hypothermic and met criteria
for SIRS but this is all likely explained by hypovolemic shock.
She ultimately had a gram stain positive for gram positive cocci
in her sputum (culture negative to date [**7-13**]), from [**2176-7-10**]. We
subsequently treated her with Vancomycin. She began her course
on [**2176-7-10**] and was dosed by level with a goal vancomycin trough
>15. She will continue this course for 7 days total. She also
had erythema on her right lower extremity. This was thought to
be more consistent with venous stasis changes than cellulitis
and did not change when vancomycin was started.
.
4. Tracheobronchomalacia - Patient was originally transferred
for stent placement for this problem. She and her family
subsequently decided not to proceed with this procedure given
the risk/benefit ratio and the complications she has had during
her hospital stay.
.
6. CV: pump - anti-hypertensives were held given hypotension.
Volume resuscitation as above.
ischemia - no evidence of active ischemia. she had one
episode of transient right-sided chest pain. her cardiac
enzymes were negative. she was continued on statin for
secondary prevention. Aspirin was held given bleeding risk.
Antihypertensives also held.
.
7. Diabetes mellitus - She was treated with an insulin sliding
scale while in the hospital to maintain glucoses <120.
.
8. Prophylaxis - She was maintained on PPI and pneumoboots
while in the hospital. We attempted to anticoagulate her, but
stopped as described above.
.
9. Access: She had a tunnel line and PICC placed under IR while
in the hospital.
Medications on Admission:
cipro 250 mg po q12h
simvastatin 80 mg daily
insulin sliding scale
pantoprazole 40 mg daily
olanzapine 2.5 mg po qhs
prednisone 10 mg tid
ferrous sulfate 325 mg daily
buspirone 10 mg daily
ezetimibe 10 mg daily
amlodipine 5 mg daily
ipratropium nebs q6h
fluticasone-salmeterol 250/50 [**Hospital1 **]
zosyn
albuterol nebs
tylenol
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
3. Buspirone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed.
5. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Amlodipine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO
TID (3 times a day).
11. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed for agitation/insomnia.
12. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous
Dosing by level for 3 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Retroperitoneal hematoma
Discharge Condition:
-Good
Discharge Instructions:
Please call if become dizzy, weak, temp >101, chills, abdominal
pain or abnormal bruising.
Followup Instructions:
You should follow up with your PCP within one week of discharge
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2176-7-13**]
|
[
"584.9",
"403.91",
"790.92",
"V43.3",
"785.59",
"414.00",
"280.0",
"276.0",
"112.2",
"519.1",
"459.0",
"570",
"518.82",
"V45.81",
"250.40",
"496",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.95",
"39.95",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12187, 12202
|
6828, 10378
|
315, 382
|
12271, 12279
|
4185, 6805
|
12418, 12649
|
3696, 3759
|
10759, 12164
|
12223, 12250
|
10404, 10736
|
12303, 12395
|
3789, 4166
|
257, 277
|
410, 2901
|
2924, 3482
|
3498, 3680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,718
| 141,804
|
44502
|
Discharge summary
|
report
|
Admission Date: [**2203-7-20**] Discharge Date: [**2203-8-16**]
Date of Birth: [**2162-8-15**] Sex: M
Service: MEDICINE
Allergies:
Betadine / Iodine; Iodine Containing / Compazine / Heparin
Agents
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
MRSA bacteremia, renal failure, hypotension, respiratory failure
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
Portacath removal
History of Present Illness:
40 yo M w/ PMH C6 paraplegia, renal tx, well known to [**Hospital1 18**] with
multiple previous admissions for UTI/sepsis, respiratory
distress, autonomic dysreflexia admitted to [**Hospital Unit Name 153**] on [**7-20**] for
SIRS. On admission, he reported that he had been feeling "lousy"
for a few days. His sx were most notable for pain at port site,
abd pain and nonbloody, nonbilious emesis x 1. Portacath has
been in place for over one year.
His reported temp at rehab was 103.9. In the ED, his HR110-125,
BP 70-132/40-78, Temp 101.3. He was given vanco, flagyl,
ceftazidime, 1gm tylenol, and 4 mg dilaudid.
Past Medical History:
1. Status post motor vehicle accident resulting in C6
quadraplegia and autonomic dysreflexia. His course is also
complicated by sacral decubiti.
2. Status post renal transplant
3. Obesity (260lbs)
4. Depression
5. Anemia
6. Chronic pain
7. Recurrent UTI with indwelling suprapubic catheter
8. History of HIT thrombosing port-a-cath
9. History of anyphylaxis with iodine refractory to pretreatment
with steroids
10. History of cocaine-induced MI '[**88**]
11. Chronic osteomyelitis
12. Status post right BKA
13. Status post diverting colostomy
14. History of adrenal insufficiency
15. Status post splenectomy
16. Asthma
Family History:
Non-contributory
Physical Exam:
97.6 HR 103-115 BP 92/54 RR 25 Sat 93 %
obese man, sitting in bed, appears uncomfortable but speaking
sentences, ox 3
thick neck, multiple scars
chest wall with left sided portacath, TTP, no drainage, no
erythema
RRR, nl S1/s2 no M/R/G
lungs: ant--no wheezes, no crackles ant
obese, dist, +BS, stoma with little material, suprpubic cath in
place
left leg with dressed heel ulcer
neuro: unable tomove legs, has limited fucntion of hands
Pertinent Results:
[**2203-7-20**] 08:49PM POTASSIUM-4.2
[**2203-7-20**] 02:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2203-7-20**] 02:15PM URINE BLOOD-LG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2203-7-20**] 02:15PM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0
[**2203-7-20**] 12:24PM LACTATE-1.6
[**2203-7-20**] 12:12PM GLUCOSE-116* UREA N-22* CREAT-0.6 SODIUM-136
POTASSIUM-5.2* CHLORIDE-96 TOTAL CO2-35* ANION GAP-10
[**2203-7-20**] 12:12PM ALT(SGPT)-44* AST(SGOT)-39 LD(LDH)-153 ALK
PHOS-268* AMYLASE-22 TOT BILI-1.4
[**2203-7-20**] 12:12PM LIPASE-13
[**2203-7-20**] 12:12PM WBC-10.1 RBC-3.42* HGB-9.5* HCT-29.4* MCV-86
MCH-27.9 MCHC-32.5 RDW-18.1*
[**2203-7-20**] 12:12PM NEUTS-90* BANDS-1 LYMPHS-6* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2203-7-20**] 12:12PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-NORMAL
[**2203-7-20**] 12:12PM PLT SMR-NORMAL PLT COUNT-165
Brief Hospital Course:
For his MRSA bacteremia:
a) MRSA bacteremia
He was admitted to [**Hospital Unit Name 153**] for observation of SIRS. He was started
empirically on azithro, ceftaz, vanco, flagyl. In the [**Hospital Unit Name 153**], his
blood cx from admission grew [**3-15**] MRSA, he was changed from vanco
to linezolid (for concern of VRE in urine in past) and the
flagyl was stopped. He had a TTE on [**7-21**] that did not show
obvious lesions. He was seen by surgery who felt that the port
should remain in and he should try a trial of therapy with abx.
He also had an abdominal US to evaluate his kidney transplant
which was within normal limits. He remained hypoxic (94-99% on
6L to face mask) but HD stable so was transferred to medicine
service on East [**Hospital 18**] campus. Patient was transferred to West
[**Hospital 18**] campus on [**2203-7-25**]. He had been afebrile for four days and
hemodynamically stable.
On [**7-27**] his POC was pulled for persistent bacteremia and a Rt.
sided PICC was placed. On [**7-28**] the pt. was intubated with
sedation (propofol) for a planned MRI to evaluate back pain and
bacteremia to see if he had an epidural abscess - he could not
fit into the scanner, however, and the study could not be
completed. He subsequently underwent TEE which was negative for
evidence of endocarditis. Given decreased renal function and
+eos, his vancomycin was changed to daptomycin on [**8-8**].
b) UTI
On [**8-9**], the patient was noted to have >100k ESBL pseudomonas,
and tobramycin/cefepime were started. His suprapubic cath was
changed by urology.
2) For his altered mental status, ?seizure:
The patient makes stereotypical flailing/flapping motion of his
upper extremities. The day of the TEE and attempted MRI, the
patient was becoming increasingly somnolent ([**7-28**]) (even prior
to propfol administration), and the morning of [**7-29**], MICU
evaluation was requested for agitation and altered mental
status. The patient was repeatedly cursing and saying "Mama" and
the primary team was unable to get a blood pressure, gas, labs.
He was transferred to the MICU and monitored overnight. His
narcotic medications were all held. The following day, he was
initially somnolent, not making his flapping movements. After a
small dose of dilauded, the patient spontaneously woke up. The
patient was later transferred to the floor and his methadone and
dilauded were continued.
Two days later, a trigger was called for somnolence with
difficulty arousing the patient. A dose of narcan was
administered and the patient regained conciousness. He
explained that he "didn't feel right" and was "burning up".
About two minutes later he became unresponsive and apneic. A
code was called and he was intubated with a fiberoptic scope.
Ativan x6mg was given as was a dilantin 1.5gm load.
Neurology was consulted and EEG was performed. EEG demonstrated
an irritable
focus in the right frontal region but it was not clear what ths
significance of this was. Dilantin was used and titrated up
with severeal extra loading doses for a corrected level [**11-30**].
Following extubation on [**8-6**], the patient had good mental
status. After chaning him from a fentanyl/versed drip, he was
transitioned to his regular narcotic regimen. On [**8-8**], his
mental status worsened. His narcotics were reduced to dilauded
1mg q3:prn and methadone 2.5 TID.
3) Renal failure: pt has history of renal transplant and is
maintained on azithioprine and prednisone. His Cr baseline in
0.3-0.5 and while on vancomycin his Cr rose to 1.7 with eos in
his urine. His vanco was d/c'd and changed to daptomycin. His
Ck's were monitored and were stable.
4) Pain: pt was on methadone and dilauded for his pain. This
required titration down for somnolence.
5) Access: pt had a PICC line placed after port-a-cath removal.
This was initially a double-lumen, and required changing by
interventional radiology on [**8-2**] and [**8-8**] (to a single-lumen)
because it was blocked.
6) Code Status: on [**2203-8-9**], the patient, in discussion with the
MICU team and his mother [**Name (NI) **], decided to be DNR. He does
want to be intubated if it is for a short time, and would not
want a tracheostomy.
ICU course: Mr. [**Known lastname 11679**] continued to have hypotension, resp
failure requiring intubation, worsening renal failure and
chronic infections including UTIs. Once Mr. [**Known lastname 11679**] was
intubated, his family was called as his wishes were to not be
intubated for a long period of time. Discussions were held with
the family, Dr. [**Last Name (STitle) **], and Dr. [**First Name (STitle) **], the hospitalist who knew
him well from CC7. The family decided to make Mr. [**Known lastname 11679**] [**Last Name (Titles) 3225**].
The pressors were stopped and he was extubated and passed away
within 10 minutes with his family surrounding him. Family choice
to have an autopsy.
Medications on Admission:
MOM prn
phenergan 25 mg IV q 6 prn
dulcolax 10 mg pr
prednisone 5 mg qd
paxil 20 mg po bid
vit b12 1000 mcg qd
protonix 40 mg qd
baclofen 20 mg tid
methadone 5 mg tid
lamictal 25 mg qd
imuran 75 po qd
lactulose 30 mg po tid
reglan 5 mg qhd po
benadryl prn
nictotine gum prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"707.03",
"995.92",
"348.31",
"276.4",
"785.52",
"V09.0",
"038.11",
"276.0",
"285.9",
"041.7",
"428.0",
"599.0",
"305.51",
"996.81",
"780.39",
"730.18",
"584.9",
"996.62",
"578.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"86.05",
"88.72",
"96.71",
"00.14",
"99.04",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8558, 8567
|
3280, 8204
|
389, 439
|
8619, 8629
|
2235, 3257
|
8686, 8697
|
1744, 1763
|
8529, 8535
|
8588, 8598
|
8230, 8506
|
8653, 8663
|
1778, 2216
|
285, 351
|
467, 1085
|
1107, 1728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,526
| 101,554
|
33687
|
Discharge summary
|
report
|
Admission Date: [**2120-3-18**] Discharge Date: [**2120-3-27**]
Date of Birth: [**2081-12-3**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p [**2081**]0-25 ft
Major Surgical or Invasive Procedure:
[**2120-3-19**]: Closed reduction Right shoulder
[**2120-3-20**]: ORIF pelvis, IVC filter placement
[**2120-3-22**]: ORIF R greater tuberosity fracture
History of Present Illness:
Mr. [**Name13 (STitle) **] is a 38-year-old male who fell approximately 25 feet
from scaffolding and sustained multiple injuries including
complex sacral ala and other pelvic injuries, and a severe
shoulder dislocation. He also sustained a retroperitoneal
hematoma after his pelvic fracture. He was transported to [**Hospital1 18**]
from [**Hospital 8641**] Hospital due to his multiple injuries.
Past Medical History:
Denies
Social History:
Lives in [**Hospital1 3494**] with friends, supportive family.
Family History:
Noncontributory
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extemities: RUE + pain with ROM. RLE + sensation/movement, +
pulses
Pertinent Results:
[**2120-3-25**] 05:49AM BLOOD WBC-14.2* RBC-3.39* Hgb-9.8* Hct-31.0*
MCV-91 MCH-29.0 MCHC-31.8 RDW-14.9 Plt Ct-552*
[**2120-3-23**] 05:20AM BLOOD WBC-11.8* RBC-3.22* Hgb-9.5* Hct-28.8*
MCV-89 MCH-29.5 MCHC-33.0 RDW-14.5 Plt Ct-434
[**2120-3-22**] 02:45PM BLOOD WBC-9.8 RBC-3.11* Hgb-9.0* Hct-27.0*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.2 Plt Ct-400
[**2120-3-22**] 04:30AM BLOOD WBC-8.6 RBC-2.81* Hgb-8.3* Hct-24.3*
MCV-86 MCH-29.7 MCHC-34.4 RDW-14.3 Plt Ct-330
[**2120-3-21**] 10:30AM BLOOD Hct-26.9*
[**2120-3-21**] 04:30AM BLOOD WBC-10.8 RBC-2.96* Hgb-8.9* Hct-25.6*
MCV-87 MCH-30.2 MCHC-34.9 RDW-14.0 Plt Ct-248
[**2120-3-20**] 09:30PM BLOOD Hct-28.6*
[**2120-3-20**] 12:51PM BLOOD WBC-10.0 RBC-3.55* Hgb-10.4* Hct-30.8*
MCV-87 MCH-29.1 MCHC-33.6 RDW-14.2 Plt Ct-228
[**2120-3-20**] 01:35AM BLOOD WBC-11.4* RBC-3.64*# Hgb-11.0*# Hct-31.2*
MCV-86 MCH-30.2 MCHC-35.2* RDW-13.9 Plt Ct-256
[**2120-3-18**] 06:35PM BLOOD WBC-18.3* RBC-4.93 Hgb-14.2 Hct-42.2
MCV-86 MCH-28.8 MCHC-33.6 RDW-13.9 Plt Ct-382
[**2120-3-23**] 05:20AM BLOOD PT-13.6* PTT-25.4 INR(PT)-1.2*
[**2120-3-25**] 05:49AM BLOOD Glucose-85 UreaN-24* Creat-0.9 Na-131*
K-4.7 Cl-97 HCO3-25 AnGap-14
[**2120-3-21**] 04:30AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.3
Brief Hospital Course:
Mr. [**Name13 (STitle) **] was admitted to the trauma service on [**2120-3-18**]. He was
found to have multiple orthopaedic injuries, R pelvic fractures,
R shoulder dislocation/fracture. He was also noted to have a
large presacral hematoma. His hematocrits were followed closely;
initial HCT was 42.2 and has slowly drifted downward secondary
to acute blood loss associated with his injuries and surgeries.
Hemodynamically he has remained stable, no orthostasis. He was
taken to the operating room for closed reduction of his
shoulder; attempts were unsuccessful. After attempted reduction
he was noted to have a radial nerve palsy. On [**3-19**] he was taken
back to the operating room for closed reduction right inferior
shoulder dislocation and placement of IVC filter secondary to
increased risk for pulmonary embolus given his fractures. He was
taken back to the operating room on [**2120-3-20**] for an ORIF of his
pelvis. On [**2120-3-22**] he again returned to the operating room for
an ORIF of his right greater tuberosity fracture. He tolerated
all procedures well. He was seen by physical therapy to improve
his strength and mobility. His foley was removed 3 times but he
was unable to void. On the third attempt urology was consulted.
The foley should be left in for one week, coming out on [**2120-4-2**].
If he is unable to void replace the foley and follow up with
urology. The rest of his hospital stay was uneventful with his
lab data and vital signs within normal limits, his radial nerve
palsy is improving, and his pain controlled. He is being
discharged today in stable condition.
Medications on Admission:
denies
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg syringe
Subcutaneous Q12H (every 12 hours) for 4 weeks.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
s/p [**2120**]0-25 feet
Right shoulder dislocation
Right sacral ala complete fracture
Comminuted right humeral head fracture with posterior
dislocation
Retroperitoneal hematoma with vena cava compression
Discharge Condition:
Good
Discharge Instructions:
Continue to be non-weight bearing on your right arm and
touchdown weight bearing on your right leg. You may bear full
weight on your left arm and leg
Continue you lovenox injections as instructed for a total of 4
weeks after surgery
You may resume all your home medications as prescribed by your
doctor
If you notice any increased redness, drainage, or swelling, or
if you have a temperature greater than 101.5 please call the
office or come to the emeregency department.
Physical Therapy:
Activity: As tolerated
Right lower extremity: Touchdown weight bearing
Left lower extremity: Full weight bearing
Right upper extremity: Non weight bearing
Left upper extremity: Full weight bearing
Right shoulder in sling at all times. NO SHOULDER MOTION
Treatment Frequency:
Staples/sutures out 14 days after surgery or at follow up
appointment
Dry sterile dressing daily or as needed for drainage or comfort
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 2 weeks. Call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up with urology if unable to void as per discharge
summary notes please. Number to urology clinic is [**Telephone/Fax (1) 772**]
Completed by:[**2120-3-27**]
|
[
"E884.9",
"868.04",
"E849.9",
"839.69",
"812.03",
"805.6",
"831.03",
"790.01",
"459.2",
"354.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.29",
"79.71",
"38.7",
"38.91",
"79.31",
"03.53"
] |
icd9pcs
|
[
[
[]
]
] |
4596, 4669
|
2549, 4166
|
341, 497
|
4916, 4923
|
1308, 2526
|
5884, 6177
|
1049, 1066
|
4223, 4573
|
4690, 4895
|
4192, 4200
|
4947, 5423
|
1081, 1289
|
5441, 5704
|
280, 303
|
525, 923
|
5725, 5861
|
945, 953
|
969, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,312
| 185,832
|
47307
|
Discharge summary
|
report
|
Admission Date: [**2196-11-30**] Discharge Date: [**2196-12-4**]
Date of Birth: [**2139-8-30**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Vancomycin / Haldol / Sulfa
(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Rectus Sheath Hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57 yo man on coumadin for chronic a-fib who reports approx 2
weeks of right sided abdominal pain. He describes the pain as
throbbing, exacerbated by movement and radiating to his groin
when he coughs. No alleviating factors. The pain started shortly
after he had an allergic reaction to PCN given for a dental
infection which caused severe hives about 2 weeks ago. He took
benadryl for this and was placed on a prednisone taper by his
PCP last [**Name9 (PRE) 2974**] (with plan to discontinue today). He reports no
further symptoms from his allergic reaction. He denies any
trauma prior to onset of pain. He also describes increasing
pressure in his RLQ of his abdomen. The pain continued and the
patient presented to the ED when he felt is was too painful to
stand. He also developed LH and feeling dizzy for 1-2 days with
associated nausea. He also complained of watery stool over the
same period since starting his antibiotics approximately 10 days
prior to admission. Today he reports feeling chilled, but
otherwise denies fevers.
.
Upon initial evaluation in ED VS 97.6, 64, 114/70, 18, 96/RA.
Initial evaluation revealed RUQ pain, which prompted a RUQ
ultrasound that was normal. He also had basic labs that revealed
a HCT 26.8 and an INR of 20.9. Given continued abdominal pain,
CT abdomen was pursued and revealed large rectus sheath
hematoma. Surgery was consulted and recommended watchful waiting
with IR if needed for an acute intervention. He was given
Vitamin K, FFP x 2u, 2L NS. Transfer was delayed with patient
developed Afib with RVR, HR to 140s. He did not take his Toprol
XL this AM do to feeling unwell. He was given additional fluid
bolus for this. Upon transfer VS 120, 105/42, 18 and 96 RA. He
has 2 x 18g IV and 1 x 20g IV.
Past Medical History:
Non-ischemic cardiomyopathy (presumable d/t ETOH) s/p VF arrest
in [**2178**] and MI x4
h/o EtOH abuse, quit [**2178**]
Hyperlipidemia
Atrial Fibrillation on coumadin (since [**2178**]), digoxin, BB
[**3-14**] DCCV s/p several CV in the past
Sleep Apnea (not on CPAP)
OCD
Obesity
Social History:
Denies EtOH (sober x 18 years) or tobacco. Former marijuana
user. No ivdu hx. Runs a copy center at [**University/College **] and works part
time as sports photographer. Lives alone, friends are primary
contacts. [**Name (NI) 4084**] married. No kids.
Family History:
Not aware of family hx because not in touch with family. No
heart disease or bleeding problems he is aware of. Father with
EtOH abuse and suicide. Mother with lung ca.
Physical Exam:
VS: 98.4 107 104/84 12/100/RA
Gen: NAD
HEENT: Symmetric, MM mildly dry, no JVD
CV: Irregularly irregular, tachycardic, no m/g/r
Lungs: CTA B/L without w/r/r
Abd: obese, generally soft but with firmness R of midline
inferiorly, tender to palpation in paramedian R abdomen, also
had R sided TTP with L sided palpation. No rebound. Minor
guarding with R sided palpation. No appreciable groin hernias.
Also with eccymoses, demarcated, on RL panus
Rectal (per ED evaluation): tone intact, guaiac negative, no
gross blood
Pertinent Results:
=========
Labs
=========
[**2196-12-3**] 06:45AM BLOOD WBC-16.3* RBC-3.01* Hgb-9.2* Hct-27.1*
MCV-90 MCH-30.6 MCHC-34.0 RDW-14.2 Plt Ct-254
[**2196-12-2**] 03:18PM BLOOD WBC-18.8* RBC-2.91*# Hgb-8.9*# Hct-26.2*
MCV-90 MCH-30.7 MCHC-34.1 RDW-14.3 Plt Ct-242
[**2196-12-2**] 04:48AM BLOOD Hct-29.8*
[**2196-12-1**] 07:55PM BLOOD Hct-25.4*
[**2196-12-1**] 12:52PM BLOOD Hct-25.1*
[**2196-12-1**] 03:41AM BLOOD Hct-22.0*
[**2196-11-30**] 08:11PM BLOOD WBC-25.9* RBC-2.29* Hgb-6.9* Hct-20.5*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.1 Plt Ct-319
[**2196-11-30**] 05:30PM BLOOD WBC-26.8* RBC-2.66* Hgb-8.3* Hct-23.6*
MCV-89 MCH-31.0 MCHC-34.9 RDW-14.1 Plt Ct-346
[**2196-11-30**] 11:55AM BLOOD WBC-24.3*# RBC-2.96*# Hgb-9.0*#
Hct-26.4*# MCV-89 MCH-30.5 MCHC-34.2 RDW-14.0 Plt Ct-324
[**2196-12-3**] 06:45AM BLOOD Plt Ct-254
[**2196-12-3**] 06:45AM BLOOD PT-14.4* PTT-24.6 INR(PT)-1.3*
[**2196-12-2**] 03:18PM BLOOD Plt Ct-242
[**2196-12-1**] 07:55PM BLOOD PT-14.3* PTT-22.7 INR(PT)-1.2*
[**2196-12-1**] 03:41AM BLOOD PT-16.0* PTT-23.9 INR(PT)-1.4*
[**2196-11-30**] 08:11PM BLOOD PT-20.9* PTT-29.5 INR(PT)-2.0*
[**2196-11-30**] 11:55AM BLOOD PT-145.2* PTT-71.2* INR(PT)-20.9*
[**2196-12-3**] 06:45AM BLOOD Glucose-90 UreaN-20 Creat-1.2 Na-142
K-4.0 Cl-106 HCO3-29 AnGap-11
[**2196-12-2**] 03:18PM BLOOD UreaN-21* Creat-1.2 Na-141 K-3.8 Cl-106
HCO3-27 AnGap-12
[**2196-12-2**] 02:30PM BLOOD Glucose-99 UreaN-22* Creat-1.2 Na-142
K-3.9 Cl-107 HCO3-27 AnGap-12
[**2196-12-1**] 03:41AM BLOOD Glucose-114* UreaN-29* Creat-1.5* Na-144
K-4.4 Cl-110* HCO3-28 AnGap-10
[**2196-11-30**] 11:55AM BLOOD Glucose-108* UreaN-37* Creat-1.5* Na-144
K-4.1 Cl-108 HCO3-27 AnGap-13
[**2196-12-1**] 03:41AM BLOOD CK-MB-3 cTropnT-<0.01
[**2196-11-30**] 08:11PM BLOOD CK-MB-2 cTropnT-<0.01
[**2196-11-30**] 11:55AM BLOOD cTropnT-<0.01
[**2196-11-30**] 08:11PM BLOOD Digoxin-0.4*
========
Radiology
========
RUQ u/s - 1. No evidence for cholecystitis or cholelithiasis.
2. Apparent ill-defined isoechoic mass in the left lobe of the
liver could be further evaluated by CT.
.
CT a/p-
1. Large right-sided rectal sheath hematoma with active contrast
extravasation. Hematoma extends inferiorly into the pelvis but
it is still
preperitoneal. There is no free pelvic fluid. There is extensive
anterior
abdominal wall fat stranding.
2. No other intra-abdominal or pelvic pathology.
.
CXR -
IMPRESSION:
1. Low lung volumes with stable scarring in the lung bases.
2. No acute cardiopulmonary process.
=========
Cardiology
=========
ECG [**11-30**] - Atrial fibrillation with a rapid ventricular
response. Right bundle-branch block. There are tiny R waves in
the inferior leads consistent with possible prior inferior
myocardial infarction. Compared to the previous tracing the rate
is faster and the axis is less leftward.
Brief Hospital Course:
# Rectus sheath hematoma: Likely spontaneous in setting of
supratherapeutic INR after antibiotics. Coumadin held and INR
trended down to 1.2 at the time of discharge. Used abdominal
binder for compression. Tranfused 4 units total [**11-30**] and [**12-1**].
Hct was stable for 72 hours prior to discharge.
# Atrial fibrillation: On Coumadin, digoxin and metoprolol XL at
home. [**Doctor Last Name **] is Cardiologist. Currently rate controlled HR
80s on Digoxin, HD stable. INR reversed. Restarted metoprolol
[**12-1**] overnight given hemodynamic stability. Coumadin as held
while patient was in house, and the decision to restarted
anticoagulation was deferred to the patient's outpatient
physicians.
# Cardiomyopathy [**3-12**] prior arrest: Last Ef=40%, no e/o volume
overload. BP stable but with potentially unstable blood volume.
No evidence of fluid overload on exam. Was not an active issue
during this hospital stay.
# Elevated Cr: Elevated to 1.5 on admission and trended down to
1.1 at d/c. Elevated from presumed baseline of 1. Fena 0.9
consistent with pre-renal azotemia. Given fluid, FFP, and now
PRBC. Lisinopril restarted prior to d/c when Cr normalized.
# OCD: Continued Trazodone 100mg QHS
# FEN: Mild hypovolemia, replete PRN, advancing diet to regular.
# Code Status: DNR/DNI
Medications on Admission:
Coumadin 5mg 4d/wk, 10mg 3d/wk
Trazodone 100mg QHS
Toprol XL 25mg daily
Lisinopril 20mg daily
Digoxin 0.25 mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Rectus sheath hematoma
Secondary:
Non-ischemic cardiomyopathy s/p VF arrest
Hyperlipidemia
Atrial Fibrillation on coumadin (since [**2178**])
Sleep Apnea
Discharge Condition:
stable, afebrile
Discharge Instructions:
You presented to the hospital with a bleed in your rectus muscle
in your abdomen. This was because your blood was overly thinned.
It was felt this occured because you took penicillin in addition
to coumadin. You required plasma to reverse your
anticoagulation, and blood to correct your anemia. Your blood
levels were stable for 48 hours prior to discharge. Your
coumadin was held and should only be restarted at the discretion
of Dr. [**Last Name (STitle) 665**] or Dr. [**Last Name (STitle) 2357**].
.
Please do not take coumadin. You may take the rest of your
medications as previously presrcibed. You should no longer take
penicillin because you have a severe allergy to this antibiotic.
.
Please seek immediate medical attention if you develop fevers,
chills, light headedness, palpitations, chest pain, shortness of
breath, bloody or dark stools, worsening abdominal pain or any
other change from your baseline health status.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 665**] on Monday to set up a follow up
appointment in the next 7 days ([**Telephone/Fax (1) 250**]). Please also
follow up with Dr. [**Last Name (STitle) 2357**] in the next 7 days ([**Telephone/Fax (1) 62**]).
Completed by:[**2196-12-4**]
|
[
"V11.3",
"412",
"327.23",
"272.4",
"E934.2",
"414.01",
"584.9",
"425.5",
"276.52",
"425.4",
"427.31",
"V58.61",
"728.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8390, 8396
|
6267, 7576
|
366, 372
|
8603, 8622
|
3462, 6244
|
9603, 9884
|
2741, 2910
|
7743, 8367
|
8417, 8582
|
7602, 7720
|
8646, 9580
|
2925, 3443
|
304, 328
|
400, 2150
|
2172, 2455
|
2471, 2725
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,526
| 138,645
|
2550
|
Discharge summary
|
report
|
Admission Date: [**2163-4-1**] Discharge Date: [**2163-4-13**]
Date of Birth: [**2082-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain, shortness of breath, diaphoresis in setting of
radiation treatment.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 80-year-old man with a history of DM II, HTN, AS
(valve area 1.1), medium-[**First Name3 (LF) 12425**] vasculitis and seronegative
arthritis (on prednisone and hydroxy-chloroquine),
3-[**First Name3 (LF) 12425**]-disease (LM 70%, Mid LAD 60%, Ramus mild disease, OM1
100%, Distal RCA 100%.) awaiting CABG, and atypical
fibroxanthoma of the nose requiring radiation who presents to ED
with chest pain, shortness of breath, and vomiting during
radiation treatment. Mr. [**Known lastname 12928**] was subsequently transferred
to the MICU with low BP, melena, Hct drop, ST depressions in
V3-V6, and elevated troponin. In ED, CXR showed new mild
pulmonary edema, moderate right pleural effusion, mild
cardiomegaly, L>R bibasilar atelectasis.
.
Cardiology consult in the ICU concluded that elevated troponins
were likely reflective of demand ischemia/NSTEMI rather than
plaque rupture. Cardiac symptoms occurred in setting of
pulmonary edema and anemia, putting added strain on an already
diseased heart. Mr. [**Known lastname 12928**] could not be started on a heparin
drip due to nasal bleeding and melena.
.
Patient was transfused 3 units of blood in the ICU and responded
appropriately (went from 23.9-->29). It was thought that anemia
was most likely the result of a slow nasal bleed rather than an
acute GI bleed. Although held initially in light of bleed and
low BP, patient was eventually continued on ASA, statin, plavix,
BB, and [**Last Name (un) **].
.
Upon transfer to the floor, patient was in good spirits. His
cardiac enzymes were trending down and EKG changes were
resolving. Vitals on transfer were: T: 98.7, HR: 64, BP:
126/55, 94% on RA.
.
ROS: Patient denied chest pain, shortness of breath, headache,
nausea, vomiting, diarrhea, fevers, chills or any other
concerning symptom.
Past Medical History:
# large atypical fibroxanthoma involving the nasal dorsum
# 3VD awaiting CABG: He was scheduled to undergo cardiac surgery
in the last week of [**2163-1-28**]. On [**2163-2-18**], he
developed profuse bleeding from the nasal mass,
#NSTEMI [**2162-8-28**]
#Moderate Aortic Stenosis,aortic valve area of 1.1cm2 in [**2162**]
#hypertension
#dyslipidemia
#type 2 diabetes
#vasculitis syndrome with requirement of amputation of toes
#seronegative nonerosive inflammatory arthritis
#anemia
# h/o gastric ulcer, history of gastritis, H. pylori positive,
gastric
polyps
# melanoma
Social History:
Mr. [**Known lastname 12928**] is originally from the [**Location (un) 3156**] but came to the US
17-years-ago. He is currently retired. He has been married for
55 years. No current ETOH use (though likes Vodka). No tobacco
use.
Family History:
Sister with MI in her 70s; Father with MI at age 76.
Physical Exam:
PHYSICAL EXAM:
VS: T: 97.1, BP: 145/67, HR: 77, RR: 20, SP02: 95% RA
GENERAL: Well appearing gentleman, NAD, lying in bed
HEENT: Nose covered in bandage
NECK: No LAD
CHEST: Decreased lung sounds at both bases, R>L
CARDIAC: RRR, 2/6 systolic ejection murmur
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: 1+ edema bilaterally
SKIN: Warm, dry, areas of ulceration on lower shins and feet
bilaterally
Pertinent Results:
LABS ON ADMISSION:
[**2163-4-1**] 03:50PM BLOOD WBC-16.5* RBC-2.85* Hgb-8.0* Hct-25.1*
MCV-88 MCH-28.2 MCHC-32.0 RDW-16.8* Plt Ct-210
[**2163-4-1**] 11:35AM BLOOD WBC-17.1* RBC-2.80* Hgb-7.7* Hct-23.9*
MCV-85 MCH-27.4 MCHC-32.1 RDW-16.7* Plt Ct-232
[**2163-4-1**] 11:35AM BLOOD Neuts-89.9* Lymphs-7.8* Monos-2.1 Eos-0.1
Baso-0.1
[**2163-4-1**] 03:50PM BLOOD Plt Ct-210
[**2163-4-1**] 11:35AM BLOOD Plt Ct-232
[**2163-4-1**] 11:35AM BLOOD PT-13.2 PTT-24.9 INR(PT)-1.1
[**2163-4-1**] 11:35AM BLOOD Glucose-127* UreaN-40* Creat-1.5* Na-139
K-5.5* Cl-105 HCO3-21* AnGap-19
[**2163-4-1**] 03:50PM BLOOD CK-MB-23* MB Indx-16.1* cTropnT-0.33*
[**2163-4-1**] 11:35AM BLOOD CK-MB-20* MB Indx-11.7*
[**2163-4-1**] 11:41AM BLOOD K-4.4
CARDIAC ENZYMES:
[**2163-4-1**] 11:35AM BLOOD CK-MB-20* MB Indx-11.7*
[**2163-4-1**] 11:35AM BLOOD cTropnT-0.33*
[**2163-4-1**] 03:50PM BLOOD CK-MB-23* MB Indx-16.1* cTropnT-0.33*
BLOOD COUNTS:
[**2163-4-1**] 11:35AM BLOOD WBC-17.1* RBC-2.80* Hgb-7.7* Hct-23.9*
MCV-85 MCH-27.4 MCHC-32.1 RDW-16.7* Plt Ct-232
[**2163-4-1**] 03:50PM BLOOD WBC-16.5* RBC-2.85* Hgb-8.0* Hct-25.1*
MCV-88 MCH-28.2 MCHC-32.0 RDW-16.8* Plt Ct-210
[**2163-4-1**]:
Interstitial pulmonary edema and small bilateral pleural
effusions. The study and the report were reviewed by the staff
radiologist.
CTA:
1. Diffuse atherosclerotic calcification of the abdominal aorta,
iliac
vessels, and throughout both lower extremities, as outlined
above.
2. No vascular wall thickening or perivascular edema to suggest
vasculitis. No central arterial thrombi.
3. Small bilateral pleural effusions.
4. Note is made of non-specific focal loss of the normal
fasciculation of the left sciatic nerve in the distal thigh.
Correlation with symptoms is
suggested.
.
CAROTID ULTRASOUND [**4-12**]:
Impression: Right ICA stenosis <40%.
Left ICA no stenosis.
.
ECHO [**4-13**]:
The left and right atria are moderately dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the basal half of the inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 45 %). Right ventricular chamber size and free wall
motion are normal. The ascending aorta and aortic arch are
mildly dilated. The aortic valve leaflets are moderately
thickened. There is moderate aortic valve stenosis (valve area
1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-29**]+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Moderate aortic valve stenosis. Moderate pulmonary artery
systolic hypertension. Mild-moderate mitral regurgitation.
Brief Hospital Course:
This is an 80-year-old gentleman with multiple medical problems
including 3-[**Name2 (NI) 12425**] CAD awaiting CABG, bleeding nasal tumor, and
DM II who was admitted to [**Hospital1 18**] for demand ischemia vs. NSTEMI
in the setting of low hematocrit and hypotension.
.
#CAD: Mr. [**Known lastname 12928**] has severe 3-[**Known lastname 12425**] disease and is awaiting
CABG (and AVR) however, surgery has been delayed in light of
bleeding nasal tumor. Patient will need to be on high doses of
heparin during bypass, thus it is imperative to wait until tumor
has shrunk and is less likely to bleed. Mr. [**Known lastname 12928**] was
admitted to the hospital after complaining of chest pain, SOB,
and diaphoresis during a radiation treatment. He was found to
have ST depressions in V3-V6, elevated troponins, drop in hct,
and low BP. It was felt that this was demand ischemia in
context of anemia (slowly bleeding nasal tumor). He was
admitted to the MICU and transfused 3 units of blood (hct bumped
appropriately). After transfer to the floor, Mr. [**Known lastname 12928**] was
continued on ASA 325mg, high dose statin, and valsartan. His
metoprolol was switched to carvedilol 25mg [**Hospital1 **] for better blood
pressure control. Plavix was stopped in light of bleeding and
in preparation for CABG. Patient remained chest pain free
throughout duration of admission. He will follow up with Dr.
[**Last Name (STitle) **] on [**4-28**] for CABG evaluation and will see Dr. [**Last Name (STitle) 171**] for
outpatient cardiology management.
.
NASAL CANCER: Mr. [**Known lastname 12928**] with atypical fibroxanthoma
diagnosed in 5/[**2162**]. Currently being treated by
radiation-oncology; treatment was extended through [**4-13**] as tumor
was slow to regress. ENT and wound care specialists directed
bandage changes. Patient with follow-up with ENT as an
outpatient.
.
SERONEGATIVE ARTHRITIS: Patient carries a diagnosis of
seronegative arthritis, managed by outpatient rheumatologist and
seen at [**Hospital1 18**] rheumatology in 7/[**2162**]. He remained on
hydroxychloroquine throughout admission.
.
MEDIUM [**Year (4 digits) **] VASCULITIS: Patient with painful leg ulcers,
diagnosed as medium [**Year (4 digits) 12425**] vasculitis. Mr. [**Known lastname 12929**]
prednisone was uptitrated to 60mgQD (from 20mgQD) upon
discharge. Dermatology and rheumatology were both consulted and
gave their recommendations. Patient will follow-up with both of
these specialties as anoutpatient. Pain was controlled with
tylenol and oxycodone.
.
ANEMIA: Most likely from slow but consistent nasal bleeding.
Mr. [**Known lastname 12928**] did not have any acute drops in hct during
admission. His hct was maintained at ~28 and received a total
of 5 units of PRBCs throughout hospital stay.
.
CHF: Patient appeared slightly volume overloaded on admission,
but after diuresis remained euvolemic. Patient was continued on
home lasix 40mg QD and received prn lasix with blood
transfusions. He was maintained on [**Last Name (un) **], BB, and statin. ECHO
showed EF of 45%. I's and O's were carefully monitored.
.
DELIRIUM: Patient had one episode of delirium during admission
at which time he reported "being in a furniture store" and
seeing "butterflies" in the halls. Mr. [**Known lastname 12928**] had been
wearing thick sunglasses (because of radiation conjunctivitis)
and after these were removed, he remained lucid. Efforts were
made to orient patient and unnecessary medications and lines
were removed. Geriatrics was consulted for further
recommendations.
.
HYPERTENSION: BP was not well controlled on admission but
improved with substitution of carvedilol for metoprolol and
administration of [**Last Name (un) **] at night. Patient may need uptitration of
BP meds in context of increase in prednisone.
.
DMII: Patient was maintained on insulin sliding scale and NPH
15AM/5PM. Outpatient doses may need to be adjusted in context
of increased prednisone.
.
GERD: Ranitidine was continued at 150mg [**Hospital1 **].
.
CONJUNCTIVITIS: Secondary to radiation. Patient was maintained
on erythromycin OPH.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 Tablet(s) by mouth once a day
CITALOPRAM - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
GLIPIZIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
HYDROXYCHLOROQUINE - (Prescribed by Other Provider) - 200 mg
Tablet - 1 Tablet(s) by mouth Twice daily
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Cartridge - Sliding Scale Pt was unsure regarding which
medication was used for sliding scale
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth once a day
NIFEDIPINE - (Prescribed by Other Provider) - 60 mg Tablet
Sustained Release - 1.5 Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq Tab
Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth once a day
PREDNISONE - 20mg daily (recently changed)
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 160 mg
Tablet - 1 Tablet(s) by mouth twice a day
ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet -
[**1-29**] Tablet(s) by mouth twice a day as needed for joint pain
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other
Provider) - 100 unit/mL Suspension - 10 Units In morning and at
bedtime
Discharge Medications:
1. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 1* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
8. Valsartan 160 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
10. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily).
Disp:*1 1* Refills:*2*
11. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical
DAILY (Daily) as needed for irritation.
Disp:*1 1* Refills:*0*
13. Oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: One (1)
15 units in AM, 5 units in PM Subcutaneous twice a day.
Disp:*1 1* Refills:*2*
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
16. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Insulin Lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: As per attached sliding scale.
Disp:*1 1* Refills:*2*
18. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
Disp:*30 1* Refills:*2*
19. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
Disp:*120 Tablet(s)* Refills:*2*
20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
21. Caltrate 600+D Plus Minerals 600-400 mg-unit Tablet Sig: Two
(2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
International Home Health Services
Discharge Diagnosis:
Primary:
1. Demand ischemia and Non ST-segment Elevation Myocardial
Infarction
2. Atypical fibroxanthoma of nose
.
Secondary:
1. Coronary artery disease
2. Hypertension
3. Hyperlipidemia
4. DM II
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname 12928**],
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having chest pain and
shortness of breath during your radiation treatment. You had
some disruption of blood flow to your heart, most likely because
you were anemic and your blood pressure was low. We transfused
blood and treated your pain. You will eventually need to go for
cardiac bypass surgery.
.
While you were here, we continued your radiation treatment for
your nasal tumor. Your last radiation treatment was on [**4-13**].
You should continue to follow-up with the radiation oncologists.
.
We also had the vascular surgeons, rheumatologists, and
dermatologist evaluate the ulcers on your legs. We continued
daily dressing changes; you should continue taking the
prednisone at your current dose.
.
Please bring all records from your outside rheumatologist to
your appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2163-4-27**].
.
The following changes were made to your medication:
--INCREASE your Aspirin to 325mg once a day
--START taking Carvedilol 25mg twice a day
--START Oxycodone 15 mg every 6 hours as needed for pain
--START Miconazole Powder 2% applied daily to groin area
--START Collagenase Ointment daily to leg ulcers
--START Gabapentin 300mg every 12 hours (for pain)
--START Tylenol 650mg every 6 hours
--START taking Ranitidine 150mg twice a day (for acid reflux)
--START taking NPH (insulin) 15 units in the morning and 5 units
at night
--START taking calcium and vitamin D
--INCREASE your prednisone dose to 60mg every day for your
vasculitis
--STOP taking Plavix
--STOP taking Citalopram
--STOP taking Metoprolol Tartrate
--STOP taking Nifedipine
.
Please keep all of your follow-up appointments. Take all of
your medication as prescribed.
.
Call you doctor or return to the hospital if you develop chest
pain, shortness of breath, severe headache, palpitations,
nausea, vomiting, diarrhea, blood in your urine or stools,
fevers, chills, sweats, or any other concerning signs or
symptoms.
Followup Instructions:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] MD [**2163-5-17**] 01:45p
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Hospital 191**] MEDICAL UNIT (SB)
.
Cardiac Surgery: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2163-4-28**] 3:30
.
Rheumatology: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2163-4-27**] 11:30
.
Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2163-4-25**] 12:20
.
DERMATOLOGY: [**Last Name (un) **],TEACHING, [**2163-4-25**] 10:15a
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Hospital **] CLINIC-CC2 (SB)
.
ENT: [**Name8 (MD) **], MD Date/Time:[**2163-4-20**] 11:30
|
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"707.12",
"414.01",
"401.9",
"578.1",
"429.3",
"584.9",
"714.0",
"518.0",
"280.0",
"428.0",
"514",
"410.71",
"707.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
14972, 15037
|
6554, 10698
|
393, 399
|
15282, 15282
|
3606, 3611
|
17554, 18460
|
3102, 3157
|
12583, 14949
|
15058, 15261
|
10724, 12560
|
15429, 17531
|
3187, 3587
|
4349, 6531
|
274, 355
|
427, 2240
|
3626, 4332
|
15297, 15405
|
2262, 2836
|
2852, 3086
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,176
| 164,610
|
47698
|
Discharge summary
|
report
|
Admission Date: [**2173-2-15**] Discharge Date: [**2173-3-13**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
OSH transfer SOB
Major Surgical or Invasive Procedure:
Intubation
Arterial line placement
History of Present Illness:
(Limited history from pt) 86 yr old male hx of CABG [**2155**], CHF,
hypercholesterolemia, ?atrial fibrillation on coumadin,
presenting from [**Hospital 46148**] hospital today. Pt reports over last two
months increasing dyspnea on exertion, general fatigue, sob with
exercise especially while walking up several stairs. Pt able to
walk several feet on flat ground without sx. No reported
orthopnea, weight gain, or worsening LE edema. pt on torzamide
with no change in dose reported. Last thursday pt cleaning
fireplace with vac when hose peice came off blowing [**Doctor Last Name **] into his
mouth, nose and over the entire room. Immediate sob, no
pleuritic chest pain, fevers, chills, nausea or vomiting. Now pt
able to walk only a few feet w/o shortness of breath. To
[**Hospital1 1562**]. No DC summary but apparently treated with abx(unknown)
for pneumonia and chemical pneumonitis and discharged. Continued
to feel unwell with worsening sob, returned to hospital. CT
chest performed with extensive bilateral alveolar infiltrates,
small bilateral pleural effusions. Of note IVC filter present.
No definite PE. Ceftriaxone, Azithromycin, 125 mg IV solumedrol,
40 IV lasix given and pt transferred to the [**Hospital1 **] given concern for
higher level of care.
.
ED COURSE: VS 100.5, 82, 123/57, 24, 94% 4L. Bibasilar crackles.
WBC to 13.5 unclear baseline. Cr 1.3. trop 0.03, CK 97, INR 1.6.
Cr 29.2 unknown baseline but 30 at OSH. CXR extensive, coarse
and nodular air space and interstitial process with Requip
given, ASA 325 mg given. Pt admitted for further work-up
Past Medical History:
CABG [**2155**] unknown territory
IVC filter placed (pt does not recall reason)
Atrial fibrillation on coumadin
Restless leg syndrome
CHF unknown EF
Arthritis
hypercholesterolemia
Social History:
Social History: Lives with wife. Previous opera and [**Location (un) **]
show singer. 30 pack yr smoking hx quit 25 years prior. No
alcohol or drug use
Family History:
nc
Physical Exam:
MICU admission PE:
T 97.6 BP 124/83 HR 101 RR 29 O2sat 92% on 100% NRB
Gen: NAD, speaking in full sentences with slight SOB
HEENT:NCAT, PERRL, EOMI, JVP 3 cm below jaw, cervical LAD and
tenderness
CV: irregular rhythm, no MRG, nl S1, S2
Resp: coarse BS throughout lung fields
Abd: benign
Rectal: Guaiac: deferred per patient overnight
Ext: No LE edema, venous stasis changes, 2+DP
Pertinent Results:
EKG: atrial fibrillation, no acute ischemic changes
Labs: see attached
.
.
CT Chest [**2173-2-16**]
PRELIMINARY REPORT: wet read: large multifocal areas of ground
glass opacities. dignostic considerations include nonspecific
interstitial fibrosis/NSIP, inflammatory process, or possibly
infectious, less likely edema. small pleural effusions.
.
CXR ([**2173-2-16**]):Extensive diffuse coarse and nodular airspace
consolidation in upper R and b/l lung bases ,along w/ diffuse
coarse prominence of interstitial markings c/w chronic pulmonary
disease. Overall, picture c/w pneumonia w/ underlying chronic
interstitial disease.
.
CXR ([**12-29**]) per cardiologist:Background interstitial markings w/
calcified granuloma and no evidence of CHF:
Echo: ([**2173-2-17**]):The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. There is mild regional left
ventricular systolic dysfunction with inferior hypokinesis and
inferolateral thinning/akinesis. The remaining segments contract
normally (LVEF = 40-45%). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with mild regional systolic
dysfunction, c/w CAD. Mild right ventricular systolic
dysfunction. Mild aortic regurgitation. Moderate tricuspid
regurgitation. Mild pulmonary hypertension.
.
Echo ([**4-28**]) per cardiologist: preserved LV fxn w/ post. wall
hypokinesis and no evidence of LV dilation
Nuclear Stress test ([**4-28**]) per cardiologist: fixed
inf./posterolateral wall defect. est EF=39% and mild LV dilation
w/ exercise
Brief Hospital Course:
A/P: 86 year old male w/ hx of CHF, s/p CABG, and 30 pk yr
smoking hx presenting with acute shortness of breath in the
setting of recent [**Doctor Last Name **] inhalation.
.
(1) Hypoxemic respiratory failure resulting in ARDS from
inhalation injury and exacerbated by pulmonary edema, ventilator
associated pneumonia (VAP) and yeast infection
The patient has had a prolonged ICU course secondary to his
tenuous respiratory status. Given his Pa/FiO2 ratio, bilaterall
infiltrates on imaging he was intubated per ARDS net protocol.
Early on in his course the patient was doing well and was
extubated. However he was re-intubated the same day due to
respiratory distress. During this time the patient became
anxious, SBP > 200 and RR >40s. Despite non-invasive
ventilation, lasix, morphine and nitrates, the patient continued
to do poorly and was re-intubated.
.
The patient course has since been complicated by VAP. Per VAP
protocol he was started on vanc/ cipro/ zosyn. The patient was
also on steroids initially for his inhalation injury, but this
was quickly tapered as it was felt there was no added benefit.
.
The patient was bronched on the [**2-22**]; [**2-26**]; [**3-4**]. Cultures from
the bronchs have grown yeast. On [**3-3**] and [**3-4**] the patient's
clinical course deteriorated. He became septic. ID was
consulted. They initially approved dose of fluconazole/ This
was later changed to caspofungin.
.
The patient later became dysynchronous with the vent. The
decision was made to paralyze him and to chnage his mode of
ventilation to PCV, which he has tolerated.
.
Given the patient's cardiac function, volume overload was also
felt to be a factor. He was intermittantly diuresed with IV
lasix and albumin/blood.
.
The patient respiratory status continued to worsen and he was
unable to be weaned from the vent. After multiple discussions
with the family the decision was made to make the aptient
comfortable and he expirted on [**2173-3-13**].
.
(2) Septic Shock
Etiology of the patient's sepsis was felt to be his lungs. He
was maintained on vanc. He was later started on meropenem,
flagyll for presumptive C.diff and levofloxacin. At one point
the patient was on 2 pressors. ID encouraged looking for other
sources of his infection. C. diff was ordered and was negative
X 5. KUB was ordered and was negative. (CT torso was not
ordered initially because of the patient's dysynchrony with the
vent and need for 2 pressors) Levo was d/cd. The patient was
started on gentamycin. The patient was also started on
caspofungin.
.
On [**3-7**] ID encouraged the discontination of vanc and meropenem.
The patient's clinical status had stabilized. CT torso was
performed. There was no abdominal pathology noted, but there
was persistence of the b/l pleural effusion. Vanc/Meropenem and
Flagyll have all been discontinued.
.
(3) CHF: Patient has an ischemic cardiomyopathy per ECHO with EF
39%. Diuresis was initially held given Cr bump from 1.2 to 1.8.
His respiratory status was quite tenuous and it was later felt
that volume overload was contributing to his inability to wean
from the vent and he was given prn lasix boluses +/- albumin.
.
(4) CAD: Continued aspirin and statin
.
(5)Afib/Aflutter: The patient is rate controlled with lopressor.
He was on propofol initially however due to the exacerbation of
the aflutter he was changed to fentanyl/versed.
Medications on Admission:
-lipitor 20 mg
-Zetia 10 mg
-Oxycontin 5mg q4d
-Torsemide 20 mg
-Requip 3 mg (several a day)
-Coumadin 8 mg T,[**Last Name (un) **], 6 mg other days
-Celebrex 200 mg
-Folic acid 400 mg
-Zetia 10 mg
-Bisoprolol 5 mg
-Celexa 20 mg
-ASA 81 mg
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"518.82",
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"117.9",
"038.9",
"995.92",
"515",
"427.32",
"285.9",
"286.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.15",
"38.93",
"96.71",
"96.04",
"96.6",
"99.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8441, 8450
|
4721, 8122
|
231, 267
|
8513, 8522
|
2683, 4698
|
8574, 8580
|
2263, 2267
|
8413, 8418
|
8471, 8492
|
8148, 8390
|
8546, 8551
|
2282, 2664
|
175, 193
|
295, 1875
|
1897, 2078
|
2110, 2247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,724
| 112,174
|
53341
|
Discharge summary
|
report
|
Admission Date: [**2144-5-25**] Discharge Date: [**2144-6-4**]
Date of Birth: [**2087-12-10**] Sex: M
Service: MEDICINE
Allergies:
Tramadol / Hydrocodone Bitartrate/Apap
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 109738**] is a 56-year old male w/ NSCLC, dementia, residual
brain damage from drug OD in [**2118**], known brain tumour from lung
CA mets and CVA who presents to the ED with altered mental
status and lethargy.
.
Per pt's wife, he had been more lethargic than usual, refusing
to get out of bed, and experiencing urinary incontinence. She
states he had been in his USOH (ambulating with a cane, A&Ox3,
conversant appropriately) until the day prior to admission when
he experienced extreme fatigue and slept all day until noon,
when he normally gets up around 7am. Per his wife, pt had been
feeling more weak and had been wetting himself while trying to
get up to go to the bathroom and urinating on himself in bed
several times, more of a function of weakness and inability to
reach the bathroom in time rather than incontinence.
.
He has residual left-sided weakness and numbness at baseline but
per wife's report this has been worse lately. Also per wife's
report pt had been eating extensively although he is not
supposed to given G-tube. He has only been receiving water
flushes.
.
Of note, he was hospitalized on [**4-28**] for changes in
mental status, and was treated empirically for meningitis with
vancomycin, ceftriaxone, ampicillin and acyclovir. He was
discharged on a 14 day course of vancomycin and cetriaxone. LP
was not done at the time and BCx showed NGTD. In the [**Name (NI) **], pt
refused LP.
He presented to [**Hospital 1474**] Hospital with altered mental status on
day of admission.
In the ED, initial vs were: 98.9 93 19 139/57 SaO2 98% on 4L.
Patient was treated w/ CTX, ampicillin, flagyl, azithromycin and
zosyn.
.
He was dx w/ NSCLC (large-cell) in [**7-/2143**] and underwent left
upper lobectomy followed by chemo XRT. (Previous notes and D/C
summaries document this as Right upper lobectomy; however,
[**Year (4 digits) **] data is consistent with Left upper lobectomy). His
post-operative courrse was c/b PAC infection requiring removal
and vocal cord paralysis. Mr. [**Known lastname 109739**] neurologic problems
began in [**2-/2144**] w/ L-sided weakness and difficulty with
cognition. MRI at the time showed a large right frontal lobe
mass. He is s/p right frontal craniotomy on [**2144-3-1**] and
pathology was c/w metastatic lung ca. He subsequently underwent
whole-brain XRT from [**Date range (1) 109740**].
ROS: unable to obtain as pt obtunded
Past Medical History:
1. Non small cell lung CA s/p radiation, chemo. left upper
lobectomy lung lobectomy.
2. Vocal cord paralysis after post lung surgery
3. DM2
4. Dementia for last 2 yrs
5. Residual brain damage from drug overdose [**2118**]
6. Possible NPH seen on MRI [**2133**]?
7. RUE DVT 4/[**2143**].
8. S/P R subclavian portcath placement [**2143-7-3**] c/b infection
removed 1 week later. Now Arteriovenous fistula between the
peripheral R subclavian artery and vein
9. cardiac catheterization [**3-/2142**] x2
[**44**]. psych hospitalization x2 for depression several yrs ago
11. MVA
12. hospitalization [**3-/2143**] for "diabetic seizure"
13. s/p head injury [**2118**]
PSurgHx:
1. s/p Right frontal craniotomy [**2144-3-1**]
2. s/p PEG [**2144-3-4**]
3. s/p LUL resection
4. s/p tonsilectomy [**2092**]
Social History:
Lives with his wife [**Name (NI) **], active [**Name (NI) 1818**] trying to quit (was 2
ppd X25 years 10 years ago); no alcohol consumption
Family History:
DM, Heart Disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 101.7, HR 97 BP 152/58 SaO2 97% on 2L NC HT 5'9 Wt 175 lbs
GEN: somnolent, lethargic difficult to arouse, falling asleep
HEENT: Sclera anicteric, MMM, oropharynx clear PERRLA
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2
LUNGS: anteriorly CTAB/L, posterior exam lim by body habitus
ABD: +BS soft, NT ND, PEG in place, not erythematous (Guiac
negative brown stool in ED)
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: somnolent, difficult to arouse, was able to state his
name and say he was in a hospital. opens eyes to voice and
touch. audibly snoring and falling asleep in conversation.
responding very slowly to questions w/ one-word answers.
Pertinent Results:
[**5-25**]- CT HEAD: post-operative change status post right frontal
lesion resection is stable. white matter hypodensity may in part
reflect post-treatment change and is also stable from prior
studies. no hemorrhage or mass effect. no acute process.
.
[**5-25**]- CT TORSO: s/p LUL resection. there is extensive new LLL
consolidation most c/w PNA. underlying mass not excluded. small
adjacent effusion unchnaged from prior study. no PTX.
abd/pelvis: no acute pathology, including no free fluid or free
air and no evidence of abscess. g-tube in good position.
left sided pneumonia, nodular opacities on R that could be
additional foci of infection, new from [**Month (only) 958**]. hard to say if
there is underlying mass lesion. Likely pulmonary mets. Also
colonic wall thickening that could be infectious.
.
EKG: NSR rate 93, w/ RAD. rSr' in V1. nonspecific septal ST-T
changes
.
DISCHARGE LABS:
WBC Hgb Hct MCV Plt Ct
[**2144-6-4**] 00:00 12.7* 12.0* 36.2* 93 376
[**2144-6-3**] 00:30 12.6* 12.7* 38.9* 93 441*
.
Gluc UreaN Creat Na K Cl HCO3 AnGap
[**2144-6-4**] 00:00 209*1 26* 0.7 138 4.6 102 27 14
[**2144-6-3**] 00:30 142*1 23* 0.7 141 4.4 104 28 13
.
Ca Phos Mg
[**2144-6-4**] 00:00 8.9 3.3 1.7
[**2144-6-3**] 00:30 9.2 3.3 1.8
Brief Hospital Course:
Mr. [**Known lastname 109738**] is a 56 year-old gentleman with non-small cell lung
cancer with known metastatic disease to the brain, s/p
R-craniotomy and whole brain radiation, history of dementia and
stroke, who presented with altered mental status and increased
lethargy.
.
ICU COURSE:
.
1. ALTERED MENTAL STATUS- The differential for Mr. [**Known lastname 109738**] was
broad given his immunocompromised state and obtunded
presentation. The patient and his wife made it clear that they
did not want a lumbar puncture performed and understood the
serious risks of turning down the LP including delay in
diagnosis or even death. Therefore, the initial differential
included bacterial meningitis and HSV encephalitis especially
given pt's lethargy and somnolence. He was initially covered
with vancomycin, cefepime (due to pseudomonal coverage and good
CSF penetration), ampicillin (for listeria coverage) and
acyclovir. Also in the differential was worsening of pts
malignancy w/ known brain mets, seizure, or other infectious
etiology such as PNA. Hyperglycemia could also cause this pt's
AMS as FSBS was > 300 on arrival. Toxic-metabolic cause cannot
be excluded given waxing and [**Doctor Last Name 688**] mental status. Also, he had
colonic wall (ascending colon and cecum) thickening on CT which
could represent infectious colitis but is a nonspecific finding;
pt's wife did not endorse specific GI complaints but stool
studies were sent. Pt's outpatient Neuro-oncologist Dr. [**Last Name (STitle) 724**] was
asked to comment on pt's status and he felt the picture was more
consistent with encephalitis and agreed with broad antibiotic
coverage, but decided to hold off on MRI until later, as pt just
had MRI at the end of his radiation treatment which did not show
new progression of disease. Dr [**Last Name (STitle) 724**] agreed with bedside EEG to
rule out seizure and this was performed on [**5-26**].
.
2. [**Name (NI) **] Pt had evidence of left lower lobe consolidation
on chest CT that was likely pneumonia. This underlying infection
was most likely the cause of his altered mental status.
Initially, broad antibiotic coverage for hospital acquired
organisms and aspiration was initiated with vancomycin, cefepime
(as above), flagyl for anaerobes and levofloxacin for atypical
coverage. Sputum cultures were also sent as well as urine
legionella, which later returned negative. The infectious
disease service was then consulted and agreed with vancomycin,
cefepime and flagyl but suggested discontinuing levofloxacin,
acyclovir and ampicillin which was done on [**5-26**]. Since patient
had been on long-term steroids, PCP prophylaxis with bactrim was
also initiated. Pt's WBC count improved as did his mental status
and by the 2nd ICU day he had become more alert and arousable.
He was transferred to the general medical service on [**5-27**].
.
3. [**Name (NI) **] pts FSBS > 300 on this admission. Home lantus was
initially continued at half pt's normal dose as he had been NPO,
but then was increased to his normal dose when tube feeds began.
He was also covered with humalog sliding scale, as outpatient
metformin was held.
.
4. LEUKOCYTOSIS- could be due to infection, inflammation,
seizure or steroid use. However, steroids are of chronic
duration and leukocytosis is relatively acute. Therefore,
infectious etiology is of concern. U/A appeared unremarkable.
White count was trending down upon transfer from the ICU.
.
OMED COURSE:
.
# Altered Mental Status: Pt was initially on abx for
meningitis, which were subsequently stopped. EEG was negative.
Blood and urine cx were negative. LLL consolidatio nwas seen on
CT chest and pt was treated for a pneumonia with
Vanc/Cefepime/Flagyl. Pt was continued on Bactrim for PCP [**Name Initial (PRE) **].
His mental status eventually came back to baseline. Pt was also
continued on home Levitiracetam and Dexamethasone taper (2mg
daily currently). Per Dr.[**Name (NI) 6767**] rec, start Dexamethasone 1 mg
daily on [**6-8**], then start 0.5mg daily on [**6-22**], then start 0.5mg
every other day on [**7-6**], and then stop dexamethasone on [**7-20**].
.
# Pneumonia: Pt was treated with Vanc/Cefepime/Flagyl. Pt was
continued on Bactrim for PCP [**Name9 (PRE) **] since he is on steroids.
.
# Leukocytosis: Pt remained afebrile. Pt was treated for
pneumonia as above. This is likely [**2-4**] steroids.
.
# NSCLC with brain mets s/p craniotomy: Treatment plan will be
per primary oncology team. Pt has a follow-up appointment next
week. Pt likely needs reimaging of lungs after resolution of
pneumonia to evaluate for underlying cancer.
.
# DMII: Pt's home Metformin was held during hospital stay but
restarted upon discharge. Pt's Lantus was titrated down to 26
units at lunch. Pt's sugars were in reasonably good range
(200s) and thus his insluin can be further titrated. Pt was
also on insulin sliding scale and fingersticks QID.
.
# C diff colitis: Pt was found to be c diff positive. Was
treated with Flagyl PO, which needs to be continued for 4 more
days to complete a 10 day course. Pt's diarrhea is much
improved at time of discharge.
.
# Tobacco abuse: Pt's on Nicotine patch daily.
.
# Anxiety/Insomnia: Pt was conitnued on home Clonazepam,
Zolpidem.
.
# Pt was on tubefeeds through PEG tube, which he tolerated well.
Pt did have occasions when he stated that he wanted to eat,
knowing that it will make him at increased risk for aspiration
and complications from it. However, after counseling him about
it, pt would decide again that he wants to stay NPO and on
tubefeeds to reduce risk of aspiration. IF pt and HCP do decide
to let him eat, he should be on ground solids and nectar thick
liquids. Pt has an outpt S&S eval on [**2144-6-25**] to reassess the
situation at that time. Pt was on SC Heparin for DVT ppx. Pt
also on PPI. Pt was full code.
Medications on Admission:
1. Amantadine 100mg [**Hospital1 **] (0700 and 1200).
2. Ambien CR 12.5g QHS.
3. Clonazepam 1mg PO q8h.
4. Dexamethasone 2mg daily (weaning, changed on [**2144-5-25**] from 2
mg [**Hospital1 **]).
5. Lantus 40u SC at noon.
6. Keppra 500mg PO BID.
7. Nystatin swish TID.
8. Omeprazole 20mg PO Daily.
9. Oxycodone 30mh PO q4h PRN pain.
10. Spiriva 18 mcg 1 puff daily.
11. Metformin HCl 500mg PO BID.
12. MVI 1 cap daily.
13. Lactulose 10 gm/15 mL - 30 mL [**Hospital1 **] prn constipation
Discharge Medications:
1. Levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Amantadine 50 mg/5 mL Syrup Sig: One (1) PO BID (2 times a
day).
6. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. Lantus 100 unit/mL Solution Sig: Twenty Six (26) units
Subcutaneous at lunch.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) 1439**]
Discharge Diagnosis:
penumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because you had confusion and fatigue. You
were initially started on antibiotics for meningitis, but that
was stopped once it became clear that you did not have that.
You did however have a pneumonia which was treated with
appropriate antibiotics. Your confusion resolved and you did
very well. You were still weak however so were discharged to a
rehab facility where you can regain your strength. We do not
expect you to be there greater than 30 days. Your wife, your
health care proxy, will be allowed to make decisions for you.
Please make the following changes to your medications:
START Nicotine 21 mg/24 hr Patch daily
START Sulfamethoxazole-Trimethoprim 800-160 mg every
Monday-Wednesday-Friday
START Metronidazole 500 mg every 8 hours for 4 more days
CHANGE Lantus to 26 units Subcutaneous at lunch.
Followup Instructions:
Please keep your appointment with your oncologist:
Provider [**Name9 (PRE) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2144-6-11**]
10:30
Provider [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2144-6-11**]
10:30
Please also keep your speech & swallow assessment appointment:
Provider [**Name9 (PRE) 326**] UPPER GI (WEST) [**Name9 (PRE) 706**] Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2144-6-25**] 9:45
Completed by:[**2144-6-4**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,805
| 185,552
|
52874
|
Discharge summary
|
report
|
Admission Date: [**2194-6-2**] Discharge Date: [**2194-6-19**]
Date of Birth: [**2130-9-29**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Codeine
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63F with h/o EtOH abuse with prior withdrawal symptoms and
pancreatitis (per report from the ED residents, patient reports
that she does not recall the having the diagnosis of
pancreatitis), presenting to the ED with abdominal pain for
approximately one day, reports some nausea and no emesis. She
was recently hospitalized per reports at [**Hospital1 2025**] for similar issues
but left AMA. At [**Hospital1 2025**], she was on the ventilator for about [**2-18**]
days for aspiration and also developed MSSA pneumonia treated
with nafcillin. She reported pain localized in the
mid-epigastric region and radiating to the back intermittently.
She also endorses recent falling down the stairs the day prior
to admission with ecchymosis of the right ankle. Her initial BP
in the ER fluctuated with a maximum of 203/130.
.
Date of last drink per ER note was 2 days prior to admission
([**2194-5-31**]) and amount is usually [**12-19**] bottle (unknown if liquor).
She was receiving valium 10 mg IV q 6 hr and ativan 10-12 mg per
CIWA scale. She was admitted to the SICU
She was admitted to the SICU given severe pancreatitis, need for
aggressive benzo and labetalol regimen. She was initially placed
on hydral but required clonidine patch. She was requiring large
amounts of lorazepam for high CIWA scores ([**8-2**]). Valium was
started at 5 mg q 6 hr and increased to 10 mg. Ativan was used
as needed. Dilaudid was used for pain control. She was continued
on high benzodiazepine and opioid requirement. Hemodynamically,
she had sinus tachycardia to 130s. It was also noted that her
Hgb was trending down slowly since admission (admission 14.8 -->
8.6). She was eventually started on dexametatomidine due to
agitation and hypertension.
Labs are significant for
WBC 24.3 --> 8.7
Hgb 14.8 --> 8.6
Plt 778 --> 212
coags had INR peak at 1.8 and down to 1.1
Cr 1.7 --> 0.4
LFTs
ALT 290 --> 1782 --> 787
AST 566 --> 2805 --> 218
LD 1564 --> 3720 --> 398
Lipase 3200 --> 87
On transfer, the patient went into respiratory distress
(wheezing, accessory muscle usage, stable pOx) requiring
intubation. Last ABG at [**2194-6-6**] 23:18 was pO2 127 pCO2 52 pH
7.35 HCO3 30. Secretions noted from ET tube and cultured. CXR
suggestive of ? pulmonary edema.
Past Medical History:
- anxiety
- alcohol abuse
- depression
- GERD
- hypertension
- ? hepatitis and fatty liver infiltration (per MRI report at
[**Hospital1 18**] [**Location (un) 620**])
- iron deficiency anemia
- Duodenal ulcer, gastritis, reflux esophagitis ([**2190**] dx via
EGD)
Social History:
Patient works as a psychologist for a private group at [**Location (un) 745**],
she is alcohol dependent, does not smoke, denies any other drugs
Family History:
NC
Physical Exam:
ON ADMISSION
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
FEX ON DISCHARGE
Tm 98.6 BP 127-150/77-120 HR 73-86 R 16-18 O2 Sat 97-100%RA
General: Alert, oriented to person place and time. No acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD not appreciated, no LAD
Lungs: Nonlabored without accessory muscle use, CTAB
CV: RRR, normal S1S2 no murmurs or S3 or S4 noted
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no HSM
Skin: No rashes or lesions noted
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2194-6-2**] 11:45PM LACTATE-1.7
[**2194-6-2**] 11:45PM freeCa-1.08*
[**2194-6-2**] 11:01PM GLUCOSE-121* UREA N-17 CREAT-0.7 SODIUM-141
POTASSIUM-3.2* CHLORIDE-113* TOTAL CO2-17* ANION GAP-14
[**2194-6-2**] 11:01PM ALT(SGPT)-833* AST(SGOT)-1694* LD(LDH)-2630*
ALK PHOS-124* AMYLASE-855* TOT BILI-0.5
[**2194-6-2**] 11:01PM LIPASE-2776*
[**2194-6-2**] 11:01PM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-3.3
MAGNESIUM-1.5*
[**2194-6-2**] 11:01PM TRIGLYCER-41
[**2194-6-2**] 11:01PM ETHANOL-NEG
[**2194-6-2**] 11:01PM WBC-19.8* RBC-3.96* HGB-12.1 HCT-36.9 MCV-93
MCH-30.5 MCHC-32.8 RDW-14.3
[**2194-6-2**] 11:01PM PT-19.1* PTT-31.4 INR(PT)-1.7*
[**2194-6-2**] 11:01PM FIBRINOGE-170
[**6-2**] CT ABD w/ Contrast:
IMPRESSION:
1. Acute pancreatitis with extensive peripancreatic stranding
and fluid, but no evidence of necrosis. Focal fluid collection
measuring up to 5.4 cm is identified superior to the pancreas.
2. Non-occlusive thrombus within the main portal and
portosplenic confluence. The splenic vein is completely
thrombosed.
3. Heterogeneous perfusion to the liver which may represent
perfusion
abnormality due to portal vein thrombus or focal fatty
infiltration.
[**6-7**] CXR:
Portable AP chest radiograph was compared to [**2194-6-3**].
The ET tube tip is relatively low, 2.5 cm above the carina. The
left
subclavian line tip is at the level of mid SVC.
There is interval development of moderate-to-severe pulmonary
edema associated by bilateral pleural effusions. There is also
left lower lobe opacity consistent with interval development of
atelectasis.
[**6-7**] ECHO:
The left atrium is dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. 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. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**6-7**] NonContrast Head CT:
There is no evidence of hemorrhage, mass, mass effect, or
infarction. No shift of the usually midline structures is
identified. Mild proportional enlargement of the ventricles and
sulci is consistent with age-related cortical atrophy.
Periventricular hypoattenuation is most likely secondary to
small vessel ischemic disease. There is no acute skull fracture
or scalp laceration. The visualized paranasal sinuses and left
mastoid air cells are well aerated. The right mastoid air cells
appear diminutive.
[**6-8**] CTA CHEST:
1. Multifocal acute PE involving distal right branch, right
upper/lower
lobes, and left lower lobe, with probable developing pulmonary
infarcts.
2. Bilateral lower lobe collapse and new moderate pleural
effusions.
3. Anasarca and mild abdominal ascites.
[**6-14**] CXR:
Interval removal of the left subclavian central line. A
nasogastric tube is seen coursing below the diaphragm with the
tip within the stomach.
Endotracheal tube is unchanged in position with its tip 3-4 cm
above the
carina. Right internal jugular central line has its tip in the
superior vena cava. Right lung appears clear. There is a
persistent left basilar opacity which most likely reflects
combination of compressive atelectasis and effusion, although an
infectious process cannot be excluded. No evidence of pulmonary
edema or pneumothorax. Overall, cardiac and mediastinal contours
appear stable. Aorta is somewhat unfolded and tortuous. Interval
resolution of interstitial edema.
[**6-15**]: EKG
Sinus rhythm. Non-specific T wave changes. Compared to the
previous tracing of [**2194-6-8**] the ventricular rate has increased.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 134 74 372/431 44 12 29
Brief Hospital Course:
63F long h/o EtOH abuse with severe pancreatitis and
non-occlusive PV thrombus and complete thrombosis of splenic
vein with hospital course complicated by PE and MSSA pneumonia.
ACTIVE PROBLEMS
1. Pancreatitis: Other than recurrent alcohol abuse, no other
known source for pancreatitis exacerbation. Patient was made NPO
and placed on IVF's. Pain was treated with fentanyl and
dilaudid. Lipase trended down from 3200 to 78 during ICU stay.
CT imaging suggestive of multiple fluid collections in pancreas
with no signs of necrosis. Surgery was consulted for the
prospect of draining the collections, but felt that in the
absence of fever, abdominal pain, drainage was not indicated
given the risks of intervening on an inflammed pancreas.
Patient was started early in ICU stay on tube feeds. She was
called down from the unit on [**6-16**] without abdominal pain or
nausea. Her diet was escalated without event, and patient was
discharged on a full diet with no pain medication requirement.
2. Respiratory failure and pneumonia
Patient developed respiratory distress secondary to flash edema
(10 L net positive) with possible component of aspiration given
her mental status. She was intubated in the ICU, diuresed, and
treated with a course of vancomycin and pipercillin/tazobactam
for possible pneumonia. A sputum culture grew MSSA for which
vancomycin was narrowed to nafcillin and finished a ten day
course, with all antibiotics stopped in [**6-16**]. It was difficult
to extubate her due to agitation as her benzodiazepines were
tapered, but she was successfully extubated on [**6-14**]. She was
transferred to the floor on [**6-16**] with no respiratory distress.
3. Pulmonary embolism
During her ICU course she became increasingly difficult to
ventilate and was noted on echocardiogram to have pulmonary
hypertension. Chest CTA on [**6-8**] showed multiple pulmonary
emboli for which she was started on a heparin gtt. She was
bridged to coumadin after transfer to the floor on [**6-16**]. On day
of discharge, her INR was therapeutic at 2.6 and heparin drip
was discontinued.
4. Splenic and portal venous thrombosis
CT of abdomen on admission showed non-occlusive thrombus within
the main portal and portosplenic confluence with complete
thrombosis of the splenic vein. Surgery was consulted and felt
that there was no indication for anticoagulation in the acute
phase. However, after patient developed PE, anticoagulation for
treating the pulmonary embolism will be therapeutic for these
thrombi.
5. Elevated transaminases
The patient had elevation of her AST and ALT to 2681 and 1782,
respectively. There was concern for alcoholic hepatits versus
shock liver versus toxins, likely acetaminophen. There were no
episodes of significant hypotension consistent with the former,
and her acetaminophen level was negative. No clear etiology was
determined, but the AST and ALT returned to [**Location 213**] by [**6-11**].
6. Altered mental status and agitation
Initially her agitation was attributed to alcohol withdrawal and
she was placed on a CIWA scale. Intracranial hemorrhage was
considered, but head CT was negative. Infection was considered,
and she did have a MSSA pneumonia but the peripancreatic fluid
collections did not appear to be infected on CT and surgery
concurred. Her agitation improved and was controlled with PRN
haloperidol, but she continued to be delirious on transfer out
of the ICU. She was seen by psychiatry who concluded that
although she expressed desire to leave the hospital, she lacked
capacity due to her delirium to leave against medical advice.
While on the floor, her mental status continued to improve while
taking haldol prn, especially at night. By discharge she was
alert and oriented x3. QTc was monitored during haldol
administration, last measure at 438ms on day of discharge.
7. Alcohol withdrawal
Patient was noted to be delirious with significant autonomic
symptoms early in ICU course. She was placed on a CIWA scale and
received significant doses of benzodiazepines for withdrawal
symptoms. Additionally, clonidine 0.1mg patch qweekly was placed
used for control of sympathetic symptoms.
.
8. Anemia
Her initial hemoglobin dropped from 14.8 to around 9 over the
first few days of her hospital course. There was no evidence of
hemorrhage, and this was thought to be due to hemodilution given
the extensive fluid resuscitation she required. On the floor,
her TIBC was noted be low at 169 with elevated ferritin of 788,
consistent with an anemia of chronic inflammation. On discharge
her hemoglobin was 8.1 and hematocrit was 25.7.
9. Hypertension
The patient initially had some problems with hypertension after
admission during withdrawal but these were controlled with a
clonidine patch.
CHRONIC ISSUES
1. Anxiety: Once on floor, patient related history of anxiety
and use of paxil. Paxil 10 mg was started without complication.
TRANSITIONAL ISSUES
-Will need QTc monitoring while taking haldol
-Please monitor blood pressure closely considering her use of
clonidine.
-Will need continued support regarding alcohol dependence.
-Will need coumadin therapy for at least three months, likely
six given burden of clot.
Medications on Admission:
- Lipitor
- Prilosec
- Paxil
- trazodone
Discharge Medications:
1. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever, pain.
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
9. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for Allergies.
10. haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for Agitation.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Pancreatitis
Pulmonary Embolism
Splenic vein thrombosis
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 109032**],
You were admitted to [**Hospital1 18**] because you were having abdominal
pain. We found that you were having severe pancreatitis, and you
were placed in the intensive care unit. While in the intensive
care unit, you had difficulty breathing and we had to use a
respirator to help you breathe. Additionally, we found that you
had pneumonia and blood clots in your lungs. We treated your
pancreatitis with pain medications and by giving you IV fluids.
We treated the pneumonia with antibiotics, and we started you on
blood thinning medication for the blood clots. You were
transferred to the floor when you started feeling better, and we
watched you for a few days until you were ready to go to
rehabilitation. Please note the following changes to your
medications:
START:
Clonidine patch 0.1mg patch every Friday
Coumadin 3mg daily
Folate 1mg daily
Fexofenadine 60mg twice daily for allergies
Multivitamin 1 tab daily
Protonix 40mg daily
Paxil 10mg daily
Thiamine 100mg daily
Trazadone 50mg at night as needed for sleep
Followup Instructions:
Please schedule a follow up appointment with your primary care
doctor within 1 week of leaving the rehabilitation facility:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] OF [**Location (un) **]
HEIGHTS
Address: [**Apartment Address(1) 31234**], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 31235**]
Fax: [**Telephone/Fax (1) 10274**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,653
| 105,880
|
3158
|
Discharge summary
|
report
|
Admission Date: [**2200-10-4**] Discharge Date: [**2200-10-17**]
Date of Birth: [**2149-11-20**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Zyprexa
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
Supraglottic hematoma
Major Surgical or Invasive Procedure:
Tracheostomy
History of Present Illness:
patient with a history of schizoaffective d/o, found down after
falling in bathroom and striking his neck on the bathtub
(secondary to EtOH intoxication). Presented to ER complaining of
hoarseness of voice and difficulty breathing since the incident.
Past Medical History:
HTN, seizure, gout, chronic back pain
Social History:
Positive for smoking, alcohol use.
Family History:
non-contributory
Physical Exam:
Gen: awake, alert, interactive. Hoarse voice quality
HEENT: OP clear, no external neck swelling, hematoma. no
stridor, no retractions. Neck tender but no crepitus over
cricoid or laryngeal cartilages.
FOE: Positive for ecchymosis of L supraglottic larynx. Airway
patent.
CV: RRR
Pulm: CTAB
Pertinent Results:
[**2200-10-4**] 11:00PM GLUCOSE-91 UREA N-17 CREAT-1.2 SODIUM-134
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-21* ANION GAP-18
[**2200-10-4**] 11:00PM WBC-7.6 RBC-4.62 HGB-14.3 HCT-41.8 MCV-91
MCH-31.1 MCHC-34.3 RDW-13.7
[**2200-10-4**] 11:00PM NEUTS-68.7 LYMPHS-26.4 MONOS-4.1 EOS-0.6
BASOS-0.2
[**2200-10-4**] 11:00PM PLT COUNT-352
[**10-7**]: PORTABLE UPRIGHT CHEST: No prior studies for comparison.
Endotracheal tube
tip is at the level of the superior margin of the clavicles, 6.5
cm above the
carina. Cuff balloon is not overinflated. NG tube is in place
with its tip
in the fundus of the stomach. There is a prominent left
retrocardiac opacity
and a equivocal right medial basilar opacity. No pneumothorax or
pleural
effusion. No congestive heart failure.
IMPRESSION:
1) ETT tip at the thoracic inlet and NG tube tip in the gastric
fundus.
2) Medial bibasilar opacities, which may relate to atelectasis,
aspiration,
and/or pneumonia.
Brief Hospital Course:
patient admitted on [**10-4**]. Transferred to ICU for monitoring of
respiratory status. Patient intubated for airway protection. On
[**10-8**] patient underwent tracheostomy under general antesthesia (#7
portex). Patient transferred from surgery to regular floor.
Patient's respiratory status was followed closely. Tracheostomy
was changed on POD 5. On [**10-15**] patient's trach was downsized to
#6 portex. Patient was d/c'd to acute rehabe on [**10-17**].
Medications on Admission:
zyprexa, trazodone, depakote, seroquel, clonazepam
Discharge Medications:
1. Benztropine 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Disp:*100 Tablet(s)* Refills:*0*
3. Perphenazine 8 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
5. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Laryngeal hematoma
Discharge Condition:
Stable
Discharge Instructions:
please call if you develop fever >101.5, bleeding, swelling,
shortness of breath, chest pain or if you have any other
concerns.
Followup Instructions:
Dr. [**Last Name (STitle) 3878**] [**Telephone/Fax (1) 7767**] in [**3-7**] weeks
Completed by:[**2200-10-17**]
|
[
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"274.9",
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icd9cm
|
[
[
[]
]
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[
"31.42",
"96.04",
"31.1"
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icd9pcs
|
[
[
[]
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3362, 3434
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2040, 2502
|
300, 315
|
3497, 3506
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1072, 2017
|
3682, 3796
|
725, 743
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2603, 3339
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2528, 2580
|
3530, 3659
|
758, 1053
|
238, 261
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343, 596
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618, 657
|
673, 709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,500
| 172,723
|
48174
|
Discharge summary
|
report
|
Admission Date: [**2138-4-29**] Discharge Date: [**2138-5-22**]
Date of Birth: [**2075-3-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
Epigastric pain which was determined to be pancreatitis
Major Surgical or Invasive Procedure:
CVL
Arterial line
endotracheal intubation
post-pyloric NG tube
Port-a-cath removal
PICC line placement
History of Present Illness:
63-year-old woman with history of EtOH abuse, hemochromatosis,
PUD, who was admitted on [**2138-4-29**] after a one period of
epigastric abdominal pain, nausea, vomiting, diarrhea found to
have clinical findings c/w acute pancreatitis.
.
At baseline the patient has nonbloody diarrhea and takes
antidiarrheal medications. One week ago she experienced
nonbilious, nonbloody vomiting once. She did not vomit again
until the night prior to admission when she experienced both RUQ
and LUQ abdominal pain, multiple nonbloody, watery bowel
movements, and nonbloody, bilious emeses. The nausea, vomiting,
abdominal pain lasted all night, prompting the patient to
present to the ED. She has never experienced this constellation
of symptoms before. She denies any fevers, chills, dyspnea,
chest pain.
.
On arrival to the ED, T 99, BP not auscultatable, HR 128, RR 26,
92% RA. Exam revealed orientation x 3, tachycardia, positive
femoral pulses, diffuse abdominal tenderness greatest in
epigastric area without any peritoneal sign, and negative
guaiac. Her initial labs were notable for lipase 1672, amylase
591, ALT 316, AST 115, AP 155, LDH 523, tbili 2.1, dbili 0.7.
WBC was 11, and Hct 51. A RUQ ultrasound revealed increase
echogenicity of the liver consistent with fatty infiltration,
but no cholecystitis, no gallstone.
She was diagnosed with likely alcoholic pancreatitis. A right IJ
sepsis central line was placed, and she received 4 L of NS in
the ED. BP rapidly improved to SBP 120s-130s. She was given
empiric levofloxacin and metronidazole and received keterolac
for pain control as she refused narcotics for fear of addiction.
Patient was then transferred to MICU for further management.
.
In the MICU she presented with a complicated course showing
acute pancreatitis with end organ damage likely secondary to
EtOH abuse. Her respiratory function decreased, her ABG showed
CO2 retention so that she was finally intubated on [**4-29**]. She
had to be continued on aggressive iv fluid therapy to stabilize
her blood pressure. She only had very low urine output at
10-20cc/h although her creatinine came back from 2.5 to her
baseline at 0.9. Despite continously improving laboratory
parameters continously her clinical presentation worsened over
time. Today she was supposed to get abdominal CT but just before
the transport she desaturated to 80% most likely caused by
volume overload. She responded to initial lasix 40mg iv but with
urine output of about 95cc over 4 hours. We were being consulted
for the further nutrition management of the patient.
Past Medical History:
* EtOH abuse: heavy drinking of [**1-21**] to whole bottle of wine per
day every day for 4-5 years; last drink reportedly on [**2138-4-24**].
* peptic ulcer disease: with frequent epigastric discomfort
after meals
* hemochromatosis: requiring therapeutic phlebotomy
* sleep apnea: per sleep study on [**2138-4-2**], patient should be
started on auto CPAP with a pressure ranging from 6-10 cm of
water; however she hasn't started using CPAP at home yet
* cognitive impairment
Social History:
Drinks 3/4 to 1 whole bottle of wine per day every day for [**2-22**]
years. No drug use. No tobacco. Retired. Lives with husband who
does not drink.
Family History:
noncontributory
Physical Exam:
On arrival to ICU
VS: T 99.1, BP 133/51, HR 113, RR 25, 100% 4L NC
GEN: Elderly woman lying in bed, anxious-looking, awake, alert,
conversant
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP dry
and without lesion
NECK: Supple, no JVD
CV: tachycardic, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, ND, diffusely tender (greatest at epigastric/RUQ), no
reboundtenderness, active bowel sounds, no HSM, no ecchymosis at
the flanks or periumbilical area
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
STUDIES:
* CXR [**2138-5-16**]: FRONTAL CHEST RADIOGRAPH: A left-sided internal
jugular central venous line has been removed. A right-sided PICC
line is seen with tip at the cavoatrial junction. There is an
increasing small right pleural effusion and atelectasis. There
is a stable small left-sided pleural effusion and left
retrocardiac opacity with air bronchograms representing
atelectasis or consolidation.
.
* RIGHT UPPER QUADRANT ULTRASOUND [**2138-5-10**]: A limited examination
was performed of the right upper quadrant, which showed a
distended gallbladder without evidence of wall thickening or
edema. No intra- or extra-hepatic biliary dilatation is
identified with the common bile duct measuring 4 mm. There is
likely a small amount of sludge within the gallbladder, without
evidence of echogenic or shadowing stones. There is a small
amount of ascites.
IMPRESSION: The gallbladder is not decompressed; however, there
is no
evidence of wall thickening or pericholecystic fluid to indicate
acute
cholecystitis.
.
TTE [**2138-5-19**]:The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are structurally normal.
No mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: No valvular pathology or pathologic flow identified.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
CT abdomen [**2138-5-2**]:
1. Extensive peripancreatic stranding and inflammatory change,
consistent
with acute pancreatitis. Without intravenous contrast, degree of
parenchymal enhancement cannot be assessed. However, no sign of
complication such as pseudocyst or abscess is noted.
2. Moderate bilateral pleural effusions, and associated
atelectasis.
3. Moderate ascites throughout the abdomen.
4. Dense material within the gallbladder. Given normal
appearance of the
gallbladder on ultrasound from three days prior, this is of
uncertain clinical significance. Could possibly represent
vicarious excretion of contrast, if this has been given. This
could simply represent concentrated bile.
5. Fatty liver.
Renal Ultrasound [**2138-5-7**]: 1. Patent renal veins.
2. Normal to minimally elevated resistive indices within both
kidneys as
above.
[**2138-4-29**] 07:03PM LACTATE-2.1*
[**2138-4-29**] 05:01PM LACTATE-2.7*
[**2138-4-29**] 04:45PM GLUCOSE-165* UREA N-31* CREAT-1.5* SODIUM-140
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-14* ANION GAP-18
[**2138-4-29**] 04:45PM WBC-7.5 RBC-4.00* HGB-14.2 HCT-42.5 MCV-106*
MCH-35.6* MCHC-33.5 RDW-14.6
[**2138-4-29**] 04:45PM NEUTS-88* BANDS-3 LYMPHS-8* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2138-4-29**] 03:26PM LACTATE-2.2*
[**2138-4-29**] 02:02PM LACTATE-2.5*
[**2138-4-29**] 02:02PM O2 SAT-79
[**2138-4-29**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2138-4-29**] 12:50PM ALT(SGPT)-316* AST(SGOT)-115* LD(LDH)-523*
CK(CPK)-72 ALK PHOS-155* AMYLASE-591* TOT BILI-2.1* DIR
BILI-0.7* INDIR BIL-1.4
[**2138-4-29**] 12:50PM LIPASE-1672*
[**2138-4-29**] 12:50PM cTropnT-<0.01
[**2138-4-29**] 12:50PM CK-MB-NotDone
[**2138-4-29**] 12:50PM ALBUMIN-3.6 CALCIUM-7.7* PHOSPHATE-8.1*#
MAGNESIUM-2.3
[**2138-4-29**] 12:50PM WBC-10.9# RBC-4.82# HGB-17.0*# HCT-50.9*#
MCV-106*# MCH-35.3* MCHC-33.4 RDW-14.5
[**2138-4-29**] 12:50PM NEUTS-86* BANDS-7* LYMPHS-4* MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2138-4-29**] 12:50PM PT-11.4 PTT-150* INR(PT)-0.9
Brief Hospital Course:
The patient is a 63yo female with history of EtOH abuse,PUD,
hemochromatosis, who was admitted [**2138-4-29**] after c/o abdominal
pain, nausea, vomiting and diarrhea x 1 day and diagnosed with
acute pancreatitis.
.
1. Pancreatitis: Thought to be due to pt's EToh abuse, no
gallstones noted on imaging, triglycerides were not elevated.
Pt's lipase on presentation was >1600, trended down normalizing
on [**2138-5-3**] after IVF hydration and bowel rest. She had a CVL
placed and had aggressive volume resuscitation the first day of
her hospital course that required ET intubation on day 2 of her
hospitalization. CT abdomen revealed no pseudocyst. Surgical
consultation felt that there was no indication for surgical
intervention. She was initially covered with broad spectrum
antibiotics including, Vancomycin, Meropenam, after cx returned
negative except for micrococcus and she had clinical
improvement. Meropenam was discontinued and she was maintained
on Vancomycin for a full course of 14 days. She was never
hypotensive after initial fluid resuscitation in ED and did not
require pressors during this hospitalization. Her pain
medications were steadily decreased and at discharge, she is on
a Fentanyl patch 25 mcg/hr Q 72 hrs, Oxycodone 5mg PO Q4H PRN
and Tylenol (liquid) 650 mg PO Q6H PRN with good pain control.
Her AST, ALT, total bilirubin, amylase and lipase are all normal
at discharge.
.
2. Respiratory Failure: in the setting of fluid overload. After
pt's pancreatitis clinically stabilized, she was able to be
diuresed. After several days of diuresis, her respiratory
status improved rapidly. She was extubated without complication
[**2138-5-15**]. She was stable for transfer to the regular medical
floor [**2138-5-16**]. At discharge, pt remains on 1L NC with O2
saturation 95%. She should be weaned from O2 as able during her
stay at rehab.
.
3. Acute renal failure: Thought to be due to contrast
nephropathy. Renal U/S revealed no hydronephrosis. Renal
consulted and felt was c/w ATN. Creatinine peaked at 3.5 on
[**5-7**] and trended down daily afterward. She was never oliguric.
Creatinine at d/c is 1.8 up from baseline 0.8 [**9-26**]. Pt is
having post-ATN diuresis.
.
4.Micrococcus bacteremia: 1 out of 2 bottles from ED on
admission. Port-a-cath removed by surgery [**2138-5-2**]. RIJ removed
[**5-6**], a-line resited [**5-7**]. Completed a 14 day course of
Vancomycin after all potentially infected lines had been
removed.
.
5. UTI- completed course of Ciprofloxacin.Urgency at d/c but no
dysuria.
.
6.Etoh abuse- She was initially on a CIWA without event. Social
work was consulted. Pt should be followed by social work at
rehab. Importance of abstaining from all alcohol has been
reinforced with pt during her hospital stay. Pt also maintained
here on seroquel, venlafaxine and PRN trazodone for h/o
depression.
.
7. h/o Hemochromatosis - stable
.
8. [**Name (NI) 1069**] Pt with diarrhea as she has tried to advance her
diet here. Pt has tested negative for C Diff toxin twice.
Diarrhea treated with immodium and thought to be due to pts
digestive system adapting after episode of pancreatitis.
.
9. [**Name (NI) 101554**] Pt kept on PPI in house
.
10. [**Name (NI) 101555**] Pt with murmur here in hospital recieved a negative
TTE. No further studies were needed.
Medications on Admission:
quetiapine 50 mg PO qhs
aspirin 325 mg PO qday
clonazepam 0.5 mg PO bid
omeprazole 20 mg PO qday
venlafaxine 75 mg PO qday
Discharge Medications:
1. Acetaminophen 500 mg Capsule Sig: [**11-20**] Capsules PO every [**2-23**]
hours as needed for pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
8. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Primary diagnosis:
Pancreatitis
Secondary diagnoses:
Acute Respiratory Distress Syndrome
Acute Renal Failure
Alcohol Abuse
Hemochromatosis
Diarrhea
Discharge Condition:
Fair, on 1 liter oxygen 95%
Discharge Instructions:
You were admitted to the hospital with a severe case of
pancreatitis. During your hospital course, you required
intubation and the help of a respirator to breathe. You are now
being discharged to [**Hospital 3058**] rehab so you can regain your
strength. You should avoid all alcohol to prevent any
recurrence of your pancreatitis.
Please return to the hospital with any fevers, chills, shortness
of breath, chest pain, leg pain and/or swelling, dizziness or
increased abdominal pain.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) 2472**]
Tues [**6-10**] at 10:45a
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
Completed by:[**2138-5-22**]
|
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"577.0",
"518.82",
"038.9",
"275.0",
"303.91",
"287.5",
"584.9",
"999.31",
"263.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.04",
"86.05",
"45.13",
"96.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12931, 12974
|
8516, 11824
|
380, 485
|
13167, 13197
|
4376, 8493
|
13734, 14078
|
3752, 3769
|
11997, 12908
|
12995, 12995
|
11850, 11974
|
13221, 13711
|
3784, 4357
|
13049, 13146
|
285, 342
|
513, 3070
|
13014, 13028
|
3092, 3568
|
3584, 3736
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,703
| 169,058
|
31389
|
Discharge summary
|
report
|
Admission Date: [**2117-7-17**] Discharge Date: [**2117-8-3**]
Date of Birth: [**2061-10-28**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
55M s/p 15' fall from tree onto truck, + LOC, Seen at St.
[**Doctor Last Name 6783**]. Transfused 2 units. Transferred to [**Hospital1 18**] by [**Location (un) **]
Major Surgical or Invasive Procedure:
[**Location (un) 282**] [**2117-7-28**]
[**Month/Day/Year 73952**] [**2117-7-27**]
History of Present Illness:
55 y.o. male who fell off a ladder approximately 15 feet on [**7-17**]
and experienced LOC. Evaluated at [**Hospital2 **] [**Hospital3 6783**] where he was
found to have multiple rib fractures, a right pneumothorax, and
a right retroperitoneal bleed. He was transfused 2 units of
PRBCs at [**Hospital2 **] [**Hospital3 6783**] and transferred to [**Hospital1 18**] by [**Location (un) **] for
further management.
Past Medical History:
HTN, seizure disorder, BPH
Social History:
Patient is married, presently smokes 2 ppd. Denies EtOH or drug
abuse.
Family History:
noncontributory
Physical Exam:
T: 98.3 HR: 82 BP: 96/58 RR: 16 97% RA
Gen: no apparent distress
HEENT: normocephalic, atraumatic, anicteric, neck supple, no
masses
Card: regular rate and rhythm, without murmurs, rubs, or gallops
Lungs: clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
Abd: soft, nontender, [**Last Name (LF) 19973**], [**First Name3 (LF) 282**] tube site clean, dry,
and intact
Ext: no clubbing, cyanosis, or edema
Neuro: CNII-XII grossly intact
Pertinent Results:
[**2117-7-17**]
CXR and pelvis XRay
1. Multiple right rib fractures, with associated subcutaneous
emphysema, and opacity along the right chest [**Known lastname **] which may
represent extrapleural fluid versus hematoma.
2. Asymmetrically increased right lung opacity likely
represents layering right pleural fluid, likely hemothorax given
associated trauma.
3. Suggestion of loss of height of the L4 vertebral body.
[**2117-7-17**]
CT C/A/P
1. small right-sided hydropneumothorax predominating at the
right base with high-density fluid likely representing a
component of hematoma
2. Right-sided subcutaneous emphysema associated with rib
fractures
3. large right retroperitoneal hematoma
4. fractures of the transverse processes of T1 and L5 through
L1
5. multiple rib fractures bilaterally including ribs 6 through 9
on
the left and ribs 2 through 12 on the right
6. left scapula is fractured in multiple sites
7. multilevel degenerative disc changes are seen throughout the
thoracic and lumbar spine with multiulever compression
deformities of unknown chronicity
8. subtle craniocaudad linear lucency of the L5 vertebral body
which likely represents an acute fracture.
[**2117-7-27**]
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION
Mr. [**Known lastname **] presented with a mild oral and moderate pharyngeal
dysphagia resulting in aspiration of liquids and solids and in
significant amounts of pharyngeal residue. The deficits seen
were somewhat concerning for a neurological condition, as they
are not completely consistent with deconditioning, although no
significant delay was seen in swallow initiation. The pt may
also have an impairment of the vocal cords, but this could not
be assessed today as the pt went into V tach and the study had
to be cut short.
The pt will need to remain strictly NPO, including medications
and will either need to have an NG or [**Known lastname 282**] placed. We will wait
until the pt is better able to manage his [**Known lastname **] before we
repeat his swallow evaluation. It is also recommended he been
seen by ENT and consider a repeat scan if there are any other
changes /signs to suggest a neurological event.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 1, not safe for any POs.
RECOMMENDATIONS:
1. Suggest the pt remain strictly NPO including all medications.
2. Place NG tube or [**Known lastname 282**] tube for alternate means of nutrition,
hydration and medication.
3. Recommend ENT consult to evaluate vocal cord closure.
4. Consider repeat head CT if there are any other changes /
signs
to suggest a neurological event.
5. Please reconsult when the pt's MS [**First Name (Titles) **] [**Last Name (Titles) **] have
cleared.
Brief Hospital Course:
After initial trauma evaluation the patient was admitted to the
trauma ICU.
Neuro: Neurosurgery was cosulted and recommended conservative
treatment, no neurosurgery needed, LSO as needed for comfort.
Follow-up in clinic in [**3-5**] weeks. Pt's pain was controlled on an
epidural. He was gradually transitioned to p.o. pain meds. He
was treated with methadone 3x daily and haldol prn.
CV: Pt was tachycardic in the ICU. His tachycardia was
controlled with beta blockers.
Resp: Initially intubated and admitted to ICU. He was gradually
weaned off the vent and extubated.
GI: ENT was consulted and recommended starting PPI at [**Hospital1 **] dosing
to minimize laryngopharyngeal reflux, safe diet recommendations
per speech and swallow, and
follow up to repeat [**Hospital1 **] in [**1-31**] weeks to evaluate for
resolution of mass, improvement of erythema.
GU: After adequate fluid resuscitation the patient was diuresed
with lasix. He had no significant GU issues during his hospital
course.
FEN: Pt was maintained on tube feeds. Formal swallow evaluation
demonstrated dysphagia and a recommendation to maintain the pt
NPO was made. In order to maintain the pt on longer-term tube
feeds the pt underwent a [**Date Range 282**] tube placement on [**2117-7-28**].
Endo: Pt's blood sugars were controlled on an insulin sliding
scale.
ID: Pt's sputum grew H. flu and S. pneumo sensitive to levo. Pt
was treated with an 8 day course of levofloxacin. Zosyn was
added to the regimen on HD14 (POD2 after [**Date Range 282**] tube placement),
and the pt received a total of 3 days of Zosyn before it was
d/c'ed.
Heme: Pt developed a stable anemia which was followed
clinically.
Medications on Admission:
flomax 0.4, dilantin 260mg qday, lyrica, Paxil 20, verapamil 240
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: One (1) PO BID (2
times a day).
2. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Date Range **]: Two (2)
Puff Inhalation Q4H (every 4 hours).
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Date Range **]: One (1)
Appl Ophthalmic PRN (as needed).
5. Gabapentin 300 mg Capsule [**Date Range **]: One (1) Capsule PO TID (3
times a day).
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Date Range **]: One (1)
Inhalation Q4H (every 4 hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Thiamine HCl 100 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 100 mcg Tablet [**Date Range **]: 0.5 Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet [**Date Range **]: One (1) Tablet PO TID
(3 times a day).
12. Phenytoin 100 mg/4 mL Suspension [**Date Range **]: Two (2) PO Q12H
(every 12 hours).
13. Nystatin 100,000 unit/mL Suspension [**Date Range **]: Five (5) ML PO QID
(4 times a day) as needed.
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
15. Trazodone 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed.
16. Methadone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
17. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: [**12-1**] PO Q4H (every 4
hours) as needed for pain.
18. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
1. Lung contusion
2. Small right pneumothorax
3. small right hemothorax
4. left comminuted scapula fx
5. Retroperitoneal hematoma right
6. T/L spine compression fx: T5,[**6-10**]; L 2,4,5
7. Transverse process fx R:T1, 8, 11; L1-5
Discharge Condition:
Stable
Discharge Instructions:
You were admitted from the hospital after you fell from a
ladder. You sustained fractures in your spine and your scapula.
You had bleeding in your abdomen. You were admitted to the ICU
and required a tube for breathing. You were seen by
neurosurgery who recommended conservative treatment and did not
recommend surgery. You were seen by Ear, Nose and Throat doctors
did [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and found a mass in your larynx which is
likely due to inflammation. A repeat [**Last Name (NamePattern4) **] has been
scheduled for [**8-30**] to evaluate for resolution of this
mass.
Because you were unable to tolerate food by mouth, a feeding
tube was placed and you were started on tube feeds for
nutrition.
Followup Instructions:
Please see your primary care doctor at your earliest
convenience.
You will need a follow-up [**Month (only) **] in [**1-31**] weeks. Monday
[**8-30**] at 2:30 (please arrive at 2:15) Dr. [**First Name (STitle) **], [**Location (un) **]. in [**Location (un) 55**] (eastbound side of route 9).
Please bring medical card to appointment Phone [**Telephone/Fax (1) 2349**]
|
[
"E884.9",
"285.9",
"482.2",
"805.2",
"958.7",
"807.08",
"805.4",
"860.4",
"481",
"868.04",
"861.21",
"305.1",
"811.00",
"345.90",
"401.9",
"600.00",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.72",
"96.04",
"43.11",
"33.24",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8067, 8119
|
4394, 6076
|
436, 522
|
8395, 8404
|
1622, 4371
|
9204, 9577
|
1118, 1135
|
6191, 8044
|
8140, 8374
|
6102, 6168
|
8428, 9181
|
1150, 1603
|
232, 398
|
550, 964
|
986, 1014
|
1030, 1102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,429
| 104,677
|
46999
|
Discharge summary
|
report
|
Admission Date: [**2150-6-26**] Discharge Date: [**2150-7-6**]
Date of Birth: [**2094-8-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
55 yo male with hx of hep C and EtOH abuse and active IVDU
presents to [**Hospital1 18**] ED with weakness, dizziness and maroon loose
stools.
Major Surgical or Invasive Procedure:
EGD with banding (5 bands) on [**2150-6-27**]
Upper GI endoscopy with banding of esophageal varices.
Nasogastric tube placement.
History of Present Illness:
55M with hx of hepatitis C and etoh abuse presents to [**Hospital1 18**] ED
with 2 days of weakness, dizziness, nausea and maroon loose
stools. Pt states he was in his usual state of health until two
days ago when he started feeling very dizzy, unable to walk. he
states he has fallen several times in the past few days. His po
intake has decreased [**1-22**] nausea although he states he has not
vomited. He did have emesis x 2 last week but he attributes it
to something he ate; it was nonbloody. Pt denies overuse of
NSAIDs, recent etoh use. This has never happened to him before.
.
In [**Name (NI) **], pt found to have SBP in the 90s with HR in the 100s. NG
lavage was positive for maroon blood that did not clear with
saline. He received 6L of NS and 2U PRBCs. He was given 10mg
of SQ Vitamin K. GI was consulted and he was started on
Protonix and Octreotide gtt.
Past Medical History:
- DM
- hepatitis C
- hx of right hand fx s/p surgery
- hx of hernia repair
Social History:
- uses heroin actively (last use, 2 days prior to admission)
- no etoh x 6 hrs, hx of heavy use x 2 years
- smokes a pipe
- works as a cook
Family History:
non-contributory
Physical Exam:
Exam: temp 95.6 (ax), BP 142/53, HR 100, R20, O2 100% on 2L
Gen: shivering, NAD
HEENT: MM dry, pale sclera
CV: tachy but regular, no murmurs
Chest: clear
Abd: +BS, soft, mildly distended, mildly tender in RUQ, liver
edge not palpable; spleen not palpable
Ext: warm, 2+ DP, no edema
Neuro: moving all extremities, AO x 3
Pertinent Results:
Labs on Admission: [**2150-6-26**] 02:30PM BLOOD WBC-16.6*# RBC-1.39*#
Hgb-3.5*# Hct-12.2*# MCV-87# MCH-24.8*# MCHC-28.4*# RDW-18.2*
Plt Ct-323# PT-19.8* PTT-25.4 INR(PT)-1.9* Glucose-415*
UreaN-40* Creat-1.4* Na-141 K-5.0 Cl-103 HCO3-7* AnGap-36*
ALT-22 AST-55* LD(LDH)-246 CK(CPK)-2467* AlkPhos-48 Amylase-40
TotBili-0.2 Calcium-8.3* Phos-6.0* Mg-2.8* ALT-71* AST-132*
LD(LDH)-266* CK(CPK)-1485* AlkPhos-65 TotBili-1.1
Day of Discharge: [**2150-6-28**] 08:52AM BLOOD WBC-11.4* RBC-4.09*#
Hgb-12.0*# Hct-34.1*# MCV-83 MCH-29.4 MCHC-35.2* RDW-15.4 Plt
Ct-81* Glucose-150* UreaN-34* Creat-1.0 Na-142 K-4.5 Cl-113*
HCO3-22 AnGap-12 Albumin-3.0* Calcium-8.0* Phos-2.7 Mg-2.5
ABG pO2-24* pCO2-30* pH-7.18* calTCO2-12* Base XS--17
EGD on [**2150-6-27**]:
4 cords of grade III varices were seen in the lower third of the
esophagus and middle third of esophagus. 5 bands were
successfully placed. Varices at the lower third of the esophagus
and middle third of the esophagus (ligation). Blood in fundus
and cardia.
Abdomen US [**2150-6-27**] :
1. Cirrhotic liver. Moderate amount of ascites. Gallbladder
edema with adjacent ascites. In the presence of diffuse ascites,
the significance of gallbladder edema is uncertain. Please
correlate clinically.
2. Small gallstones.
3. Two right renal cyst.
CXR [**2150-6-26**] : No evidence of pneumonia or CHF. Nasogastric tube
coiled in the distal esophagus.
KUB - [**2150-6-30**] : Ileus
Brief Hospital Course:
55 yo male with h/o Hep C, EtOH abuse, on methadone with active
IVDU who presented with UGIB and lactic acidosis.
.
1) UGIB:
EGD demonstrated 4 cords of grade III varices in lower [**12-23**] of
esophagus and a normal duodenum. 5 bands were successfully
placed. Patient then received a total of 4 units PRBCs and 1
FFP, and Hct remained stable at ~34. Patient was started on IV
protonix and octreotide gtt for 48 hours. Diet was advanced to
liquids and was transferred to the floor. While on the floor,
patient did not have any further episodes of bleeding and was
hemodynamically stable. Patient was scheduled for re-banding
procedure on [**2150-7-10**] with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 437**].
.
2) Cirrhosis and ascites:
Patient presented to the hospital with a history of EtOH abuse
and hepatitis C. Ultrasound showed evidence of cirrhosis. Labs
demonstrated undetectable HCV viral load, although patient was
HCV Antibody positive. To further evaluate etiology of
cirrhosis, patient was tested for qualitative HCV to determine
low levels of HCV, alpha 1 antitrypsin, and Hepatitis B PCR,
which were still pending as of discharge. During the admission,
patient had greatly increased ascites resulting in stomach
discomfort and nausea. For initial treatment of ascites, patient
was started on diuretic therapy on [**2150-6-29**] with spironolactone
and furosemide.
.
3) Klebsiella Bacteremia
During this admission, patient was found to have blood culture
positive for pansensitive Klebsiella and treated with
levofloxicin for 2 weeks. Patient has been afebrile for the
length of his stay and surveillance blood cultures have been
negative.
.
4) Ileus
Patient also developed an ileus on [**2150-6-30**] with greatly
distended bowel, abdominal discomfort, and shortness of breath
which resolved with enemas and NGT placement. Patient slowly
progressed from being NPO to a regular diet.
.
5) Shortness of Breath:
Patient developed acute shortness of breath during admission
secondary to bilateral PEs confirmed on CTA. Patient was
anticoagulated with IV heparin drip and then converted to
lovenox. Patient's SOB was further compounded with abdominal
distension secondary to ileus and fluid overload. Patient was
discharged with lovenox and will be converted to coumadin at
outpatient.
.
6)Lactic acidosis:
Patient's lactic acidosis was likely secondary to reduced
cardiac output in hypotension and quickly resolved after
transfer from MICU to floor.
.
7) Diabetes mellitus:
Patient presented with elevated sugars on admission which was
corrected and then remained under control with insulin sliding
scale.
.
8) Prophylaxis: PPI, pneumoboots
Medications on Admission:
methadone 30mg QD
glipizide
other DM medication (not further specified)
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*50 syringes* Refills:*2*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Upper gastrointestinal bleed
Klebsiella bacteremia
Bilateral Pulmonary Emboli
Liver cirrhosis
.
SECONDARY:
Diabetes
Discharge Condition:
Good, patient is ambulating, tolerating oral intake, and back to
his baseline condition.
Discharge Instructions:
Please take medications as prescribed. Please seek immediate
medical attention if you develop signs of blood in stools,
vomiting with blood, light-headedness, shortness of breath, or
chest pain.
.
You were started on lovenox for a pulmonary embolism.
.
You are being discharged without your glipizide. Please see your
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] within one week. Call him at [**Telephone/Fax (1) 2936**]. Please
continue to check your blood sugars at home and bring a log to
your primary care doctor.
Followup Instructions:
Call to schedule appointment with Dr. [**Last Name (STitle) 2903**] [**Telephone/Fax (1) 2936**] to be
seen within one week.
.
Please see Dr. [**Last Name (STitle) **] on Friday [**2150-7-10**] for a rebanding
appointment. Please call liver clinic at [**Telephone/Fax (1) 2422**] for
appointment time for rebanding.
.
Also, please call for follow-up liver clinic for within one
month of discharge. Liver center phone number is [**Telephone/Fax (1) 2422**].
-- Hepatitis C viral load (qualitative) is pending
-- alpha anti-trypsin Ab is pending
.
|
[
"305.50",
"041.3",
"305.03",
"789.5",
"415.19",
"276.2",
"285.1",
"456.20",
"070.54",
"571.2",
"584.9",
"560.1",
"250.00",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
7225, 7231
|
3595, 6270
|
456, 587
|
7401, 7492
|
2142, 2147
|
8080, 8630
|
1769, 1787
|
6392, 7202
|
7253, 7380
|
6296, 6369
|
7516, 8057
|
1802, 2123
|
274, 418
|
615, 1497
|
2161, 3572
|
1519, 1596
|
1612, 1753
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,291
| 117,277
|
42749
|
Discharge summary
|
report
|
Admission Date: [**2153-7-9**] Discharge Date: [**2153-7-23**]
Date of Birth: [**2100-9-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 8238**]
Chief Complaint:
Upper GI bleeding
Major Surgical or Invasive Procedure:
Upper endoscopy
Angiogram
History of Present Illness:
52 year old male with PMH stage IIb pancreatic adenocarcinoma
s/p whipple and ajuvent chemoradiation. He was believed to be in
remission until presenting in [**2-/2153**] with weightloss and
abdominal pain. Found to have cholelithiasis CA19-9 uptrending,
PED scan showed Focal FDG avidity in proximal pancreatic body
just distal to the anastomosis is concerning for recurrent
disease. He underwent EUS [**6-21**] which confirmed adenocarcinoma.
Post proceedure, he had bright red blood in the toilet bowel and
has noted intermittant blood intermixed with stool. He has had
episotic abdominial pain and nausea after eating and [**3-9**] weight
loss over 1 month. Seen in clinic on [**7-6**] where vitals were HCT
28.5 (down from 32.8 on [**6-28**], and 43.8 on [**5-23**]) where rectal
exam showed external hemorrhoids GUIAC positive. He was admitted
to OMED but left AMA because of frustrations with not being able
where he described melena and black, tarry stools. Repeat Hct
was 20, so he was referred to the ER. In the ER he was
hemodynamically stable. He describes fatigue that is new and
progressive, not associated with shortness of breath or chest
pain.
Past Medical History:
# Onc Dx: Stage IIB (T3N1MO) pancreatic adenocarcinoma
# Onc Tx: s/p Whipple [**2151**] followed by adjuvant chemoradiation
with
gemcitabine and radiation with concurrent 5FU which finished
[**2152-1-5**].
# Onc Hx: Mr. [**Known lastname **] was diagnosed with Stage II pancretic
cancer
in [**2151-4-5**] when he presented with a two week history of
abdominal pain and jaundice. FNA of a pancreatic head mass
showed
atypical cells suspicious for adenocarcinoma and he underwent a
Whipple at [**Hospital1 112**] on [**2151-4-19**]. Pathology revealed a 4.5cm
moderately to poorly differentaited adenocarcinoma of the
pancreatic head with extension directly into the peri-pancreatic
soft tissue and peripancreatic lymph nodes and wall of the
duodenum and duodenal mucosa. There was LVI and perineurla
invasion, although the margins were negative. Two out of 26
lymph
nodes were involved. Of note, chronic pancreatitis and PanIN 3
were present diffusely. He recieved adjuvant chemoradiation with
gemcitabine and radiation with concurrent 5FU which finished
Finished [**2152-2-1**].
# Pt lost to follow up from [**1-/2152**] to [**2-/2153**], represented wtih
abdominal pain, weight loss - CT imaging [**2153-2-19**] demonstrated a
new heterogenously enhancing 2.7x3.6cm lesion in the posterior
aspect of the right lobe of the liver abutting the liver
capsule. Also noted was a stable 1.3x0.7 mesenteric lymph node
adjacent to the SMA. Labs demonstrated glucose to 318 as well as
CA19-9 of 742. He was evaluated by Dr. [**First Name (STitle) **] who discussed
systemic chemotherapy options for a presumed metastatic
pancreatic cancer.
PAST MEDICAL HISTORY:
- Liver cysts
- Pancreatic insufficiency
- chronic pancreatitis on whipple specimen
- PanIN 3 diffusely on whipple specimen.
- tonsillectomy as a youth
- surgical repair for wrist/forearm injury
Social History:
Works full-time in IT Prior cabinet maker: + lacquer and enamel
exposure. + Asbestos exposure in [**2119**]. Remote tobacco history of
< 1 year. + etoh hx. + coffee. Two sons. Married.
Family History:
- no pancreatic cancer
Mother: diabetes
Father: HTN
[**Name (NI) **]: Stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98 Ht 73" Wt 173.1lbs, bp 116/60 HR 91 RR 18 SaO2
99RA
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP slightly
dry and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
Discharge Exam:
T 97.7, P 68, BP 108/70, R 18, O2 97RA
Gen- alert, well appearing
Psych- nl affect/mood, pleasant
Eyes- PERRL. Conjunctivae slightly pale.
Skin- cap refill < 2 seconds.
CV- rrr no m/g
Lung- ctab
Abd- soft, NT/ND, well healed surgical scars noted
Pertinent Results:
Admission Labs:
[**2153-7-9**] 06:37PM HGB-6.6* calcHCT-20
[**2153-7-9**] 06:20PM GLUCOSE-185* UREA N-20 CREAT-1.0 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16
[**2153-7-9**] 06:20PM ALT(SGPT)-20 AST(SGOT)-24 ALK PHOS-49 TOT
BILI-0.3
[**2153-7-9**] 06:20PM cTropnT-<0.01
[**2153-7-9**] 06:20PM ALBUMIN-4.1
[**2153-7-9**] 06:20PM WBC-4.4 RBC-2.42*# HGB-6.5*# HCT-20.6*#
MCV-85 MCH-27.0 MCHC-31.7 RDW-13.8
[**2153-7-9**] 06:20PM NEUTS-73.1* LYMPHS-18.8 MONOS-4.7 EOS-2.9
BASOS-0.5
[**2153-7-9**] 06:20PM PLT COUNT-139*
[**2153-7-9**] 06:20PM PT-11.8 PTT-27.9 INR(PT)-1.1
Studies:
EGD REPORT ([**2153-7-10**]): Normal mucosa in the esophagus. Erythema
and friability in the Gastro-jejunal anastomosis. Normal mucosa
in the duodenum. Normal Jejunal mucosa was noted. Otherwise
normal EGD to Jejunum.
CTA [**Last Name (un) **]/PELVIS ([**2153-7-11**]):
1. Marked, increased venous enhancement around the
gastrojejunal anastomosis along with increased venous varices
from the gastroepiploic collateral system because of new splenic
vein thrombosis is very suggestive that this is the site of GI
bleeding. No luminal extravasation however.
2. Increased size of the pancreatic body cancer. No metastasis
evident.
3. Newly thrombosed splenic vein from tumor encroachment.
4. Differential arterial hyperenhancement of the liver without
portal venous lesion that would explain it. No definite
metastasis.
.
TAGGED RBC SCAN ([**2153-7-12**]): Blood flow images show normal tracer
flow through the large vessels of the abdominal and pelvic
vasculature.
Dynamic images of the abdomen show no evidence of GI bleeding.
The lateral pelvis view shows no evidence of GI bleeding.
.
MESENTERIC ANGIOGRAM REPORT ([**2153-7-12**]):
1. DSA arteriograms of the celiac trunk, superior mesenteric
artery, and
inferior mesenteric artery with superselective in
characterizations of two
second order branches of the superior mesenteric artery revealed
no
perceptible arterial extravasation, arterial spasm or other
vascular
pathology.
2. Hemostasis at the right common femoral artery puncture by
deployment of 6 French Angio-Seal vascular closure device.
.
EGD REPORT ([**2153-7-12**]): Mild esophagitis was seen. Evidence of
known Whipple anatomy was encountered, and a large amount of
fresh blood was seen in the stomach and suctioned. Shortly
afterwards, the patient vomited a moderate amount of blood, and
the decision was made to convert electively to endotracheal
intubation/GA. Brisk bleeding was identified at the GJ
anastamosis. The specific cause of bleeding could not be
ascertained because of the volume of blood. It is not possible
to determine definitively if the bleeding is arterial or venous
in nature. The area was marked with 2 endoclips. The efferent
and afferent limbs of the GJ anastamosis were explored. There
was minimal blood in the afferent limb and a moderate amount of
blood in the efferent limb which appeared to be secondary to
bleeding from the GJ anastamosis. Otherwise normal EGD to
afferent and proximal efferent limbs of the jejunal anastamosis.
--Recommendations: IV PPI. Surgery and IR were made aware of
large volume blood loss and need for emergent intervention. The
patient will be emergently transported to IR for angiography.
Empiric embolization can be considered if no extravasation is
seen, however, there is CT evidence of possible venous source
related to splenic vein thrombosis/varices.
Unfortunately, there are no further endoscopic options that
would be helpful.
.
MESENTERIC ANGIOGRAM REPORT ([**2153-7-12**]): Diagnostic angiography of
SMA and celiac axis, which did not demonstrate any active
extravasation. Selective cannulation and diagnostic angiogram
of the jejunal branch, which courses towards the gastrojejunal
anastomosis and endoscopic clips also did not demonstrate any
active extravasation.
.
EGD REPORT (GLUE EMBOLIZATION, [**2153-7-16**]): At the G-J anastomosis
there appeared to be a possible visible vessel with an
underlying varix. The area started spurting blood during the
procedure. 5cc of epinephrine was injected with temporary
hemostasis. 2 cc of glue were then injected into the two sites
at the source of the bleeding with successful hemostasis. The
area was washed an no further bleeding was noted. Erythema,
congestion and mosaic appearance in the body compatible with
portal hypertensive gastropathy Otherwise normal EGD to Jejunum
Discharge Labs:
WBC 2.9, Hct 30.7, plt 96k
Hct [**7-22**] 31.0
Hct [**7-21**] 28.5
Brief Hospital Course:
52 yo M with pancreatic cancer s/p Whipple with recurrent
disease, diabetes mellitus on NPH insulin admitted with massive
gastrointestinal bleeding and acute blood loss anemia due to
bleeding from gastric varix.
#Gastrointestinal bleeding/Gastric varix/Acute blood loss
anemia/Hypotension:
The patient was admitted to the ICU and received 6 units of
packed red cells. Initial upper endoscopy did not reveal the
source of bleeding, but the scope could not be advanced passed
his surgical anastomosis. Patient continued to have melenic
stools and had repeat EGD showing bleeding from the GEJ,
engorged splenic vessels, and gastric varix most likely due to
splenic vein thrombosis s/p Whipple. This could not be clipped
successfully and bleeding continued necesitating addition 5
units of red cells, 6 pack of platelets and 2 units of FFP via
the massive transfusion protocol. Tagged RBC scan did not reveal
bleeding and IR angiogram did not show extravasation. Patient
finally underwent repeat EGD where cyanoacrylate glue was
injected on [**7-16**]. Patient received additional 3 units red cell
transfusion and hematocrit remained relatively stable following
the procedure without need for further transfusion.
On day of discharge and the day prior, patient is having some
ongoing maroon color to his stools. However, he remains
completely asymptomatic and hemodynamically stable, and
importantly his Hct has been stable ~30 for > 3 days.
He will have a repeat Hct checked by his oncologist within the
week.
If in the future he bleeds again, surgery would not be a good
option for further management, instead warrants IR embolization
via splenic artery embolization or splenic vein retrograde
embolization.
.
#Pancreatic cancer s/p Whippe with recurrent disease:
Patient was continued on Creon and will follow up with his
Oncologist in [**Location (un) **] for consideration of chemotherapy for his
recurrent disease. He was continued on prn oxycodone for
abdominal pain. Of note, only the patient's sister [**Doctor First Name **] is
aware of his diagnosis and recurrence of cancer; the patient
wishes that his family not be made aware of his diagnosis for
now.
.
#Type 2 diabetes mellitus: Patient was continued on home NPH
with sliding scale insulin
.
#Anxiety - Patient's chronic anxiety was stable, and he received
Ativan QHS and clonazepam when he was NPO.
.
#PPx - The patient received pneumoboots for prophylaxis.
.
# Code: Full (confirmed with patient )
# Disposition: Patient was discharged home with PCP, [**Name10 (NameIs) **], and
Oncology follow up.
TRANSITIONAL ISSUES:
-pt should have follow-up hematocrit drawn later this week by
oncology
-f/u appt made in [**Hospital **] clinic with Dr. [**First Name (STitle) 908**]
Medications on Admission:
clonazepam 2mg PO qHS
lipase-protease-amylase [Creon] 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) [**2-8**] Capsule(s) by mouth with
meals.
oxycodone 5 mg Capsule 1 Capsule(s) by mouth q4-6
pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth once a day
NPH 10 units SC qHS
Humolog sliding scale with meals
Discharge Medications:
1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: [**2-8**] Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain/ headache.
3. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Ten (10) units Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous with meals.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed from gastrojejunal anastamosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with massive GI bleeding. You were managed
initially in the ICU and received a significant number of blood
transfusions. You had an upper endoscopy which showed a bleeding
blood vessel near your recent surgery in your stomach. This was
injected with epinephrine (to shrink the vessel) and your
bleeding stopped. You were monitored for a number of days and
your blood counts were stable prior to your being discharged.
You are being discharged on an acid reducing medication called
omeprazole which you should take twice a day indefinitely.
Please call your doctor if you experience any darkening of your
stools or see frank blood in your stools or if you develop
increased shortness of breath, nausea, chest pains, increased
fatigue, or dizziness or lightheadedness or feel as if you are
going to pass out as these may be signs that your blood counts
are low.
You should call your outpatient Oncologist to schedule a follow
up appointment on Thursday or Friday of this week to make sure
that you continue to feel well and to recheck your blood counts
to ensure they are stable and to discuss further treatment of
your cancer.
You should also follow up with the gastroenterology clinic.
Followup Instructions:
We are working on a follow up appt with Dr. [**Last Name (STitle) 67137**] in the
16-30 days. You will be called at home with the appointment.
If you have not heard or have questions, please call
[**Telephone/Fax (1) 34405**].
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2153-8-15**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
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icd9cm
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icd9pcs
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26,693
| 195,029
|
10838
|
Discharge summary
|
report
|
Admission Date: [**2152-3-9**] Discharge Date: [**2152-3-14**]
Date of Birth: [**2086-6-4**] Sex: F
Service: CCU
CHIEF COMPLAINT: Shortness of breath and weakness.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
female with a history of esophageal cancer diagnosed in [**2151-5-21**], status post treatment with cisplatin,
5-fluorouracil, radiation therapy, as well as esophagectomy
in [**2151-10-21**] who presents markedly worsening shortness
of breath times two days.
The patient says that she has experienced shortness of breath
since her surgery; however, on a recent trip to [**State 8842**] she
noted dyspnea on exertion even with minimal activity as well
as generalized weakness.
The patient returned to [**State 350**] and her shortness of
breath markedly worsened along with an associated productive
cough. She visited her oncologist one day prior to admission
and was sent for an echocardiogram today with findings of a
large circumferential pericardial effusion.
The patient was noted to be tachycardic to approximately 140s
and in atrial fibrillation. In addition, there was right
ventricular compression consistent with impaired filling
tamponade physiology. The patient was taken for a right
heart catheterization with right atrial pressure of 12 mmHg,
a pericardial pressure of 14 mmHg, and a wedge of 19 mmHg. A
pericardiocentesis removed approximately 500 cc of bloody
fluid, and subsequently right atrial pressure to be 8 mmHg,
pericardial pressure of 3 mmHg, and a wedge of 7 mmHg.
Cardiac index increased from 1.7 prior to pericardiocentesis
to 2.6, and the patient's heart rate decreased from 140s down
to 110. In addition, the patient's shortness of breath
improved with tap, and she was sent to the Coronary Care Unit
for further monitoring with a pericardial drain in place.
PAST MEDICAL HISTORY:
1. History of esophageal cancer diagnosed in [**2151-5-21**];
treated with cisplatin, and 5-fluorouracil, and six weeks of
radiation therapy. The patient is status post 3-hole
esophagectomy in [**2151-10-21**].
2. Status post appendectomy.
3. History of gastroesophageal reflux disease.
4. Status post large left pleural effusion and thoracentesis
in [**2151-12-21**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Protonix 40 mg p.o. q.d. (which
was recently discontinued), Ativan 1 mg p.o. q.h.s.,
Reglan 10 mg p.o. five times per day, and Robitussin-AC.
SOCIAL HISTORY: Positive smoking history with 1.5 packs per
day times 10 days. Social alcohol use. The patient lives in
[**Location 620**] and is a housewife.
FAMILY HISTORY: Family history positive for coronary artery
disease in father. Positive for hypertension in paternal
grandmother and mother. She denies any history of cancer,
diabetes, or hypercholesterolemia. Primary care physician is
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Oncologist is Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**].
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with a temperature of 99.5, heart rate
of 105, blood pressure of 126/74, respiratory rate of 20, and
oxygen saturation of 98% on 2 liters. In general, the
patient was a middle-aged white female lying in bed, in no
apparent distress. Head, eyes, ears, nose, and throat
examination revealed normocephalic and atraumatic. Pupils
were equally round and reactive to light. Extraocular
muscles were intact. Sclerae were anicteric. Mucous
membranes were dry. Neck was soft and supple. Positive
jugular venous distention; however, the patient was supine.
Heart had a regular rate, tachycardic to the 100s, positive
first heart sound and second heart sound. No murmurs, rubs
or gallops. Lungs revealed coarse breath sounds bilaterally
and anteriorly. No wheezes or rhonchi. Subxiphoid drain in
place which was clean, dry, and intact. The abdomen was
soft, nontender, and nondistended. Decreased bowel sounds.
Right groin had no hematoma or bruit. Extremities revealed
no clubbing, cyanosis or edema, warm. Dorsalis pedis pulses
were 2+ bilaterally. Neurologically, awake, alert and
oriented times three. Motor and sensory were grossly intact.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
revealed a white blood cell count of 11.7 (with
90% neutrophils, 4% lymphocytes, and 5% monocytes),
hematocrit of 34.3, platelets of 366. Sodium of 137,
potassium of 4, chloride of 100, bicarbonate of 22, blood
urea nitrogen of 16, creatinine of 0.7, glucose of 141. PT
of 12.3, PTT of 32.1, INR of 1.1. Pericardial fluid revealed
a total protein of 5.3, a glucose of 102, an albumin of 2.9,
and LDH of 2143, and an amylase of 12. The remainder of the
pericardial fluid analysis including Gram stain,
differential, culture, fungal culture, and acid-fast bacillus
culture were pending.
RADIOLOGY/IMAGING: A CT of the chest showed a large
pericardial effusion significantly increased in size since
prior study, moderate bilateral pleural effusions (right
greater than left). A right-sided effusion which was
partially loculated. No interstitial lung disease, minimal
central lobar emphysema, status post esophagectomy with
likely radiation therapy changes.
Electrocardiogram #1 showed atrial fibrillation in the 140s
to 150s, normal axis. No ST changes. No Q waves. T wave
flattening in V4 through V6, and possible electrical
alternans.
Electrocardiogram #2 status post tap, showed ST changes in
the 100s. No ST changes. No Q waves. T waves upright in V5
and V6.
An echocardiogram showed an ejection fraction of 55%, right
ventricular and left ventricular chamber size and motion were
normal. Aortic regurgitation of 1+, 1+ mitral regurgitation,
2+ tricuspid regurgitation. Large circumferential
pericardial effusion with right ventricular compression;
consistent with impaired filling and tamponade physiology.
Right heart catheterization revealed hemodynamics consistent
with tamponade physiology (as described in the History of
Present Illness).
IMPRESSION: A 65-year-old female with a history of
esophageal cancer diagnosed in [**2151-5-21**], status post
treatment with cisplatin, 5-fluorouracil, radiation therapy,
and esophagectomy who presented with a 10-day history of
worsening shortness of breath and noted to have a large
circumferential pericardial effusion with tamponade
physiology on echocardiogram, prompting a pericardiocentesis
with indwelling catheter placement.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: (a) PERICARDIUM: Drainage from the
pericardial catheter was minimal on hospital day two.
However, a repeat echocardiogram showed a moderate sized
pericardial effusion primarily located anteriorly as well as
a trivial pericardial effusion posteriorly which appeared to
be loculated. At this time, there were no further
echocardiographic signs of tamponade.
Based on these findings, Cardiothoracic Surgery was
consulted, and the patient was taken to the operating room
for partial pericardectomy. The patient tolerated the
procedure well and a left chest tube was subsequently placed.
Drainage from the chest tube remained somewhat brisk
initially; however, on the day prior to discharge,
Cardiothoracic Surgery felt that the chest tube could be
removed at this point. Drainage prior to the removal of the
chest tube was notable for a serosanguineous fluid.
(b) ISCHEMIA: The patient with no known coronary artery
disease and was not found to have any ischemic-related events
while a patient at [**Hospital1 69**].
(c) RHYTHM: As above, the patient was admitted in sinus
tachycardia to the Coronary Care Unit; however, she was noted
to be in atrial fibrillation with rapid ventricular response
on hospital day two to the 140s, prompting the use of beta
blockers for rate control and subsequent trip to the
operating room to treat the underlying etiology of the atrial
fibrillation. Status post partial pericardectomy, the
patient converted spontaneously to sinus rhythm and remained
in sinus rhythm for the remainder of her hospital course.
The patient remained rate controlled with beta blockers for
the remainder of her hospital course and was discharged on
Lopressor at 50 mg p.o. b.i.d.
(d) PUMP: The patient with an ejection fraction of 55% and
noted elevated wedge pressure prior to pericardiocentesis.
Status post pericardiocentesis, wedge pressure returned to
within normal limits. The patient was noted to have slight
flash pulmonary edema when noted to have rapid atrial
fibrillation; however, her shortness of breath improved with
better rate control.
2. PULMONARY: The patient's upper respiratory infection
symptoms including a productive cough was thought to be
likely secondary to a viral infection. The patient remained
afebrile with a mild leukocytosis.
A chest x-ray obtained on [**2152-3-12**] showed a new left
lower lobe infiltrate which was thought to be more likely
atelectasis rather than a pneumonia. The decision to defer
antibiotics was made with close follow up as an outpatient.
The patient was treated symptomatically with Robitussin-AC.
3. ONCOLOGY: As above, the patient with a history of
esophageal cancer, treated with multiple modalities. The
pericardial effusion was concerning for a malignant etiology.
Cytology from the pericardial fluid was subsequently found to
be negative for malignant cells. The patient was to follow
up with her outpatient oncologist, Dr. [**Last Name (STitle) 3274**], for further
management.
4. GASTROINTESTINAL: As above, the patient is status post
esophagectomy with occasional nausea and vomiting treated
with Reglan as an outpatient for nausea as well as motility
purposes. The patient was maintained on her outpatient dose,
and gastrointestinal symptoms were moderately well controlled
along with the use of Protonix.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be discharged to home
with no home services.
DISCHARGE DIAGNOSES:
1. Pericardial tamponade; status post pericardiocentesis,
status post partial pericardectomy.
2. History of esophageal cancer.
3. New onset atrial fibrillation in the setting of
pericardial tamponade.
4. Upper respiratory infection.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Reglan 10 mg p.o. five times per day.
2. Lopressor 50 mg p.o. b.i.d.
DISCHARGE FOLLOWUP: Follow-up appointments included with
Cardiothoracic Surgery and Oncology on [**2152-3-16**].
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Name8 (MD) 2054**]
MEDQUIST36
D: [**2152-3-31**] 00:01
T: [**2152-4-1**] 08:31
JOB#: [**Job Number 35340**]
|
[
"397.0",
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icd9cm
|
[
[
[]
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[
[
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2623, 6525
|
10057, 10295
|
10322, 10430
|
2300, 2443
|
6553, 9901
|
9916, 10036
|
148, 183
|
10452, 10808
|
212, 1838
|
1860, 2273
|
2460, 2606
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,375
| 159,483
|
21464
|
Discharge summary
|
report
|
Admission Date: [**2139-7-6**] Discharge Date: [**2139-7-9**]
Date of Birth: [**2091-4-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2139-7-6**] Endoscopy with banding of esophageal varices
History of Present Illness:
48-year-old gentleman with hepatocellular versus intrahepatic
cholangiocarcinoma with massive disease progression on reduced
dose sorafenib therapy comes in with syncope and coffee ground
emesis. UGIB, NG lavage cleared after 1 liter. 20 point
hematocrit drop, hematocrit 16.7 from 35. WBC 22. Negative
cardiac enzymes. 2 units blood, 4 liters of fluid.
Vanco/levo/flagyl. Liver fellow was contact[**Name (NI) **] and they plan on
scoping him early this morning.
CT abd/pelvis prelim read shows advanced, infiltrative HCC with
unchanged occulssion right portal vein seen on [**6-8**] scan,
increase in ascites now moderate to large in volume. Diffuse
hyperenhancement of small bowel wall which may reflect ischemia
related to GIB, small perf cannot be excluded. Surgery did not
think this was in vascular distribution, attribute [**1-10**] low flow
state, do not think clot for them to retrieve or immediate
surgical issue at the current time.
ED vitals: 98.9, 100-110, 100-112/34-50, 97 ra
Exam: guaic +, NG lavage +
Access:16 and [**Street Address(2) 56659**]
Mr. [**Known lastname 16267**] first noted early satiety, bloating in 01/[**2137**]. His
liver function tests were abnormal. Right upper quadrant
ultrasound revealed a 7.3 x 6.4 x 9 cm mass in the right lobe of
the liver, extending in to the left lobe.
[**1-/2138**], a biopsy was performed, which revealed a neuroendocrine
carcinoma positive for CK7 and 20, chromogranins and
synaptophysin and S-100. In [**2-/2138**], a CT scan showed the mass
was enlarging and causing biliary obstruction. He had a
negative octreotide scan at that time. However, on [**2138-3-19**]
an AFP was over 3000. On [**2138-3-28**] he had an exploratory
laparotomy and nodule biopsy along with intraoperative
ultrasound which suggested that the carcinoma was unresectable.
Since that time he has had seven cycles of gemcitabine and
cisplatin as well as sorafenib who has continued to have disease
progression on those therapies.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
MVA in [**Country 3587**] with head trauma and diminished near vision
and occasional low back pain.
recent +PPD
Social History:
He is married, his wife and he lives in [**Location 686**]. He has
eleven children, many of whom remain in [**Country 3587**]. He smokes
one pack of cigarettes a day for twenty three years and quit one
month ago. He drinks alcohol socially. He
works in construction.
Family History:
His mother is alive at 72 without any medical
problems. His father has heart palpitations and is 87. He has
six brothers and four sisters, none of whom have any medical
problems.
Physical Exam:
Vitals: 99.0 124/90 81 16
GENERAL: Thin, NAD, appears chronically ill.
HEENT: NCAT. Anicteric sclerae. PERRL. EOMI. OP clear, dry MM.
NECK: supple, no cervical or periclavicular LAD
CARDIOVASCULAR: RRR, no M/R/G
RESPIRATORY: CTA bilaterally. no W/R/C
ABDOMEN: Soft, nontender, and moderately distended. Liver is
not palpable. Ascites present. Fluid wave is present.
EXTREMITIES: No edema.
NEUROLOGIC: A+Ox3. CN II-XII grossly normal. Steady gait.
Strength full in all major muscle groups.
Pertinent Results:
LABS
Admission [**2139-7-5**] Hct 16.7
Discharge [**2139-7-9**] Hct 31.0
.
ENZYMES & BILIRUBIN ALT AST LDH AlkPhos TBili
[**2139-7-9**] 05:05AM 122* 241* 205 203* 4.4*
[**2139-7-8**] 05:05AM 165* 330* 244 220* 3.5*
[**2139-7-7**] 05:22AM 197* 393* 261* 234* 3.3*
[**2139-7-6**] 07:01AM 133* 296* 264* 247* 2.4*
[**2139-7-5**] 10:00PM 138* 299* 288* 1.4
*SPECIMEN SLIGHTLY HEMOLYZED
.
[**2139-7-6**] 4:10 am BLOOD CULTURE # 2.
.
Blood Culture, Routine (Preliminary):
VIRIDANS STREPTOCOCCI. ISOLATED FROM ONE SET ONLY.
PRELIMINARY SENSITIVITY.
_____________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- S
VANCOMYCIN------------ S
.
IMAGING
CT abdomen/pelvis with contrast [**2139-7-6**]
Large amount of pelvic ascites is present. The rectum and
sigmoid colon appear grossly unremarkable. The bladder is also
unremarkable.
Bone windows demonstrate no suspicious lytic or blastic lesions.
IMPRESSION:
1. Advanced infiltrate of hepatocellular carcinoma with probable
occlusion of the right portal vein as described on previous CT.
New interval increase in large volume ascites likely indicates
disease progression.
2. Diffuse hyperenhancement of the small and large bowel likely
related to
occlusion of the portal system. Lack of progression of oral
contrast material beyond the stomach despite two-hour interval
of administration. There is no definite obstruction as there are
no dilated loops of small bowel or air-fluid levels. NG tube
terminates within the stomach.
3. No definite free intraperitoneal air.
.
CXR [**2139-7-5**]
FINDINGS: The heart is normal in size. The mediastinal and hilar
contours
are normal. There is no subdiaphragmatic free air. The lungs are
clear. The visualized osseous structures appear within normal
limits.
IMPRESSION: No radiographic evidence of free air.
.
KUB [**2139-7-6**]
No gross evidence of change. Contrast now in the colon thus no
obstruction. No supine evidence of free air.
.
EGD [**2139-7-6**]
Findings:
Esophagus: Protruding Lesions 4 cords of grade II varices were
seen in the lower third of the esophagus. The varices were not
bleeding. 4 bands were successfully placed.
Stomach: Mucosa: Diffuse continuous erythema, congestion and
mosaic appearance of the mucosa with no bleeding were noted in
the whole stomach. These findings are compatible with mild
portal hypertensive gastropathy. Small ammout of dark blood was
seen in the stomach.
Duodenum: Mucosa: Normal mucosa was noted.
*Impression*: Varices at the lower third of the esophagus
(ligation)
Erythema, congestion and mosaic appearance in the whole stomach
compatible with mild portal hypertensive gastropathy
-Normal mucosa in the duodenum
-Otherwise normal EGD to third part of the duodenum
.
------------------
CT Torso [**2139-6-8**]
CT Chest
Thyroid and thoracic inlet appear unremarkable. Paraseptal blebs
are present. No discrete metastases of note.
.
CT ABDOMEN AND PELVIS.
There is a massive confluent infiltrative hepatocellular
carcinoma . This has substantially increased in size, and now
involves the entire liver. Ascites is now present. This is a new
finding. Focal areas of Ethiodol uptake are identified within
the more central necrotic parts of this tumor. Aneurysmal
dilatation of the left portal vein. Hepatic right portal vein
appears occluded. The hepatic veins appear patent, although
parts of the middle hepatic vein are grossly attenuated.
Enlargement and recruitment of the hepatic artery is seen. There
is infiltration into the anterior omentum, which may represent
tumor spread. No definite metastatic disease is seen.
.
CT PELVIS
Ascites as before. Prostate is normal. Bladder appears normal.
Large and small bowel appear grossly unremarkable.
.
CT BONES AND SOFT TISSUES:
No suspicious lytic or sclerotic lesion.
There are degenerative changes, possibly represent old trauma,
along the right inferior pubic ramus.
CONCLUSION:
Massive disease progression with right portal vein and possibly
middle hepatic veins are occluded. No definitive extra-hepatic
spread.
.
Brief Hospital Course:
# UGIB
Given his history of right portal vein thrombosis there is
concern he may have back up of blood flow to the esophageal and
gastric veins which may have ruptured and led to his UGIB.
- Pt transfused 6 units of pRBCs (Hct on presentation 16.7). He
was also placed on octreotide gtt and PPI [**Hospital1 **]. GI performed EGD
with banding of 4 cords of non-bleeding, grade II varices that
were seen in the lower third of the esophagus. Carafate was
begun with a plan for 5-day course. Repeat EGD in 2 weeks was
recommended by GI.
- After EGD pt was transferred from the ICU to the floor where
his Hct was followed closely. Pt maintained stable Hct
post-transfusion throughout hospitalization (Hct 31.0).
- Pt was started on cipro ppx given UGIB and ascites.
- AST/ALT slightly elevated above baseline, however his alk phos
is lower and t/bili only slightly elevated when compared to b/l.
Given these findings it is less likely he has developed a
recurrent common hepatic duct stricture (s/p removal pigtail
stent on [**9-15**]).
.
# GPC in ED blood culture, 1/4 bottles
- possibly contaminant, however, pt was started on vancomycin
while speciation and sensitivities were pending. Final culture
revealed S. viridans. Cultures were obtained prior to EGD and
pt has no lines of concern for infection. Pt underwent Echo
which showed no vegetations or signs of SBE. Because all follow
up cultures were negative and pt was afebrile and asymptomatic
during his hospitalization the vancomycin was discontinued and
he was startd on a two week course of clindamycin.
.
# Anion gap metabolic acidosis
Secondary to elevated lactate in setting UGIB with
hypoperfussion. Resolved with blood products and IVF.
.
# Hypercalcemia
- On transfer to the floor pt was found to have elevated serum
calcium (Ca 11.8, Alb 3.0). Pt was started on continuous IVF
and lasix. Pt responded well and had calcium of 9.1 on
discharge.
.
# Liver cancer
- Patient off treatment since early [**Month (only) 205**]. Pt was not restarted
on any chemotherapy during hospitalization. [**Month (only) 116**] benefit from
palliative care.
Medications on Admission:
MEGESTROL [MEGACE ORAL] - 400 mg/10 mL Suspension - 10 ml daily
ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 1 Tablet, Rapid
Dissolve(s) by mouth every twelve (12) hours as needed for
nausea
OXYCODONE - 5 mg Tablet - [**12-10**] Tablet(s) by mouth q3h as needed
PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - 1
Tablet(s) by mouth q4-6h as needed for nausea
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet daily
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*1 bottle* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for nausea.
8. Megace Oral 400 mg/10 mL Suspension Sig: Ten (10) cc PO once
a day.
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every twelve (12) hours as needed for nausea.
10. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours) for 14 days.
Disp:*126 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatocellular vs intrahepatic cholangiocarcinoma with portal
vein occlusion
UGIB secondary to portal HTN
Anemia secondary to blood loss
Hypercalcemia
Discharge Condition:
stable; Hct stable > 48 hrs; no active bleeding; does not
require supplemental oxygen; ambulating without assistance;
tolerating po diet and meds
Discharge Instructions:
You were admitted to the ICU after you experienced upper GI
bleeding requiring multiple units of blood. During the
admission, an endoscopy was performed in which you had multiple
blood vessels banded in your esophagus to try to stop the
bleeding. You tolerated the procedure well and were transferred
out of the ICU. We continued to watch your blood counts and
monitor you for signs of repeat bleeding. During your
hospitalization you were found to have high calcium levels in
your blood. To lower the calcium we gave you IV fluids and IV
medications. When your calcium decreased to normal range and
your blood counts were stable you were cleared for discharge.
.
We were also concerned about a possible infection in your blood,
and so we did an ultrasound of your heart to make sure there was
no infection there. The study showed no signs of any infection.
However, we are sending you home with a 2 week course of an
antibiotic called clindamycin.
.
There are several other new medicines you should take: the first
is called Protonix (pantoprazole). You should take this pill
twice per day, to prevent more bleeding. The next is called
ciprofloxacin, another antibiotic. You only need to take this
pill for 2 days. Another is called sucralfate, which you should
take for 1 more day. Finally, we are giving you prescriptions
for laxatives to help you move your bowels.
.
Please take all of your medicines as prescribed. Please follow
up with you primary care physician within the next week to check
your blood counts and your calcium level. Please notify your
physician or return to the emergency department in you have any
return of blood in your stool or vomit.
Followup Instructions:
Please follow/up with your primary care physician [**Name Initial (PRE) 176**] 1 week
to check hematocrit and calcium levels.
.
Follow up with GI to have repeat endoscopy on Monday, [**2139-7-20**]
.
Oncology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2139-8-5**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12766**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2139-8-5**] 11:00
|
[
"280.0",
"155.0",
"789.59",
"276.2",
"452",
"275.42",
"572.3",
"456.21",
"578.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11946, 11952
|
8149, 10260
|
322, 384
|
12147, 12295
|
3910, 4392
|
14013, 14526
|
3191, 3374
|
10733, 11923
|
11973, 12126
|
10286, 10710
|
12319, 13990
|
3389, 3891
|
4436, 8126
|
275, 284
|
412, 2752
|
2774, 2887
|
2903, 3175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,435
| 146,904
|
35458
|
Discharge summary
|
report
|
Admission Date: [**2109-2-20**] [**Month/Day/Year **] Date: [**2109-2-26**]
Date of Birth: [**2060-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
cardiac catheterization with stenting x2
History of Present Illness:
48 yo male with hypertension, diabetes, hyperlipidemia,
presented with several hours of substernal chest discomfort. The
pain started at 4PM while shoveling snow for 10 minutes. The pt
layed down and the pain did not resolve. He had a BM and was
diaphoretic and had continued chest pain. Also was lightheaded.
His wife called 911 after 30 min. In ambulance pt was given SLN
and pain resolved in less than 5 minutes. Pain was [**5-3**]
substernal, pressure like, tightness, and radiated to the left
back. No prior hx of chest pain.
Patient presented to the ED, VS were T-98.4, HR-99, BP-210/131,
RR-18, O2-100%. He was noted to have inferior lead and V6 ST
elevations with reciprocal depressions in V1-V4 and avL. He was
given ASA, plavix 600mg, heparin gtt, integrillin, and morphine.
He was transferred to the catheterization laboratory where he
was found to have 99% subtotal mid-LAD chronic lesion, 80%
proximal OM1, and total distal RCA occlusion with thrombus. He
underwent thrombectomy followed by DES to PDA and distal RCA
(xience stent). He was transferred to CCU team for blood
pressure control and further monitoring. During the procedure he
was hypertensive to 180s. No chest pain.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: - CAD, S/P Xience stents to RCA and PDA on
[**2109-2-20**]
3. OTHER PAST MEDICAL HISTORY:
Pt has not taken any medications or seen any doctor for at least
5 years. Prior to this his blood gluose was at least in the 130s
per pt.
Social History:
Works as a coumpter programer. Married, three children, oldest
14. Little current exercise.
-Tobacco history: 25 years, 1-1.5ppd Quit smoking: 13yrs ago
-ETOH: 0-3/drinks per week
-Illicit drugs: none
Family History:
Father with heart disease, died in 60s, unclear age of first MI.
Cousin with MI and death in 50s.
Mother with HTN, alive in 70s.
Three sisters in good health.
Physical Exam:
VS: 159/99, 102, 17, 100%
GENERAL: middle aged male, NAD, lying flat, awake, alert
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, unable to tell JVP
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. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits, no hematoma in groin.
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:
LABS ON ADMISSION:
[**2109-2-20**] 05:45PM BLOOD WBC-8.4 RBC-5.49 Hgb-16.4 Hct-44.8 MCV-82
MCH-29.9 MCHC-36.7* RDW-13.5 Plt Ct-414
[**2109-2-20**] 05:45PM BLOOD PT-11.2 PTT-21.2* INR(PT)-0.9
[**2109-2-21**] 04:07AM BLOOD Glucose-278* UreaN-18 Creat-0.9 Na-136
K-4.0 Cl-104 HCO3-24 AnGap-12
[**2109-2-20**] 05:45PM BLOOD cTropnT-<0.01
[**2109-2-20**] 09:07PM BLOOD CK-MB-131* MB Indx-3.9
[**2109-2-21**] 04:07AM BLOOD CK-MB-139* MB Indx-4.5 cTropnT-10.65*
[**2109-2-20**] 05:45PM BLOOD CK(CPK)-65
[**2109-2-20**] 09:07PM BLOOD CK(CPK)-3339*
[**2109-2-21**] 04:07AM BLOOD CK(CPK)-3121*
[**2109-2-21**] 04:07AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.9
[**2109-2-20**] 08:44PM BLOOD %HbA1c-12.3*
[**2109-2-20**] 05:45PM BLOOD Triglyc-225* HDL-48 CHOL/HD-6.7
LDLcalc-229* LDLmeas-244*
[**2109-2-20**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
CARDIOLOGY:
TTE ([**2109-2-21**]):
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 inferior and
inferolateral akinesis. The remaining segments contract normally
(LVEF = 40-45%). 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
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD.
.
Cardiac catherization [**2109-2-25**]
1. Planned PCI. Access was via LFA.
2. Angiography revealed the two stents in the RCA to be widely
patent
and unchanged from post intervention 4 days ago. The LAD had a
mid
diffuse lesion to 90%. The LCX had a OM1 with ostial 80%
disease but
this vessel is too small for PCI.
3. Limited hemodynamics with BP 109/76 with HR 68 in sinus.
4. Stenting of mid LAD with Xience 2.5x28mm stent posted to 3mm.
5. Groin closure with Mynx device.
FINAL DIAGNOSIS:
1. Stenting of mid LAD with drug eluting stent.
.
EKG - [**2109-2-24**] - Sinus rhythm. Compared to tracing #1
inferolateral myocardial ischemia/injury pattern persists but is
improved. Clinical correlation is suggested.
.
Chest x-ray - FINDINGS: Heart size is at upper limits of normal.
A catheter extends from below overlying the IVC with tip
overlying the region of the left main pulmonary artery.
Pulmonary vascularity is within normal limits without evidence
of edema. No effusion or pneumothorax.
IMPRESSION: No CHF. Catheter tip in the expected location of the
left main PA.
.
Cardiac catherization [**2109-2-20**] - COMMENTS:
1. Selective coronary angiography of this right-dominant system
revealed multi-vessel coronary artery disease. The LMCA was
without
significant stenoses. The LAD had a mid-segment 99% stenosis
with TIMI
III flow, and serial bridging segments with moderate diffuse
disease in
the distal vessel. The LCX had no significant stenoses. OM1
had an 80%
proximal stenosis in a large vessel. The RCA was dominant and
had a
mid-to-distal occlusion with left-to-right collaterals and
substantial
acute thrombus.
2. Limited resting hemodynamics demonstrated moderate systemic
arterial
hypertension with a central aortic pressure of 159/107 mmHg.
Swan-Ganz
catheterization demonstrated normal right-sided filling
pressures and
mildly elevated LV filling pressures with a mean PCWP of 16
mmHg.
Cardiac output was preserved.
3. Sucecssful thromebectomy, PTCA and stenting of the proximal
RPDA with
2.5x28 mm Xience V DES. Final angiography revealed 0% residual
stenosis
without dissection or distal emboli.
4. Successful thrombectomy, PTCA and stenting of the istal RPDA
with a
3.0x23 mm Xience V DES. Final angiography revealed 0% residual
stenosis
with no dissection or distal emboli.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate systemic arterial hypertension.
3. SUcecssful stenting of the proximal RPDA (2.5x28 mm Xience V)
and
distal RCA (3.0x23 mm Xience V) drug-eluting stents.
Brief Hospital Course:
48 yo m with hx of DM, HTN, HL, presented with chest pain, found
to have NSTEMI.
.
# CORONARIES: He was given ASA, started on heparin gtt,
integrillin, and loaded with clopidogrel. He was taken to
cardiac catheterization where he was found to have thrombus in
RCA; thus, he underwent thrombectomy and revascularization with
DES to the distal RCA. He was subsequently chest pain free. CK
peaked at 3339. Medical management of CAD including ASA 325 mg,
clopidogrel, atorvastatin 80 mg, metoprolol titrated to HR,
lisinopril, was initiated. Integrillin was stopped 18 hrs
post-catherization. Patient underwent repeat catherization for
additional lesions with DES to the LAD which was uncomplicated.
.
# PUMP: Echo showed inferior and inferolateral akinesis with EF
40-45%. ACEI was initiated.
.
# RHYTHM: Sinus rhythm, metoprolol was uptitrated to HR 60s.
.
# Hypertension - Lisinopril and metoprolol were started. He was
subsequently normotensive.
.
# Diabetes mellitus: Patient had uncontrolled type 2 DM and had
not seen a physician [**Last Name (NamePattern4) **] 5 years. HgA1C was 12.3% on admission
with fingersticks were 300s. [**Last Name (un) **] was consulted. Patient was
begun on Lantus daily which was titrated up daily as well as
aggressive sliding scale. Patient was discharged on IV Lantus as
well as sliding scale. patient given appointment to follow up
with [**Hospital **] clinic in one week.
.
# Hyperlipidemia: LDL 244. High-dose statin therapy for STEMI
was initiated.
.
# Full Code
Medications on Admission:
none
[**Hospital **] 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain for 3 days.
7. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) Units
Subcutaneous qAM.
Disp:*1 month supply* Refills:*2*
8. One Touch Ultra System Kit Kit Sig: One (1)
Miscellaneous three times a day: please record your fingersticks
prior to meals and bring log with you to [**Last Name (un) **] appointment.
Disp:*1 month supply* Refills:*2*
9. Syringe with Needle (Disp) Syringe Sig: One (1)
Miscellaneous qAM: for insulin.
Disp:*1 month supply* Refills:*2*
10. One Touch Test Strip Sig: One (1) In [**Last Name (un) 5153**] three times
a day.
Disp:*1 month supply* Refills:*2*
11. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale Subcutaneous three times a day: please see attached
sliding scale.
Disp:*1 month supply* Refills:*2*
[**Last Name (un) **] Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
[**Name (NI) **] Diagnosis:
Primary: ST-elevation myocardial infarction
.
diabetes mellitus, type 2 - uncontrolled
hypertension
hyperlipidemia
[**Name (NI) **] Condition:
afebrile, vital signs stable, chest pain free
[**Name (NI) **] Instructions:
You were admitted to the hospital with chest pain from a heart
attack. You underwent cardiac catherization and drug eluting
stent placement to the right coronary artery as well as your
left anterior descending artery.
.
We changed your medications as follows:
1) You were started on a statin
2) You were started on a beta blocker
3) You were started on 35 Units of Lantus qAM
4) You were started on full strength aspirin
5) You were started on Plavix, you will need to take this for at
least one year. It is important that you take this medication
EVERY day and do not stop this medication without talking to
your cardiologist.
.
Should you have chest pain, shortness of breath, lightheadedness
or any other problems that concern you, please return to the ED.
We have made you follow up appointments with our cardiologist as
well as [**Last Name (un) **] diabetes center. It is very important that you
continue to follow up with your doctors [**First Name (Titles) **] [**Last Name (Titles) **].
.
You should return to the ED if you experience any chest pain,
shortness of breath, or abdominal pain. It has been a pleasure
taking of you at [**Hospital1 **].
Followup Instructions:
We have scheduled you an appointment to follow up with
cardiology for Thursday [**4-11**] at 1:20 pm, [**Hospital Ward Name 23**] 7 with
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-4-11**] 1:20.
Please call if you are unable to make this appointment.
.
In addition, as you have not seen a primary care doctor in
several years so we have set your up with a new primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 191**]. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6522**] [**3-14**] at 3 pm -
[**Hospital Ward Name 23**] [**Location (un) 453**] Atrium suite. If you would prefer to see you
previous PCP at [**Name9 (PRE) 2025**] please feel free to schedule an appointment
there within 2 weeks and cancel your appointment here.
.
We have set you up with an outpatient [**Last Name (un) **] diabetes
appointment. [**3-4**] at 12:00 pm with Dr. [**Last Name (STitle) 12746**].
Appointment on the [**Location (un) 1773**] of the [**Hospital **] clinic. Please
keep a careful record of your fingersticks. Please call and ask
to speak with person who makes appointments, as we are adding on
a nursing appointment for you in addition to your M.D.
appointment at [**Last Name (un) **].([**Telephone/Fax (1) 4847**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2109-2-26**]
|
[
"410.31",
"250.62",
"401.9",
"357.2",
"V17.3",
"355.5",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.45",
"99.20",
"00.41",
"37.23",
"37.22",
"00.66",
"00.46",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
8021, 9535
|
334, 377
|
3757, 3762
|
12558, 14049
|
2708, 2870
|
9561, 12535
|
7788, 7998
|
2885, 3738
|
2243, 2302
|
289, 296
|
405, 2129
|
3777, 5938
|
2333, 2473
|
2151, 2223
|
2489, 2692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,450
| 159,376
|
9243
|
Discharge summary
|
report
|
Admission Date: [**2144-1-3**] Discharge Date: [**2144-1-8**]
Date of Birth: [**2118-3-12**] Sex: F
Service: MEDICINE
Allergies:
Plaquenil
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
sore throat, hypertension
Major Surgical or Invasive Procedure:
Tunneled dialysis line placement
Hemodialysis
History of Present Illness:
25 F with history of HTN, SLE c/b lupus nephritis, CKD presents
with sore throat/cough x 2 weeks, progressive fatigue x 3 weeks,
and abdominal pain for the last 2-3 days. She reports an
associated cough which is productive of a dark, nearly black,
sputum. Describes it as a sticky sputum, she had a very
difficult time coughing it up at times. Endorses some slight
orthopnea, found it slightly more difficult to breathe while
lying flat. Denies headache, syncope, dizziness, vision changes,
fever, chills, SOB, DOE. Her fatigue is vague, she just feels
that she has no energy. It's been getting progressively worse
over the last 3 weeks.
.
She has also been having intermittent abdominal pain located in
her epigastric region over the last 2-3 days. Denies nausea,
vomiting, hematochezia, melena, diarrhea. Per patient, she has
lupus flares approximately once a year, usually in the
wintertime. Usual presentation of one of her flares is with
worsening rash and joint pains. Her lupus has been difficult to
control, she has been treated in the past with IV steroids and
cytoxan, most recently with cellcept.
.
Of note, she has not taken any of her prescribed medications
since [**2143-2-16**] as she got frusted with taking meds, and has
not followed up with her nephrologist since.
.
She has intermittently noticed some swelling in her legs. She
has not been taking any NSAIDs or herbal medications. Notes that
her urine has been more frothy, but otherwise no other changes
to quality, volume, or color of urine. Denies any hematuria,
dysuria, urgency, or frequency.
.
Today since her symptoms have not gotten any better, she went to
clinic to be seen, was found to have every elevated BP and was
referred to the emergency room. In the ED inital vitals were,
98.7 87 173/108 16 100%. Initial labs were notable for
hematocrit of 18.5 and creatinine of 11.6. She was transfused 1
unit of pRBC with improvement of hct to 23.4. Stool guaiac was
positive. CT of abd/pelvis preliminarily showed significant wall
thickening of the jejunal bowel loops, consistent with lupus
vasculitis. Her abdominal exam was notable for some abdominal
tenderness. CXR shows mild pulmonary edema. She received 10 mg
of amlodipine with improvement of BP to 148/94. She was
evaluated by nephrology who left recommendations for workup of
her acute on chronic renal failure. Lastly, patient was noted to
be depressed, but denied any SI or HI. Prior to transfer to the
ICU her vitals were: 148/94, 110, 20, 100%RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1. SLE diagnosed [**2140**], c/b nephritis.
2. Class IV Lupus Nephritis with persistent proteinurea
3. Possible h/o rheumatic fever (unverified and may have been
diagnosed prior to lupus diagnosis)
4. Normocytic anemia
5. Vitamin D deficiency (now on supplement)
6. Evidence of pulmonary hypertension on echo in [**4-/2141**] (no
coagulopathy identified yet in context of Lupus). No symptoms.
Social History:
lives with her mother and brother. She dropped out of college
because couldn't keep up. She immigrated from [**Country 651**]
approximately 10 years ago. She denies any alcohol or tobacco
use.
Family History:
No family history of DM, lupus, renal disease, cardiac disease,
malignancy.
Physical Exam:
Admission exam:
Vitals: 99.8, 112, 156/98, 19, 100%RA
General: AAOx3, NAD
HEENT: PERRLA, EOMI, sclera anicteric, MMM, OP clear, no LAD,
neck supple, no JVP
CV: S1S2, RRR, no m/r/g
Chest: soft bibasilar crackles, no wheezes, no rales
Abdomen: soft, ND, tender to palpation in epigastric area, no
rebound, no guarding, no HSM, no CVA tenderness
Ext: WWP, no e/c/c, 2+ peripheral pulses
Discharge exam: BPs 160s/90s, otherwise unremarkable
Pertinent Results:
ADMISSION LABS:
[**2144-1-3**] 01:58PM BLOOD WBC-5.4 RBC-2.15*# Hgb-6.2*# Hct-18.5*#
MCV-86 MCH-28.6 MCHC-33.2 RDW-13.8 Plt Ct-191
[**2144-1-3**] 01:58PM BLOOD Neuts-74.9* Lymphs-18.3 Monos-4.0 Eos-2.4
Baso-0.4
[**2144-1-3**] 02:56PM BLOOD PT-12.8 PTT-32.2 INR(PT)-1.1
[**2144-1-3**] 08:10PM BLOOD Glucose-81 UreaN-104* Creat-11.5* Na-138
K-4.5 Cl-106 HCO3-14* AnGap-23*
[**2144-1-3**] 01:58PM BLOOD ALT-13 AST-20 AlkPhos-63 TotBili-0.1
[**2144-1-3**] 08:10PM BLOOD Calcium-5.5* Phos-7.9*# Mg-1.9 Iron-88
OTHER LABS:
[**2144-1-4**] 04:11AM BLOOD ESR-60*
[**2144-1-4**] 04:11AM BLOOD Ret Aut-1.2
[**2144-1-3**] 08:10PM BLOOD calTIBC-244* Hapto-207* Ferritn-39
TRF-188*
[**2144-1-4**] 04:11AM BLOOD Osmolal-317*
[**2144-1-4**] 04:11AM BLOOD PTH-528*
[**2144-1-4**] 04:11AM BLOOD CRP-6.3*
[**2144-1-3**] 01:58PM BLOOD freeCa-0.73*
Labs on discharge:
[**2144-1-8**] 06:25AM BLOOD Hct-23.9*
[**2144-1-8**] 06:25AM BLOOD Glucose-89 UreaN-82* Creat-9.2*# Na-137
K-3.8 Cl-102 HCO3-23 AnGap-16
[**2144-1-7**] 06:00AM BLOOD Albumin-3.0* Calcium-6.1* Phos-6.4*
Mg-2.1
[**2144-1-7**] 06:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2144-1-7**] 06:00PM BLOOD HCV Ab-NEGATIVE
IMAGING:
CXR: Mild cardiomegaly and pulmonary edema which could reflect
fluid
overload due to acute renal failure though cardiac dysfunction
is not
excluded. Please correlate clinically. Findings d/w Dr. [**Last Name (STitle) 31723**]
at the time
of initial review.
CT abd/pelvis:
IMPRESSION:
1. Jejunal bowel loop wall thickening likely consistent with
vasculitis in
the setting of lupus. No small bowel obstruction.
2. Moderate right and small left pleural effusion as well as
pulmonary edema.
3. Mild to moderate gallbladder wall edema in a non-distended
gallbladder,
and no other findings to suggest cholecystitis. Cholecystitis
unlikely,
gallbladder wall edema may be secondary to renal, cardiac, or
liver
dysfunction.
RENAL U/S: Echogenic and small kidneys compatible with
parenchymal renal
disease.
Jejunal biopsy: Small intestinal mucosa, within normal limits.
Brief Hospital Course:
Assessment and Plan:
25 F with history of HTN, SLE c/b lupus nephritis, CKD presents
with sore throat, abdominal pain, and progressive fatigue x 3
weeks with hypertension and renal failure.
# Renal failure: Patient with known renal insufficiency [**3-20**] SLE
nephritis. Her baseline creatinine ranges anywhere from [**3-21**].
Presented with creatinine of 11.6. Renal u/s and FeNa of 11.2%
consistent with parenchymal disease. Pt was hypocalcemic and
hyperphosphatemic with PTH of 528, consistent with renal
failure. Patient has been noncompliant with medications and
medical follow up. Nephrology and Rheumatology consulted and
both felt this was not secondary to lupus flare bit to chronic
medication non-compliance. Nonetheless, checked C3, C4, and
dsDNA to rule out lupus flare and they only showed low C3 and
were otherwise normal. Renal recommended non-urgent hemodialysis
to manage electrolyte abnormalities, as well as calcitriol,
calcium gluconate, sodium bicarb, and aluminum hydroxide with
meals to manage electrolytes. Family meeting was held and
patient decided to initiate dialysis. A tunneled line was
placed and she was dialyzed for 2 days, discharged for placement
of an AVF the following day, followed by the 3rd day of
dialysis.
# Abdominal pain: Patient was complaining of epigastric pain and
had positive stool guaiac on admission. CT prelim read
suggested vasculitis in jejunal loops of bowel, possibly due to
SLE. She had not seen any frank blood in stool or melena at
home. Other considerations included gallstone, pancreatitis,
PUD, GERD. Pt was started on high dose methylprednisolone per
rheum recs for treatment of suspected lupus enteritis. She was
also started on an IV PPI and kept NPO. Pt reported improvement
in epigastric pain and repeat guaiac was negative on HD2. GI
was consulted and recommended enteroscopy which did not reveal
any jejunal pathology. Biopsies were taken and were negative.
# Sore throat/dark sputum: etiology uncertain. CXR did not
suggest pneumonia. No systemic symptoms of fever or SOB.
Sputum sample obtained and throat swab sent for culture with
growth of likely contaminant. No evidence of infection on exam
and pain resolved.
# Anemia: baseline hematocrit in the low 30s. Presented with hct
of 18.5, likely a contributor to her fatigue symptoms. Noted to
have possible vasculitis in her jejunal bowel loops on CT and
was also having dark sputum (?hemoptysis) which could be sources
of chronic blood loss. She also has renal failure which was
likely contributing to poor RBC production. Labs negative for
hemolysis. Iron studies show anemia of chronic disease. She
was started on epo and ferrilect. She received 2 units PRBC and
her Hct stabilized near 28.
# SLE: Has been through multiple different treatments with lupus
remaining difficult to control. Also has long history of med
non-compliance and denies taking meds since [**2143-2-16**].
Course complicated by lupus nephritis and recent worsening of
renal function (as described above). Rheum was consulted and
recommended starting high dose methylprednisolone transitioning
to prednisone with a taper, especially given the negative
jejunal biopsy for any enteric vasculitis.
# HTN: thought to be [**3-20**] renal failure. Started carvedilol per
renal recs for further management
Medications on Admission:
(has not taken any medications since [**2143-2-16**], but per OMR
had been on:)
ergocalciferol (vitamin D2) 50,000 unit qMonday
mycophenolate mofetil 1500 mg [**Hospital1 **]
prednisone 20 mg every other day
simvastatin 10 mg qhs
sulfamethoxazole-trimethoprim 400 mg-80 mg daily
Discharge Medications:
1. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
2. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for
6 days: Take 10mg for 3 days, 5mg for 3 days, then stop.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
renal failure
lupus
lupus nephritis
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted to the hospital with renal
failure. You had a dialysis line placed and dialysis was
initiated. Your lupus was treated with prednisone. You were
given blood and started on medications for your anemia.
**Due to the [**Holiday 1451**] holiday, the dialysis unit is closed
tomorrow. Therefore, you will need to return to the hospital on
Friday to finish your dialysis initiation. On Friday morning,
you are scheduled to receive your AV fistula, a procedure
performed by the Transplant surgeons. You will then be admitted
under Dr.[**Name (NI) 8584**] service and will receive your final
hemodialysis session. IT IS EXTREMELY IMPORTANT THAT YOU RETURN
TO [**Hospital1 **] (CLINICAL CENTER) AT [**Hospital1 18**] AT 6:15AM FOR
YOUR PROCEDURE! INSTRUCTIONS HAS BEEN PROVIDED TO YOU. PLEASE
DO NOT HAVE ANYTHING TO EAT AFTER UNTIL MIDNIGHT THE NIGHT
PRIOR.**
We have made the following changes to your medications:
START Prednisone 10mg for 3 days, then 5mg for 3 days
START carvedilol 25mg twice daily
STOP Bactrim
STOP simvastatin
Please take your medications as prescribed. Follow up with your
physicians and go to dialysis. You will informed about the
details regarding outpatient dialysis upon finishing your
initiation on Friday.
Followup Instructions:
Upon starting outpatient dialysis, the nephrologist at the
center will be coordinating your care.
Social work has recommended you see an outpatient therapist.
Please contact the following to make an intake appointment:
[**Hospital1 1680**] Counseling Services - [**Location (un) 3786**]
[**Street Address(2) 31724**], [**Location (un) 895**]
[**Location (un) 3786**], [**Numeric Identifier 31725**]
([**Telephone/Fax (1) 31726**]
We have also scheduled the following appointments for you:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2144-1-22**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2144-3-3**] at 2:00 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT SOCIAL WORK
When: TUESDAY [**2144-3-3**] at 3:00 PM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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icd9cm
|
[
[
[]
]
] |
[
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|
[
[
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294, 342
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,336
| 134,036
|
26700
|
Discharge summary
|
report
|
Admission Date: [**2163-11-26**] Discharge Date: [**2163-11-30**]
Date of Birth: [**2103-5-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary catheterization x 2
- stenting of RCA with 2 [**Name Prefix (Prefixes) **]
- [**Last Name (Prefixes) 5303**] of LCx and LAD with 1 DES each
History of Present Illness:
60 yo M PMH sig for sz disorder presented with onset of severe,
burning/heavy substernal CP and SOB. He had no N/V. Pain started
at 1:00 pm and pt presented to [**Location (un) **] ED. EKG showed < 1mm STE
in II, III, aVF, and V1. Also with RV4 <1mm STE. In ED got asa,
plavix, heparin, aggrostat, and nitro - not pain free. [**Location (un) 7622**]
to [**Hospital1 18**] and to cath lab. In cath lab found to have mid RCA
total occlusion. 85% mid-LCX and LAD. RCA was stented x 2 with
DES with good restoration of flow. Vagal decr in BP and HR -
given atropine with increase in HR and BP - this was followed by
onset of chest pain ([**8-24**]). Unclear if this was due to cath
procedure itself or if the pt had ongoing ischemia. Wedge in
cath lab was 24.
.
Pt has age and smoking as traditional risk factors for MI - FH
and cholesterol unknown. No known HTN.
Past Medical History:
Sz d/o s/p head injury at age 16 - last sz at age 18
Social History:
FH: unknown as pt is adopted. 2 healthy children and 4 healthy
grandchildren.
.
SH: Denies etoh except socially, illicits. + smoking hx - 25
pack years quit 30 years ago. Works as security guard.
Physical Exam:
Vitals immed in Unit: AF, 140/84, 88, 14, 95%
Gen: NAD, conversant, pleasant
HEENT: NCAT, no bruits, JVD diff to assess, no LAD
CV: RRR, no murmurs appreciated
Lungs: Clear laterally
Abd: Soft, NT, ND, + BS
Ext: groin with sheath in and some oozing, DP 2+ R and poorly
dopplerable L, PT non-palp bilat, feet cool but not mottled,
good cap refill bilat
Neuro: MS: AAOx3, appropriat with fluent speech but some mild
dysarthria, naming and fund of knowledge intact. CN II-XII
intact. Moves all extr. Coord intact to modified FNF. [**Last Name (un) **]
intact throughout. Refl 2+ bilat. Gait deferred.
Pertinent Results:
[**2163-11-26**] 07:03PM BLOOD WBC-9.2 RBC-4.66 Hgb-13.9* Hct-38.9*
MCV-83 MCH-29.9 MCHC-35.8* RDW-13.1 Plt Ct-251
[**2163-11-26**] 07:03PM BLOOD Plt Ct-251
[**2163-11-26**] 07:03PM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-24 AnGap-15
[**2163-11-26**] 07:03PM BLOOD ALT-29 AST-53* LD(LDH)-191 CK(CPK)-504*
AlkPhos-171* TotBili-0.3
[**2163-11-26**] 07:03PM BLOOD Albumin-3.9 Mg-1.7 Cholest-157
[**2163-11-26**] 07:03PM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE
[**2163-11-26**] 07:03PM BLOOD Triglyc-74 HDL-43 CHOL/HD-3.7 LDLcalc-99
[**2163-11-26**] 07:03PM BLOOD Phenyto-4.4*
[**2163-11-26**] 05:30PM BLOOD Type-ART pO2-116* pCO2-52* pH-7.28*
calHCO3-25 Base XS--2 Intubat-NOT INTUBA
[**2163-11-26**] 05:30PM BLOOD O2 Sat-98
[**2163-11-26**] 09:38PM BLOOD Hgb-14.1 calcHCT-42 O2 Sat-77
.
[**2163-11-27**] 04:21AM BLOOD CK(CPK)-853*
[**2163-11-27**] 12:28PM BLOOD CK(CPK)-660*
[**2163-11-28**] 03:30AM BLOOD CK(CPK)-313*
[**2163-11-26**] 07:03PM BLOOD CK-MB-65* MB Indx-12.9*
[**2163-11-26**] 07:03PM BLOOD cTropnT-1.07*
[**2163-11-27**] 04:21AM BLOOD CK-MB-101* MB Indx-11.8* cTropnT-3.88*
[**2163-11-27**] 12:28PM BLOOD CK-MB-64* MB Indx-9.7* cTropnT-2.96*
[**2163-11-28**] 03:30AM BLOOD CK-MB-20* MB Indx-6.4* cTropnT-1.76*
.
[**2163-11-29**] 05:35AM BLOOD WBC-8.2 RBC-4.54* Hgb-13.8* Hct-39.6*
MCV-87 MCH-30.3 MCHC-34.7 RDW-12.9 Plt Ct-224
[**2163-11-29**] 05:35AM BLOOD Plt Ct-224
[**2163-11-29**] 05:35AM BLOOD Glucose-112* UreaN-9 Creat-0.7 Na-140
K-4.1 Cl-106 HCO3-25 AnGap-13
[**2163-11-28**] 03:30AM BLOOD CK(CPK)-313*
[**2163-11-29**] 05:35AM BLOOD Calcium-9.0 Phos-2.4* Mg-1.8
[**2163-11-26**] 07:29PM BLOOD Type-ART pO2-98 pCO2-42 pH-7.36
calHCO3-25 Base XS--1
[**2163-11-27**] 05:37AM BLOOD Hgb-13.3* calcHCT-40 O2 Sat-75
.....
Cath Films ([**11-26**]):
1. Selective coronary angiography of this right dominant system
revealed
3 vessel coronary artery disease. Teh LMCA had no
angiographically
apparent flow limiting lesions. The LAD had a 80% proximal
stenosis. The
D1 had a 70% stenosis. The Lcx was a large vessel with an 80-85%
proximal stenosis and a 50% distal stenosis. The RCA was a
dominant
vessel and was occluded proximally.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures. The PCWP was 24 mmHg and the RVEDP was 14mmHg.
3. left ventriculography was deferred.
4. Successful predilation using a 2.0 X 20mm Voyager balloon,
stenting
using 2.5 X 23 and 3.0 X 33mm Rx Cypher stents and post dilating
using
the stent balloon and 3.25 X 18mm High sail ballon of the
acutely
occluded proximal RCA with lesion reduction from 100 % to 0%.
The final
angiogram showed TIMI III flow with no dissection and no
embolisation.
(see PTCA comments)
FINAL DIAGNOSIS:
1. Angiographic evidence of three vessel coronary artery
disease.
2. Elevated left and right sided filling pressures.
3. Acute inferior STEMI with urgent PCI of the RCA.
.....
Cath Films ([**11-28**]):
FINAL DIAGNOSIS:
1. Succesful stenting of the proximal Cx lesion.
2. Successful stenting of the proximal LAD lesion.
.....
ECHO ([**11-28**]): Conclusions:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction. Overall left ventricular
systolic function is mildly depressed. Resting regional wall
motion abnormalities include basal to mid inferior
akinesis/hypokinesis, basal to mid inferolateral hypokinesis,
and basal inferoseptal hypokinesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened. The mitral valve leaflets are mildly
thickened. There is no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2163-11-26**],
there is no
definite change but prior study is technically suboptimal for
comparison.
.....
CXR ([**11-27**]):
No previous films for comparison. Allowing for supine technique,
heart size is within normal limits and there is no evidence for
CHF. The left CPA is partly coned off the film. The lungs are
otherwise clear.
Brief Hospital Course:
BRIEF OVERVIEW: The patient is a 60 yo with a h/o sz d/o who
presented from [**Location (un) **] with CP and STEMI (IMI). Found to have
focal lesions in 3 vessels. Stented x 2 in RCA with very little
change in EKG. Cath also revealed LCx and LAD lesions. During
the cath procedure, after stenting, the patient had a vagal
episode with decreased BP and HR and was given atropine. HR and
BP returned, but pt had 8/10 chest pain. Swan showed elevated
BP, right sided pressures, and wedge. The pain subsided and the
patient was given lasix and nitro in the lab and BB in the CCU
(where he was taken for monitoring). He then became hypotensive
and was symptomatic with nausea and LH. Swan showed decreased
wedge and R sided pressures. He was placed in trendelenberg
postition and given fluids to bring up his BP. It was though
that his low BP was due to decreased preload in a preload
dependent state. Echo at the bedside revealed a hypokinetic
free RV wall. After fluids and time for meds to wear off, the
patient was normotensive and felt well. ASA and plavix were
continued. Integrellin was d/c'd after 18 hours per protocol.
The remainder of his recovery was uneventful.
Two days later, the pt was taken back to cath lab on [**11-28**] for
successful stenting of the remaining 2 lesions. He recovered
well clinically. Echo revealed an LVEF of 35-40%. RV appeared
unaffected in this repeat echo. Low dose BB was started and
pressures withstood this. He was transferred to the floor and
evaluated by PT who thought he was able to go home from a PT
standpoint.
.
Sz d/o: longstanding and stable. Pt is on a very low dose of
medication and has not been seen by a neurologist since he was
18. His dilantin level was subtherapeutic. He likely does not
need to continue to take this medication.
.
Endocrine: glucose was elevated. The patient should be tested
for diabetes at future visits as an outpatient.
.
F/E/N: cardiac and low salt diet
.
Prophy: Pt was maintained on sq heparin until he was ambulating
regularly on his last day of hospitalization.
.
Code: Full
Medications on Admission:
Dilantin 100mg po daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take as directed to lower cholesterol.
Disp:*30 Tablet(s)* Refills:*2*
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take as directed: one tablet under tongue for chest pain. Wait
5 min and repeat. [**Month (only) 116**] take up to 3 tablets. Call physician if
even one tablet is taken.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): For heart
protection.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take as directed to prevent stent closure.
Disp:*90 Tablet(s)* Refills:*4*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO DAILY (Daily).
6. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day: Take as directed
for heart protection.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
3 vessel coronary artery disease
hypotension
seizure disorder
Discharge Condition:
Good - no chest pain, ambulating, no groin pain/hematoma
Discharge Instructions:
You were admitted to the hospital with chest pain due to a heart
attack (Myocardial Infarction). In the catheterization of your
heart, it was found that each of the three major vessels of your
heart had blockages. You had 3 stents put in at two visits to
the cath lab. You seem to have recovered well, though your
heart may not be functioning as well as it was prior to the
heart attack.
.
You have been started on a number of new medications. It is
important that you take them as prescribed. It is particularly
important that you never miss a dose of Plavix and aspirin -
these medications keep your stents from closing.
.
You should follow up with Dr. [**Last Name (STitle) 24305**] for a general health check
up within 2 weeks of this hospitalization. You can call for an
appointment at [**Telephone/Fax (1) 24306**].
.
You will need follow up with a cardiologist, as well. You
should follow up with Dr. [**Last Name (STitle) **], who did your catheterization.
You should have an appointment with him in [**4-20**] weeks. You can
call him for an appointment at: ([**Telephone/Fax (1) 5909**]. He will set you
up with an echocardiogram to re-evaluate your heart function and
with cardiac rehabilitation to further help in your recovery.
.
For two weeks you should avoid heavy lifting (more than 10lbs)
or strenuous activity.
.
If you develop chest pain, loss of consciousness, groin pain or
bleeding, new shortness of breath, fever, or any other worrisome
symptom, please return to the hospital or seek immediate medical
attention.
Followup Instructions:
Dr. [**Name (NI) 24305**] - pt to call for appointment in next 2 weeks.
- pt will need chem 7 (acei), BP measurement, lipid check
Dr. [**Name (NI) **] - pt to call for appointment in next 4-6 weeks.
- pt will need echo and likely cardiac rehab
Completed by:[**2163-12-1**]
|
[
"410.71",
"458.29",
"272.4",
"414.01",
"790.29",
"992.0",
"V15.82",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"00.40",
"88.56",
"99.20",
"37.22",
"00.41",
"00.46",
"36.07",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
9653, 9659
|
6376, 8457
|
329, 482
|
9765, 9824
|
2296, 5007
|
11416, 11695
|
8531, 9630
|
9680, 9744
|
8483, 8508
|
5243, 6353
|
9848, 11393
|
1677, 2277
|
279, 291
|
510, 1372
|
1394, 1448
|
1464, 1662
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,049
| 163,919
|
35437+57998
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-9-19**] Discharge Date: [**2169-10-24**]
Date of Birth: [**2133-11-30**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. CT guided drainage of peritoneal abcess [**2169-9-21**]
2. Replacement of pelvic drain [**2169-9-26**]
3. Exploratory laparotomy with sigmoid resection and primary
anastomosis and diverting ileostomy.
4. Ultrasound guided Paracentesis [**2169-10-8**]
5. CT guided drainage of peritoneal abscess [**2169-10-10**]
History of Present Illness:
35F with history of recurrent diverticulitis presents with
recurrent LLQ pain X 3 weeks. Pt's first episode was in [**1-/2169**],
was most recently admitted in [**5-/2169**] for diverticulitis
complicated by an anterior pelvic abscess, discharged with a
drain on flagyl and levo. Drain was removed and abx dc-ed 5
weeks
ago.
LLQ pain recurred 3 weeks ago with associated jaundice. Pain is
similar in quality and severity to prior episodes. Pt has had
non-melanotic diarrhea X 2 weeks. Jaundice got markedly worse
several days ago, associated with dark urine. Brown stool. Pt
denies fever.
No urinary symptoms
Past Medical History:
PMH: ETOH abuse with withdrawal symptoms, Palpitation w
reportedly negative stress and cardiac work up, Anxiety,.
PSH: T&A age 4; Bilateral breast implants
Social History:
-patient states she was drinking 1.5 pints of vodka daily prior
to her admission. She endorses heavy drinking since the age of
27, with multiple detoxes and withdrawal seizures
-denies drug abuse
-reports history of smoking cigarettes
The patient states she currently lives in [**Location 2624**] with her friend
[**Name (NI) 401**]. She finished high school and worked as a hair stylist, but
reports not working for awhile due to her medical condition. She
was previously married and divorced, with one 15yo child who is
in the custody of
Family History:
Diverticulitis father
Physical Exam:
Vitals: Time Pain Temp HR BP RR Pox
+ 14:53 4 98.3 97 142/101 18 100%
GEN: A&O, NAD
HEENT: scleral icterus present, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, Min tenderness Suprapubic and LLQ, no
rebound or guarding, normoactive bowel sounds, no palpable
masses
DRE: normal tone, no gross blood; pos for occult blood
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2169-9-19**] 03:10PM WBC-6.3 RBC-3.43* HGB-12.2 HCT-35.0* MCV-102*
MCH-35.5* MCHC-34.8 RDW-15.4
[**2169-9-19**] 03:10PM NEUTS-77* BANDS-2 LYMPHS-15* MONOS-4 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2169-9-19**] 03:10PM PLT COUNT-238
[**2169-9-19**] 03:10PM ASA-NEG ETHANOL-40* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2169-9-19**] 03:10PM ALBUMIN-3.6
[**2169-9-19**] 03:10PM ALT(SGPT)-28 AST(SGOT)-208* ALK PHOS-187* TOT
BILI-9.7* DIR BILI-6.4* INDIR BIL-3.3
[**2169-9-19**] 03:10PM LIPASE-10
[**2169-9-19**] 03:10PM GLUCOSE-91 UREA N-5* CREAT-0.4 SODIUM-135
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15
[**2169-9-19**] CT Abd/pelvis : 1. Despite interval drainage with a
pigtail catheter (since removed), there is no significant change
of the pelvic abscess compared to [**2169-6-23**].
2. Unchanged sigmoid colon diverticulosis and thickening of the
sigmoid colon bowel wall without evidence of acute
diverticulitis.
[**2169-9-21**] CT guided drainage :
Technically successful CT-guided drainage of diverticular
abscess
[**2169-9-25**] CT Abd/pelvis : 1. Pigtail catheter is seen
appropriately placed curling within the pelvic abscess however
the pelvic abscess is unchanged in size. The case was discussed
with the surgical resident caring for the patient, Dr. [**Last Name (STitle) **].
Dr. [**Last Name (STitle) **] suggested that the drain should be attached to
negative suggestion to facilitate appropriate evacuation of the
abscess.
[**2169-9-26**] TTE :
no obvious vegetations seen, but technically suboptimal study
[**2169-9-29**] CT Abd/pelvis :
1. Interval increase in amount of ascitic fluid within the
abdomen and
pelvis, with suggestion of abscess rupture inferiorly with
increased size to abscess. Barium within the cavity consistent
with known fistulization to the adjacent sigmoid colon which
remains thick walled. Drain remains positioned within anterior
aspect of collection.
2. Interval development of small bilateral simple pleural
effusions as well as some adjacent compression atelectasis.
3. Unchanged hepatomegaly with underlying fatty infiltration.
[**2169-10-6**] CT Abd/pelvis :
1. Status post sigmoidectomy and ileostomy.
2. Persisting suprapubic fluid collection and pigtail catheter
removal.
3. Moderate-to-large amount of ascites with enhancing
peritoneum, concerning for peritonitis.
4. Bilateral pleural effusions with compressive atelectasis.
5. Cirrhosis
[**2169-10-11**] CT Abd/pelvis : Recently placed pigtail catheter is at
least partially within the bladder dome with the overlying
suprapubic simple fluid collection has been decreased in size
from most recent imaging.
These findings were discussed in detail with the caring surgical
resident, Dr. [**Last Name (STitle) **], via phone immediately after exam completion
at 6:20 p.m. A joint
decision between the radiology and surgical team was to remove
the catheter and continue bladder foley decompression for one to
two weeks to allow further healing of the inflamed bladder dome.
The catheter was removed uneventfully by Dr. [**Last Name (STitle) 12919**] shortly
after exam completion. Can consider cystogram prior to foley
removal to ensure no leak.
[**2169-10-23**] Cystogram : No evidence of bladder leak in this normal
cystogram.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2169-10-21**] 10:05 8.6 3.82* 12.4 37.7 99* 32.4* 32.9 16.2*
529*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2169-10-16**] 06:05 56.4 23.8 7.0 10.9* 1.9
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2169-9-28**] 22:30 1+ 3+ NORMAL 3+ NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2169-10-21**] 10:05 529*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2169-9-29**] 21:43 330
PLEASE CALL RESULTS TO [**3-/3253**]
LAB USE ONLY
[**2169-10-21**] 10:05
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2169-10-22**] 05:45 881 7 0.8 138 3.9 103 27 12
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2169-10-20**] 06:10 Using this1
Using this patient's age, gender, and serum creatinine value of
0.6,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 30-39 is 107 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2169-10-23**] 05:20 18 81* 151 104 2.3*
OTHER ENZYMES & BILIRUBINS Lipase
[**2169-10-23**] 05:20 62*
CPK ISOENZYMES cTropnT
[**2169-9-27**] 02:05 <0.011
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2169-10-22**] 05:45 3.1* 9.4 4.7* 1.7
HEMATOLOGIC calTIBC TRF
[**2169-10-6**] 05:25 99* 76*
OTHER CHEMISTRY Ammonia
[**2169-10-7**] 08:20 26
Brief Hospital Course:
On [**2169-9-19**], the patient was admitted to general surgery for
persistent diverticulitis and pelvic abscess. Hepatology was
consulted for elevated LFTs suspicious for infectious vs.
alcoholic aetiology. She was started on levofloxacin and
metronidazole. She was rendered NPO, and on [**2169-9-21**], she
underwent CT-guided drain placement of the pelvic abscess.
Drained fluid was sent for culture. Her pain was improved and
she was started on regular diet with nutritional
supplementation, which she tolerated. Nutrition consult was
obtained for poor nutritional status likely associated with EtOH
abuse. WBC showed no leukocytosis.
On [**2169-9-25**], vancomycin was started for daily recurrent fevers.
Repeat CT abdomen/pelvis showed stable pelvic abscess with
appropriate drain placement. As the abscess was not diminishing
significantly, the drain was placed on bulb suction.
Echocardiogram looking for occult infection was unremarkable.
On [**2169-9-26**], she underwent CT-guided drain replacement, as the
drain had fallen out overnight. Drained fluid was again sent
for culture.
On [**2169-9-28**], the patient was transferred to the MICU on
hepatology for intermittent fevers and hypotension.
On [**2169-9-29**], CT abdomen/pelvis showed perforation of the
sigmoid with extravasation of oral contrast into the pelvic
abscess with suggestion of abscess rupture, and that evening,
she was brought to the operating theater for exploratory
laparotomy, sigmoid resection with primary reanastomosis,
wash-out, and loop ileostomy. Post-operatively, she was
admitted to the SICU on general surgery, and on [**2169-9-30**], she
was transferred to the floor.
Following her transfer to the Surgical floor she continued to
have problems with elevated temperatures. A repeat CT scan of
the abdomen showed a suprapubic fluid collection and ascites
which prompted an ultrasound guided drainage and eventually CT
guided pigtail catheter drainage. The peritoneal fluid grew
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and her antibiotics were adjusted to Micafungin
for a 10 day course. In the interim her diet was resumed
following return of bowel function but unfortunately she
required a feeding tube as her appetite was poor.
From a nutritional standpoint she was placed on Marinol which
was gradually increased over time and her appetite gradually
improved to the point where she could have her tube feeding
cycled and eventually stopped. Currently she is tolerating a
regular diet with Ensure supplements TID as well as Carnation
Instant Breakfast.
Her narcotic pain medications were gradually weaned off and her
incisional pain was controlled with Tylenol or Motrin. Her
abdominal wound was clean and healing well without evidence of
erythema. Her ostomy was functioning well with brown fluid
effluent and a red stoma. The ostomy nurses worked with her on
many occasions for basic teaching and caring for the ostomy.
Her baseline confusion from her liver disease initially was a
barrier but as time went on and her mental status was clearing
her ability to understand improved however she will still need
VNA services to assist her. Staples were removed prior to her
discharge.
The Psychiatric service was consulted to help evaluate her
depression related to this new hospitalization and surgical
procedure in addition to her history of alcohol abuse. They
felt that she was mainly exhibiting signs of delirium and until
that resolved an underlying depression could not be diagnosed.
Seroquel was recommended as she had been on that prior to
admission. She was only placed on it at bedtime as she had
periods of over sedation when on it twice daily. They
recommended CNS imaging if her cognitive exam does not improve
and on multiple occasions recommended out patient follow up with
them or her own psychiatrist. [**Known firstname 11894**] prefers to follow up with
the [**Hospital1 18**] Psychiatry service and she will make an appointment on
her own.
Prior to her discharge she has a voiding cystogram to ensure the
integrity of the bladder and there was no leak identified. Her
renal function was normal after antifungal therapy and her LFT's
gradually decreased with a Total Bili in the 2.3 range which was
down from 9 on admission.
After a long and protracted course she was discharged to home on
[**2169-10-24**] and will follow up in the [**Hospital 2536**] Clinic in [**2-1**] weeks.
Medications on Admission:
Seroquel 50 mg Tab PRN
Clonidine 0.1 mg Tab [**Hospital1 **]
Thiamine 100 mg Tab Daily
Atenolol 50 mg Tab twice a day
Trazodone 50 mg Tab HS prn for Insomnia
B Complex Vitamins 1 Daily
Oxybutynin Chloride 5 mg three times a day
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
Disp:*500 ML(s)* Refills:*2*
5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO BID (2 times a day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. dronabinol 2.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
Disp:*180 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
1. Perforated diverticulitis
2. Alcoholic hepatitis
3. Delirium
4. [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] peritonitis
5. Anxiety/depression
6. Severe malnutrition
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with persistent
diverticulitis and a pelvic abscess which eventually required
surgery due to perforation.
* You have had a long hospital course but over the last week you
have progressed very well.
* You will need to continue to eat well in order to heal your
incision and help regulate your ostomy.
* Do NOT drink alcohol as your liver function is very marginal
and alcohol will only harm it further.
* It is important to get up and walk frequently.
* The VNA will help you take care of your ostomy.
* Check your incision daily and if any drainage or redness
develops please call the Acute Care Clinic or return to the
Emergency Room.
* It is important to follow up with the Psychiatry service here
at [**Hospital1 18**] or with your own psychiatrist so please make an
appointment this week to continue forward progress and to assess
your medications.
Followup Instructions:
Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in [**2-1**] weeks.
Call the Ostomy nurse for an out patient appointment in 2 weeks
at [**Telephone/Fax (1) 23664**]
The the Psychiatry Clinic at [**Telephone/Fax (1) 1387**] for an out patient
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr. [**First Name8 (NamePattern2) 3095**] [**Last Name (NamePattern1) **]
Call Dr. [**First Name (STitle) **] for a follow up appointment in [**12-31**] weeks.
Completed by:[**2169-10-24**] Name: [**Known lastname **],[**Known firstname 12953**] Unit No: [**Numeric Identifier 12954**]
Admission Date: [**2169-9-19**] Discharge Date: [**2169-10-24**]
Date of Birth: [**2133-11-30**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin
Attending:[**First Name3 (LF) 4216**]
Addendum:
Asked by Mass Health to provide documentation re: patient's
nutritional status and the necessity for using Marinol as a
stimulant for her appetite.
From a nutritional standpoint she was started on Marinol as a
result of anorexia and weight loss; her weight in [**6-7**] was 130
lbs and on [**2168-9-19**] at time of admission her weight was 113 lbs.
She required total parenteral nutrition in the postoperative
period and then tube feedings via a Dobhoff. Eventually she was
transtioned to a regular diet but because of her very
deconditioned status her appetie was very poor. She was started
on Marinol 2.5 mg twice a day with little effect; the dose was
increased to 7.5 mg twice a day with marked improvement in her
appetite. She was able to consume adequate calories and was
discharged to home on Marinol.
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
Disp:*500 ML(s)* Refills:*2*
5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO BID (2 times a day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. dronabinol 2.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
Disp:*180 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2333**] Area VNA
Discharge Diagnosis:
1. Perforated diverticulitis
2. Alcoholic hepatitis
3. Delirium
4. [**First Name5 (NamePattern1) 1441**] [**Last Name (NamePattern1) 2619**] peritonitis
5. Anxiety/depression
6. Severe malnutrition
[**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 4218**] MD [**MD Number(2) 4219**]
Completed by:[**2169-11-2**]
|
[
"038.9",
"293.0",
"576.8",
"790.4",
"458.8",
"569.5",
"567.29",
"584.9",
"486",
"995.91",
"789.59",
"300.00",
"261",
"571.1",
"562.11",
"782.4",
"311",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.77",
"38.93",
"96.6",
"54.91",
"46.01",
"45.76"
] |
icd9pcs
|
[
[
[]
]
] |
17201, 17265
|
7621, 12074
|
324, 642
|
13502, 13502
|
2543, 7598
|
14568, 16334
|
2039, 2063
|
16357, 17178
|
17286, 17646
|
12100, 12332
|
13655, 14545
|
2078, 2524
|
270, 286
|
670, 1284
|
13517, 13631
|
1306, 1465
|
1481, 2023
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,706
| 177,424
|
34958
|
Discharge summary
|
report
|
Admission Date: [**2157-12-2**] Discharge Date: [**2157-12-11**]
Date of Birth: [**2079-7-2**] Sex: F
Service: SURGERY
Allergies:
Hydromorphone / Vicodin / Percocet
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Right Colon Infarction
Major Surgical or Invasive Procedure:
open right hemi-colectomy
History of Present Illness:
Ms [**Known lastname 79974**] is a 78 yo F with a history of severe vascular
disease including s/p fem/[**Doctor Last Name **] bypass. The patient was discharged
from [**Hospital1 18**] on [**11-29**] after placement of a celiac stent complicated
by a brachial artery pseudoaneurysm. The patient was doing well
s/p stent when she presented to an OSH with acute right sided
abdominal pain. Given her history the patient underwent a CT
scan that showed pneumatoses with portal venous gas and was
transferred to [**Hospital1 18**] for surgical management. Prior to transfer
the patient was given zofran and morphine.
.
In the [**Hospital1 18**] ER the patient was initially found to be febrile to
99 with BP 195/70, HR 75 and 100 % RA. She was given morphine
IV, Zofran, hydralazine, zofran phenergan, vancomycin, zosyn and
lopressor. Also possibly unasyn given.
.
Patient was initially admitted to the surgical service and had a
right colectomy done [**12-2**]. Intraoperative findings included a
pale right colon without perforation and clear transition points
that was resected with primary anastamoses. The patient
received IV fluids, labetolol and hydralazine perioperatively
and had a brief episode of hypotension requiring pressors.
.
Past Medical History:
Chronic mesenteric ischemis/celiac artery stenosis and SMA
occlusion
Crohn's disease
HTN
GERD
PVD
Hyperlipidemia
CAD
Past surgical history:
Ileocecectomy [**2154**]
R fem-[**Doctor Last Name **] bypass [**2152**]
L fem-[**Doctor Last Name **] bypass [**2150**]
Social History:
Occasional EtOH. 50 PY tobacco, quit 4 years ago. The patient's
son lives with her. She is independent of all ADLS and IADLs.
She still drives. She walks without a walker or cane. She fell
twice in [**Month (only) **] but not since. + spectacles. + dentures. no
hearing aides. No home services. Her son helps her with the
housework. She is a retired homemaker. She was widowed 22 years
ago. She has a 54 pkyear smoking history.
Family History:
She suspects that her mother had [**Name (NI) 4522**] disease but was never
diagnosed. Her father was in good health and died at 90. All 4
children and grandchildren in good health.
Physical Exam:
VS 98.0 70 180/68 20 97 RA
Gen: WN, NAD
HEENT: NCAT, neck is supple
CV: RRR, S1S2. There is b/l LE pitting edema, 2+
Lungs: CTAB, good BS b/l
Abd: Soft, mildly distended, appropriatley tender, incision is
c/d/i. There are several areas of ecchymosses throughout her
abdomen
Ext: several areas of ecchymosses in all 4 ext
Pertinent Results:
[**2157-12-2**] 06:05AM BLOOD WBC-19.0*# RBC-4.15* Hgb-12.6 Hct-36.8
MCV-89 MCH-30.4 MCHC-34.2 RDW-16.4* Plt Ct-347
[**2157-12-2**] 03:20PM BLOOD WBC-15.0* RBC-3.83* Hgb-12.2 Hct-33.7*
MCV-88 MCH-31.9 MCHC-36.3* RDW-15.8* Plt Ct-312
[**2157-12-3**] 04:25AM BLOOD WBC-10.5 RBC-2.49*# Hgb-7.7*# Hct-22.0*#
MCV-88 MCH-30.8 MCHC-34.9 RDW-16.1* Plt Ct-275
[**2157-12-3**] 03:15PM BLOOD Hct-24.6*
[**2157-12-4**] 12:36AM BLOOD Hct-27.7*
[**2157-12-4**] 04:22AM BLOOD WBC-9.8 RBC-3.28*# Hgb-10.0*# Hct-27.7*
MCV-84 MCH-30.5 MCHC-36.2* RDW-17.0* Plt Ct-208
[**2157-12-4**] 01:00PM BLOOD WBC-10.8 RBC-3.65* Hgb-11.1* Hct-31.1*
MCV-85 MCH-30.6 MCHC-35.8* RDW-16.4* Plt Ct-207
[**2157-12-5**] 10:36AM BLOOD WBC-11.1* RBC-3.93* Hgb-12.2 Hct-34.4*
MCV-88 MCH-31.2 MCHC-35.6* RDW-16.3* Plt Ct-306
[**2157-12-5**] 01:15PM BLOOD WBC-9.4 RBC-3.82* Hgb-11.7* Hct-33.8*
MCV-89 MCH-30.6 MCHC-34.6 RDW-16.2* Plt Ct-277
[**2157-12-7**] 05:31AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.1* Hct-29.5*
MCV-87 MCH-29.7 MCHC-34.4 RDW-15.8* Plt Ct-274
[**2157-12-7**] 05:31AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.1* Hct-29.5*
MCV-87 MCH-29.7 MCHC-34.4 RDW-15.8* Plt Ct-274
[**2157-12-8**] 03:15PM BLOOD WBC-6.6 RBC-3.47* Hgb-10.9* Hct-30.1*
MCV-87 MCH-31.4 MCHC-36.1* RDW-15.8* Plt Ct-323
[**2157-12-2**] 06:05AM BLOOD PT-12.0 PTT-19.3* INR(PT)-1.0
[**2157-12-3**] 07:44AM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.3*
[**2157-12-4**] 04:22AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2*
[**2157-12-2**] 07:55AM BLOOD Glucose-118* UreaN-10 Creat-0.5 Na-139
K-2.8* Cl-100 HCO3-30 AnGap-12
[**2157-12-2**] 03:20PM BLOOD Glucose-194* UreaN-8 Creat-0.4 Na-137
K-3.5 Cl-105 HCO3-26 AnGap-10
[**2157-12-3**] 04:25AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-135
K-3.9 Cl-104 HCO3-28 AnGap-7*
[**2157-12-4**] 04:22AM BLOOD Glucose-95 UreaN-12 Creat-0.4 Na-142
K-3.5 Cl-107 HCO3-28 AnGap-11
[**2157-12-5**] 10:36AM BLOOD Glucose-151* UreaN-15 Creat-0.5 Na-141
K-3.1* Cl-103 HCO3-29 AnGap-12
[**2157-12-5**] 01:15PM BLOOD Glucose-46* UreaN-14 Creat-0.5 Na-141
K-3.2* Cl-101 HCO3-27 AnGap-16
[**2157-12-6**] 04:13PM BLOOD Glucose-134* UreaN-11 Creat-0.5 Na-138
K-4.9 Cl-102 HCO3-28 AnGap-13
[**2157-12-7**] 05:31AM BLOOD Glucose-92 UreaN-10 Creat-0.4 Na-134
K-3.9 Cl-98 HCO3-30 AnGap-10
[**2157-12-8**] 05:00AM BLOOD Glucose-102 UreaN-9 Creat-0.6 Na-132*
K-3.7 Cl-91* HCO3-32 AnGap-13
[**2157-12-2**] 03:20PM BLOOD ALT-21 AST-24 AlkPhos-67 TotBili-1.2
[**2157-12-2**] 03:20PM BLOOD Albumin-3.0* Calcium-7.7* Phos-2.9
Mg-1.5*
[**2157-12-3**] 04:25AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.0
[**2157-12-4**] 04:22AM BLOOD Calcium-8.1* Phos-1.9*# Mg-2.0
[**2157-12-5**] 10:36AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.1
[**2157-12-5**] 01:15PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2
[**2157-12-6**] 04:13PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9
[**2157-12-7**] 05:31AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.7
[**2157-12-8**] 05:00AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
[**2157-12-2**] 06:11AM BLOOD freeCa-1.08*
[**2157-12-2**] 12:51PM BLOOD freeCa-1.06*
[**2157-12-2**] 01:57PM BLOOD freeCa-0.94*
CTA abd/pelvis [**2157-12-2**]:
IMPRESSION:
1. Patent celiac artery stent. Heavily calcified SMA, likely
occluded with
distal flow, probably from collaterals. Patent [**Female First Name (un) 899**].
2. Significant worsening of right and transverse colon
pneumatosis, new
portal venous gas, new free fluid, new free air and new
thickening of the
distal ileum. These findings all suggest worsening of mesenteric
ischemia.
3. Occluded right femoropopliteal bypass graft. Almost complete
occlusion of right iliofemoral bypass.
4. Atherosclerotic aorta and peripheral arteries.
5. Stable small hiatal hernia. Stable gallstones. Stable kidney
hypodensities, likely cysts.
6. Bladder distention.
7. Status post remote ileocecectomy for Crohn's disease.
Abd Xray (supine) [**2157-12-8**]:
Non dilated loops of bowel with air fluid levels . Contrast seen
within
rectum. Vascular stent in mid abdomen. Free air, pneumatosis,
and portal
venous gas seen on prior CT is not well identified on today's
study.
LLE doppler [**2157-12-9**]:
Brief Hospital Course:
The patient was transferred from an OSH and admitted from the ED
to the surgical service. She was taken to the OR for a right
hemi-colectomy and she tolerated the procedure well. She was
initially transferred to the [**Hospital Ward Name 332**] ICU. In the ICU, she
received 3 units of PRBCs, and her HCT increased appropriately.
She remained in the ICU in stable condition until [**12-4**], when
she was transferred to the 5 [**Hospital Ward Name 1950**] general [**Hospital1 **].
Due to her history of mesenteric ischemia and recent stent
placement with the vascular surgery service, she was restarted
on her home doses of ASA and Plavix on POD 1. She remained on
these medications without complication throughout her hospital
stay.
Pain:
Her pain was initially treated with IV pain medication, but she
was tolerating oral pain medication with good pain control when
she began tolerating PO.
GI/Diet:
The patient remained NPO, until post-op day 2 when she began
tolerating sips. She was slowly advanced with the return of
bowel function. She was tolerating regular food by POD 4.
However, she became nauseous on POD 5 and one episode of emesis.
She was revereted back to an NPO diet. A KUB at that time showed
some air/fluid levels. Her nausea/vomiting resolved on it's own.
She began toleratin a regular diet again prior to discharge.
Hypertension:
Throughout her hospital stay, she had transient episodes of
hypertension with SBP in the 170-200 range. This was controlled
with IV and PO metoprolol and hydralazine.
Hyponatremia:
The patient was noted to have a sodium level of 134 on POD 5.
She was treated conservatively with free water restrictions and
her sodium increased appropriately.
Lower extremity edema:
The patient was noted to have b/l LE edema on POD 3. She was
given IV lasix and this resolved. However, she was noted to have
unilateral LE edema (left) on POD 7. An ultrasound of her LE
showed no DVT.
The patient was discharged home in good condition on POD 8.
Medications on Admission:
ASA 81, plavix 75, pentasa [**2148**]", toprol 75, protonix 40,
prednisione 40, trazadone PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
12. Metoclopramide 5 mg/mL Solution Sig: [**12-22**] Injection Q6H
(every 6 hours).
13. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days: switch to 5mg on [**12-12**].
16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: start [**12-12**].
17. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO
three times a day.
Disp:*180 Tablet(s)* Refills:*0*
18. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Pneumatosis and portal venous air in patient with chronic
mesenteric ischemia.
2. Ischemic right colon.
3. Acute blood loss anemia
.
Secondary:
Hypertension, chronic mesenteric ischemia (celiac stenosis, SMA
out on [**10-29**] MR); Crohns; SBO '[**53**], CAD, MI, hypercholesteremia,
PVD, GERD
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1.Please follow up with Dr. [**Last Name (STitle) 1120**] by calling her office ASAP to
make an appointment ([**Telephone/Fax (1) 3378**].
2.Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7640**] [**Telephone/Fax (1) 79975**]
as soon as possible.
.
Scheduled appointments:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2157-12-20**] 10:00
SUMMARY NEITHER DICTATED NOR READ BY ME
Completed by:[**2157-12-11**]
|
[
"414.01",
"440.0",
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"276.1",
"996.74",
"555.9",
"569.89",
"276.52",
"530.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
10744, 10750
|
6954, 8942
|
317, 344
|
11100, 11178
|
2908, 6931
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12606, 13188
|
2367, 2551
|
9086, 10721
|
10771, 11079
|
8968, 9063
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11202, 12353
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12368, 12583
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1782, 1905
|
2566, 2889
|
255, 279
|
372, 1619
|
1641, 1759
|
1921, 2351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,480
| 104,415
|
20789
|
Discharge summary
|
report
|
Admission Date: [**2138-10-22**] Discharge Date: [**2138-10-24**]
Date of Birth: [**2068-5-13**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
elective carotid stenting
Major Surgical or Invasive Procedure:
[**Doctor First Name 3098**] stenting
History of Present Illness:
70 yo male with PMH DM, HTN, hyperlipid, smoking, mult strokes
admitted for elective carotid angiography/intervention.
*
Carotid ultrasound in [**Month (only) **] found occlusion of right internal
carotid artery and a high grade stenosis of the origin of the
left internal cartoid artery.
*
Pt denies any neurologic symptoms (visual, slurred speech,
numbness, weakness, other stroke-like sx.
*
In cath lab found occluded [**Country **], focal 90% stenosis of [**Doctor First Name 3098**].
Successful stenting of the [**Doctor First Name 3098**] was performed.
Past Medical History:
NIDDM (diet control)
Non small cell lung cancer 16 yrs ago s/p chemo and XRT
2-3 years ago had EMPYEMA rx??????d with decortication & chest tube
Hematuria 2 weeks ago, now resolved
S/P IVP/cystourethrogram on [**2138-9-24**]
COPD
s/p cardiac stent
h/o pseudomona sepsis [**4-29**]
hypercholesterolemia
HTN
Social History:
+ Cigs (now smokes 1/2ppd (previously [**1-28**])for 50years) still
smoking, occasional alcohol, no illicit drugs. lives with wife
on farm, owns bed and bkfst.
Family History:
dad ?; mom died of pneumonia, (+) HTN; daughter- HTN
Physical Exam:
VS: t98, p80, 120/80
Gen: NAD, pleasant
HEENT: PERRL, EOMI, clear OP
Neck: supple, no LAD
CVS: RRR, nl s1 s2, no m/g/r, distant heart sounds
Lungs: CTAB, no c/w/r
Abd: soft, NT, ND, +BS
Ext: no c/e/e
Neuro: CN2-12 intact, [**4-30**] upper and lower extremity strength,
sensation intact to light touch
Pertinent Results:
[**2138-10-23**] 05:57AM BLOOD WBC-8.4 RBC-4.15* Hgb-12.3* Hct-35.4*
MCV-85 MCH-29.6 MCHC-34.7 RDW-14.4 Plt Ct-196
[**2138-10-23**] 05:57AM BLOOD PT-12.6 PTT-25.9 INR(PT)-1.0
.
[**2138-10-22**] 08:56PM GLUCOSE-84 UREA N-26* CREAT-0.9 SODIUM-135
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12
[**2138-10-22**] 08:56PM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.8
.
[**2138-10-22**] Cardiac cath:
1. Access was retrograde via the right CFA to the selective
subclavian,
carotid, and vertebral arteries.
2. The thoracic arch was Type I without significant disease.
3. Subclavian arteries: The RSC was normal. The LSC had mild
disease
without lesions.
4. Carotid/vertebrals: The RCCA was normal. The [**Country **] was
occluded.
The right vertebral was normal. The right vertebral filled the
cerebellar and basilar sytems and the right MCA via the PCOM.
The left
vertebral was without lesions. The [**Doctor First Name 3098**] had a focal 90% lesion.
The
ICA filled the ACA/MCA with contralateral filling of the ACA.
5. Successful stenting of the [**Doctor First Name 3098**] was performed with a tapered
[**10-2**] x
30 mm Acculink stent.
6. Angioseal of the right groin was performed.
FINAL DIAGNOSIS:
1. Occluded [**Country **].
2. Severe stenosis of [**Doctor First Name 3098**].
3. Stenting of the [**Doctor First Name 3098**].
4. Angioseal of groin.
Brief Hospital Course:
1. [**Doctor First Name 3098**] stenosis. Pt had a left carotid stent placed without any
complications. He was initially started on neosynephrine given
risk of hypotension with disruption of baroreceptors. He was
gradually weaned off of neo for SBP between 95-140. Serial neuro
checks were normal. Pt was continued on Plavix.
*
2. CAD: No active issues. Pt was continued on asa, bb, ace,
statin.
*
3. DM: No active issues. Pt was continued on amaryl
*
4. COPD: Pt was continued on home inhalers.
Medications on Admission:
NIDDM, HTN, CAD ([**4-29**]:s/p PCI x 2,cypher to LAD and taxus to
RCA), hyperlipid,COPD, hematuria 2 weeks ago (s/p
IVP/cystourethrogram), non-small cell lung cancer
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. 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*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-27**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*3*
5. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 1* Refills:*3*
7. Amaryl 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
L internal carotid artery stenosis
Discharge Condition:
Stable
Discharge Instructions:
Restart your home medications.
call Dr. [**First Name (STitle) **] to schedule a follow-up appointment
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **]
|
[
"250.00",
"496",
"272.4",
"305.1",
"V10.11",
"433.30",
"401.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
5049, 5055
|
3301, 3800
|
363, 403
|
5134, 5142
|
1906, 3107
|
5294, 5343
|
1516, 1570
|
4017, 5026
|
5076, 5113
|
3826, 3994
|
3124, 3278
|
5166, 5271
|
1585, 1887
|
298, 325
|
431, 993
|
1015, 1323
|
1339, 1500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,510
| 160,775
|
3384
|
Discharge summary
|
report
|
Admission Date: [**2101-7-28**] Discharge Date: [**2101-8-5**]
Service: MED
Allergies:
Iodine; Iodine Containing / Cardura / Flomax
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
History of Present Illness:
ACCEPT NOTE:
86 y.o. male with multiple medical problems including lymphoma,
CRF, sent from Outside Hospital for change in mental status. He
was treated from [**6-24**] to [**2101-6-28**] at [**Hospital6 33**] for
Herpes Zoster in occipital area complicated by Coag Negative
Staph bacteremia due to a skin breakdown from the zoster. He
was treated with 2 weeks of vancomycin QOD with resultant
negative cultures.
Since d/c from [**Hospital3 **], he has had constant LBP and was
directly admitted to [**Hospital 38**] rehab [**2101-7-20**] for back pain and
alternating right and left hip pains and inability to ambulate.
Work up there included:
-MRI (w/o gadolenium) of cervical and lumbar spine showing bad
OA but no osteomyeltitis
-Bone Scan with increase uptake in L5-S1 (prelim result)
-TEE negative for vegetations
-TTE showed mild/mod AS
-Given oxycodone, robaxin, tylenol (QID scheduled) with
improvement in pain symptoms but mild delirium
On admission he was noted to be delirious and hypoxic to 72% on
RA (improved to 94%4L NC). Diuresed with 40IV lasix x2 with only
100cc out in 2hr (however, low UOP prior to lasix). Labs drawn
prior to diuresis consistent with acute renal failure (Cr 3.3,
BUN 77) and infection with 14K WBCs and 42% Bands. UA was
equivocal for UTI. He has been afebrile there but on scheduled
tylenol.
Other rehab notes: Guaiac positive with hct of 29 (trended down
from 34.5).
Patient unreliable historian given AMS but denies any localizing
symptoms. He did recall some SOB earlier today but no cough,
fever, chills. +constipation, dysuria, and decreased UOP (2x in
one week?). +back pain xwks, unchanged recently. Not getting OOB
at rehab but on lovenox.
In ED at [**Hospital1 18**], he was found to have WBC of 16 with 22% bands,
increased TB/alk phos and ARF on CRF. Renal U/S w/o hydro. RUQ
U/S with sludge-filled gallbaldder, no cholecystitis. ABG:
7.34/33/56 on 3L NC. V/Q scan showing low probability for PE.
Lactate 2.9. UA+ for UTI. In ED, patient was given Vanc 1 gm,
Levo 250 mg, and NS 500 cc.
Patient admitted to [**Hospital1 18**] MICU on [**2101-7-28**] for change in mental
status and ARF.
While in MICU, mental status improved with treatment of UTI,
bactermia, sepsis, ARF and dehydration. Patient with TEE no
vegetations, thus endocarditis unlikely. Patient with epidural
abcess, continued back pain. ARF improved slightly with
creatinine of 2.3 today. Crit currently stable, platelets
currently stable. Patient also with hyperbilirubinemia,with
elevated alk phosphate, largely unchanged from admission .
Past Medical History:
1) Polyarthritis of Hips, Knees and Lower Back
2) Non-Hodgkin's Lymphoma s/p radiation dx in [**2098**]
3) BPH s/p TURP in [**2096**]
4) HTN
5) Aortic Stenosis
6) Mitral Valve Regurgitation
7) Hearing Deficit, mild
8) Urinary Tract infections
9) Herpes Zoster
Social History:
Widow x 2 years. Still works part time in law office. No
EtOH/Tob since WWII.
Family History:
3 siblings: 1 died of unknown cause, 1 was murdered. Brother in
his 90s with Alzheimer's Dementia and brother in 70s in good
health. Parents died in their 90s.
Physical Exam:
VS: 168/90, 75, 22 96% rm air
GEN - no apparent respiratory distres, some pain on movement
HEENT - MM dry, anicteric, pupils constricted but responsive
bilat, difficutly following instructions for extraocular muscle
exam, well healed vesicles at the occipital area on left
NECK - mild JVD
CHEST - crackles at right base [**1-15**] way up, o/w CTA
CV - reg rate, harsh [**3-19**] SM at LUSB -> apex and carotid, no
s3/s4
ABD - soft, NT/ND, +BS
EXT - +1 ankle/pedal edema bilat
Neuro - A+Ox1 (only to name), A+Ox3 at ED no asterixis but mild
intention tremor, ROM: LE 45 degree of passive flexion, no
saddle anesthesia, no bowel, bladder incontinence (Foley). No
sensory deficits.
Rectal - Guaiac + (per ED)
Back - no CVAT, +lumbar paraspinal TTP, midline lumbar
tenderness, no warmth/erythema. Foley with dark urine
Pertinent Results:
---CXR7/15--CHF
--[**7-28**]---REnal U/S--non-obstructing stone,
V/Q-low probability PE,-- RUQ U/S-sludge-
[**7-31**] MR [**Name13 (STitle) 15662**] abcess/osteomyletis
[**8-3**] CXR-improved CHF
SPEP/UPEP negative-
D/c labs
[**2101-8-5**] 08:03AM BLOOD WBC-16.7* RBC-3.50* Hgb-9.7* Hct-29.4*
MCV-84 MCH-27.8 MCHC-33.1 RDW-16.0* Plt Ct-183
[**2101-8-5**] 08:03AM BLOOD Glucose-74 UreaN-54* Creat-2.0* Na-134
K-3.3 Cl-99 HCO3-20* AnGap-18
[**2101-8-4**] 06:20AM BLOOD ALT-47* AST-23 AlkPhos-305* TotBili-3.3*
[**2101-8-5**] 08:03AM BLOOD Mg-1.8
Brief Hospital Course:
In ED at [**Hospital1 18**], he was found to have WBC of 16 with 22% bands,
increased TB/alk phos and ARF on CRF. Renal U/S w/o hydro. RUQ
U/S with sludge-filled gallbaldder, no cholecystitis. ABG:
7.34/33/56 on 3L NC. V/Q scan showing low probability for PE.
Lactate 2.9. UA+ for UTI. In ED, patient was given Vanc 1 gm,
Levo 250 mg, and NS 500 cc.
Patient admitted to [**Hospital1 18**] MICU on [**2101-7-28**] for change in mental
status and ARF.
While in MICU, patient treated for E. Coli UTI, gram positive
bactermia/sepsis with vancomycin. TEE no vegetations, thus
endocarditis was ruled out and patient found to have epidural
abcess/osteomyletis by MRI with gadolinium. Patient's ARF on
his CRF (baseline creatinine 1.8), hyperbilirubinemia,
thrombocytopenia, coagulopathy, leukocytosis and anemia all
improved during his ICU with primary sepsis treatment.
Patient was then transferred to the floor and MRI with
gadolinium results came back indicating osteomyletis/epidural
abcess. Subsequently on [**8-2**] +5/5 blood cultures from admission
returned MSSA sensitive to oxacillin and patient was switched
from vancomycin to oxacillin.
1.Altered MS: Patient's confusion has resolved considerably with
treatment of his sepsis/UTI and thus toxic/metabolic causes were
largely responsible. He is still occasionally confused about
the hospital setting, thinks he is at home. Recent addition of
Zyprexa has helped with this delirium. In addition, he is very
sensitive to narcotics, which worsens his delirium. Thus
narcotics have been restricted in the use of his pain. He is
currently alert and oriented x 3 with rare episodes of delirium.
He is currently on a low prn dose of oxycodone/
2.MSSA sepsis/bacteremia--Patient with MSSA sepsis secondary to
epidural abcess/osteomyletis (+[**5-18**] for MSSA [**7-28**]--MRI w. gad),
initially treated with vancomycin for 4 days prior to culture
results sensitivity indicating MSSA, now on day 4 of oxacillin
and subsequent surveillance cultures ([**7-31**], 7?20, [**8-3**]) have
been negative. Labs indicated above are trending toward normal
limits with resolution of symptoms. Of note are his elevated
LFT's which are improving but trending down. Oxacillin can be
continued with weekly LFT's, with the consideration that
elevation of his LFT's are elevated in response to his resolving
bacteremia/sepsis
3.UTI - E. Coli resolved on full course of Levoquin. and +[**5-18**]
blood cultures gram positive cooci.
4. Shortness of Breath/CHF: Patient originally dysnpeic on
admission/respiratory distress. Given fluids in MICU for
sepsis, up about 5 liters. Gently diureses on the floor due to
renal function with complete improvement of shortness of breath.
Etiology CHF consistent with Xray--ruled out for PE given low
probability V/Q.
5. ARF on CRF: creat 2.9 on admission with baseline 1.5-1.7.
CRF likely secondary to hypertension, ARF sepsis/dehyrdation.
Patient is returning to baseline with restriction of NSAIDs,
ACE, and gentle hydration. Renal U/S negative for other
causes.UPEP/SPEP-no MM>
6. GIB/anemia: hct 29.3 down from baseline of 35-39. Guaiac
positive on exam. Gastritis. Patient's anemia improving with
treatment of sepsis-likely primary cause. Anemia work-up
consistent with that.
7. HYperbilirubinemai--as above.
8. Thrombocytopenia, increased INR--given 2.5 mg vitamin K [**8-2**],
likely secondary to sepsis because resolving well with
treatment.
9. Neuro status/epidural abcess -as above: patient discharged
with normal lower extremity examneurological exam--no sensory or
motor deficits, although his exam is limited by pain--active hip
flexion limited to 45 degrees. He has no evidence of chord
compression and never has-no saddle anesthesia, bowel or bladder
incontinenece. Seen by neurosurgery. Some radicular pain.
Follow up treatement will require oxacillin until [**2101-9-11**], an
MRI 1 month from this discharge and weekly LFT's to check for
oxacillin tox--consider of resolving cholestatsis secondary tos
sepsis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
MSSA sepsis, chronic renal failure, osteomyletis, epidural
abcesss-
Discharge Condition:
stable
Discharge Instructions:
Patient to follow up with PCP from rehab facility.
Followup Instructions:
-Oxacillin until [**9-11**]--
--Weekly Liver function tests--
MRI in one month
|
[
"578.9",
"287.5",
"202.80",
"599.0",
"276.5",
"584.9",
"403.91",
"038.11",
"324.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8915, 9004
|
4875, 8892
|
267, 299
|
9115, 9123
|
4307, 4852
|
9223, 9304
|
3292, 3455
|
9025, 9094
|
9147, 9200
|
3470, 4288
|
206, 229
|
327, 2895
|
2917, 3178
|
3194, 3276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,271
| 148,595
|
31010
|
Discharge summary
|
report
|
Admission Date: [**2131-5-29**] Discharge Date: [**2131-6-9**]
Date of Birth: [**2064-8-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Transfer from outside hospital for concern of tracheomalacia
Major Surgical or Invasive Procedure:
Flexible bronchoscopy ([**5-30**])
placement of interpulmonary stent ([**6-1**])
History of Present Illness:
Pt is a 66F transferred from [**Hospital1 1562**] with tracheomalacia. She
was admitted on [**5-21**] for COPD exacerbation after outpatient taper
of prednisone from 40 to 20mg and was intubated there. Ms.
[**Known lastname **] was extubated over the weekend prior to admission but
night of [**5-28**] had increased bp, tachycardia. She was
re-intubated [**5-29**], s/p bronch which demonstrated 90% occlusion
w/ expiration. Patient experienced hypotension to systolic 80's
during bronch thought to be medication related (7mg versed). Pt
rec'd 700 cc of NS, and levophed at 2mcg/min weaned to off on
the ride over from OSH.
Of note, lovenox was d/c'd this a.m. due to hematuria but with
stable hct.
Past Medical History:
COPD
GERD
depression
50 pack year smoker
Social History:
lives at home with husband. 50 pack year hx quit in 82. occ
etoh.
Family History:
Mother died at 63 from MI, Father died 81 from etoh related
Physical Exam:
V/S: Tm 101 HR 114 BP 121-147/50s 100% on FiO2 40% PS 17 PEEP 8
GEN: awakes to name, follows commands suchs as hand squeeze and
toe movement
HEENT: intubated, PERRLA
CV: s1 s2 no m/r/g
LUNGS: occais wheezes anteriorly
ABD: soft, nt/nd +bs, bruising on lower abd extending to upper
labia
EXT: no c/c/e, bruising on upper arm
Pertinent Results:
Labs on admission:
[**2131-5-29**] 08:52PM BLOOD WBC-8.5 RBC-3.39* Hgb-11.0* Hct-31.3*
MCV-92 MCH-32.4* MCHC-35.0 RDW-14.3 Plt Ct-226
[**2131-5-29**] 08:52PM BLOOD Neuts-84.8* Bands-0 Lymphs-10.1*
Monos-4.5 Eos-0.5 Baso-0.1
[**2131-5-29**] 08:52PM BLOOD PT-12.7 PTT-23.7 INR(PT)-1.1
[**2131-5-29**] 08:52PM BLOOD Glucose-119* UreaN-17 Creat-0.6 Na-142
K-3.6 Cl-103 HCO3-28 AnGap-15
[**2131-5-29**] 08:52PM BLOOD ALT-31 AST-16 LD(LDH)-231 AlkPhos-44
Amylase-26 TotBili-0.5
[**2131-5-29**] 08:52PM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.9 Mg-2.0
[**2131-5-29**] 09:23PM BLOOD Lactate-1.4
[**2131-5-29**] 09:23PM BLOOD freeCa-1.13
Labs on discharge:
Microbiological data:
[**2131-6-1**] c diff- negative
[**2131-6-1**] 12:56 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2131-6-3**]**
GRAM STAIN (Final [**2131-6-1**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2131-6-3**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2131-6-1**] Bcx -pending
[**2131-5-31**]-Bcx- pending
[**2131-5-31**]-UCx- no growth
[**2131-5-30**]-
GRAM STAIN (Final [**2131-5-30**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2131-6-1**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2131-5-30**] BCx x 2- No growth
[**2131-5-30**] UCx- No growth
_______________________________________
Radiology:
[**2131-5-30**] CXR AP-Lungs are clear. Heart size is normal and there
is no evidence of appreciable pleural effusion. ET tube and
right subclavian line are in standard placements respectively
and a nasogastric tube passes below the diaphragm and out of
view. No pneumothorax.
[**2131-5-31**] CXR AP-
The ET tube tip is 5.4 cm above the carina. The NG tube tip
terminates in the stomach. The right subclavian line tip is in
the mid SVC. Heart size is normal. Lungs are unremarkable. No
sizeable pleural effusion is identified.
[**2131-6-1**] CXR AP-
Interval development of mild lower lobe interstitial pulmonary
edema.
Findings were discussed with Dr. [**First Name (STitle) **] on date of exam at
approximately 4:30 p.m.
[**2131-6-2**] CXR AP-IMPRESSION: No CHF or pneumonia. Satisfactory
endotracheal tube tip placement.
[**2131-6-3**]-IMPRESSION: No pneumomediastinum. Support tubes and
lines stable. Lungs clear.
Brief Hospital Course:
Impression/Plan: 66 yo female with COPD flare s/p intubation;
transferred secondary to concern for tracheomalacia. s/p stent
by interventional pulmonary on [**2131-6-1**].
1. COPD- initially admitted for exacerbation at OSH and was
intubated. She was successfully extubated but reintubated [**5-29**]
due to ?tracheomalacia. Pt was transferred here vented and is
s/p IP stent placement with good resolution of tracheomalacia on
[**6-1**]. She was continued on a steroid taper and nebulizer
treatments. In terms of weaning, she was changed from AC to
pressure support but had a lot of tachypnea, likely secondary to
a large anxiety component. Ativan was too sedating for her. On
HD 5, she was able to be changed to pressure support and was
weaned down. She was successfully extubated on [**2131-6-4**]. She
required BiPAP for a short period of time on [**2131-6-5**] for
increased WOB, but has been stable since then, on [**2-17**] L NC and
comfortable. She had PFTs and a 6 minute walk test with IP prior
to discharge. She remained stable on 2-3L NC (baseline).
2. [**Name (NI) 25933**] pt had several fever spikes during her first few days
of hospitalization. Patient was pancultured, without any obvious
source. CXR did not reveal evidence of PNA. Sputum cultures here
were mixed oropharyngeal flora. The central line was d/cd on HD
#6 when a PICC was placed; tip was sent to culture. It is
possible that the central line (placed [**2131-5-22**]) at OSH was a
potential source. Pt was on vancomycin and levaquin started on
HD 3 for a 10 day course (end [**2131-6-11**]). She had no futher fever
after transfer to the floor.
3. Tachycardia and HTN- EKG showed sinus tachycardia which was
attributed to severe anxiety. She was started on IV metoprolol
q4 hours which was required HD [**2-19**] and then d/cd. Her
tachycardia is also likely [**2-16**] albuterol nebs and dehydration.
IVF were given, which helped her tachycardia to some degree.
Patient was not symptomatic. Her tachycardia has improved since
transfer to the floor, she is baseline in the low 100's (sinus
tach) with occasional bumps to the 120's with anxiety.
4. Anxiety- as above. Ativan was attempted but lead to severe
somnolence. Lexapro was continued.
5. GERD- continued protonix
6. Anemia-baseline Hct is 34. There was evidence of extensive
ecchymosis from lovenox SC on pt's lower abdomen/labial area.
She was guaiac positive though Hct remained stable. PPI was
increased to [**Hospital1 **] and this will need to be addressed as an outpt.
7. Hypokalemia - Pt had mild hypokalemia noted on the day of
discharge. She was repleted with po KCL and lab rechecked. It
should be monitored intermittently while in rehab.
8. FEN- Was on tubefeeds while intubated.
9. PPx- pneumoboots, insulin sliding scale as on iv steroids .
Heparin sc not given [**2-16**] ecchymosis was above. Pneumoboots were
employed.
10. ACCESS- RIJ placed [**5-22**] d/cd [**2131-6-4**] when PICC was placed.
We d/ced A-line on [**6-2**]
10. CODE- FULL
Medications on Admission:
Duonebs
Combivent
Ativan
[**Doctor First Name **]
Spiriva
colace
lovenox 40 sc
lexapro 20' (from celexa 40 QDay)
[**Doctor First Name 130**] 60''
lasix 20 iv prn (last given [**5-28**] 23:51)
Insulin ss
solumedrol 10 mg'
pantoprazole 40 iv'
propofol drip
senakot
tylenol prn
ativan 2mg IV prn
maalox prn
zofran
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day) as needed.
2. Fexofenadine 60 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times
a day).
3. Prednisone 10 mg Tablet [**Month/Year (2) **]: As instructed Tablet PO once a
day: Take 4 tablets daily x 3 days (40 mg), 3 tablets daily x 3
days (30 mg), 2 tablets daily x 3 days (20 mg), 1 tablet daily x
3 days (10 mg) and then 0.5 tablet daily x 3 days (5 mg), then
stop.
Disp:*22 Tablet(s)* Refills:*0*
4. Escitalopram 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
6. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Guaifenesin 600 mg Tablet Sustained Release [**Hospital1 **]: Two (2)
Tablet Sustained Release PO bid ().
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
11. Lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]- [**Hospital1 1562**]
Discharge Diagnosis:
Tracheomalacia s/p stenting
COPD
Pneumonia
Discharge Condition:
Stable.
Discharge Instructions:
You were hospitalized for tracheomalacia following intubation
for COPD. You had a stent placed in your trachea by
interventional pulmonology and will need to be carefully
followed by them after your discharge. You were also treated for
pneumonia, and will need to continue antibiotics as an
outpatient until [**2131-6-9**].
Call your doctor or return to the emergency department if you
experience any of the following:
- worsening shortness of breath
- new cough
- chest pain or difficulty breathing
- fever > 102
- any new or concerning symptoms
Followup Instructions:
Please follow up with the Interventional Pulmonology clinic one
week following your discharge. You will need to call for an
appointment. The number to call is ([**Telephone/Fax (1) 17398**].
Please make an appointment to see you primary care provider
after your discharge from rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"785.0",
"530.81",
"496",
"519.19",
"486",
"300.00",
"792.1",
"276.8",
"V17.3",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"33.23",
"96.6",
"96.72",
"33.22",
"38.93",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
9306, 9375
|
4432, 7438
|
336, 418
|
9462, 9472
|
1732, 1737
|
10068, 10447
|
1311, 1372
|
7800, 9283
|
9396, 9441
|
7464, 7777
|
9496, 10045
|
1387, 1713
|
236, 298
|
2380, 4409
|
446, 1148
|
1751, 2360
|
1170, 1212
|
1228, 1295
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,202
| 164,976
|
30386
|
Discharge summary
|
report
|
Admission Date: [**2146-9-20**] [**Month/Day/Year **] Date: [**2146-9-30**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Cipro
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
fall, open left leg wound
Major Surgical or Invasive Procedure:
Left leg open wound debridement
History of Present Illness:
56-year-old man with history of acute myeloid leukemia ([**2142**]),
status post allogeneic stem cell transplant ([**2142**]) complicated
by graft-versus-host disease, also history of pulmonary embolism
on warfarin presents after a recent mechanical fall and
subsequent bleeding from leg wound.
.
On [**2146-9-19**] patient fell onto his left side, bruising his left
lower leg, which became swollen. He also noted increased pain
in L hip, however this was within the range of his chronic pain
in b/l hips due to AVN. He noted pain in Left leg, however
decided to monitor the pain an bruising. On the day of
admission, the swelling worsened, his leg became dusky, after
taking a shower, LE pain worsened . He presented to OSH, where
the hematoma ruptured and bled profusely. He was given vitamin K
10 mg IM x 1 and FFP. Surgicel was applied. He was then
transferred to [**Hospital1 18**].
.
At [**Hospital **] hospital initial VS were 98 130 158/97 22 98% RA w/
SBP to 110s by 1900 and HR 90s - 100s. INR was 2.8, PTT 42, HCT
was 32, Cr 1.4. Pt. was given 1 FFP, 10mg IM Vitamin K, 4 mg of
Dilaudid and transferred to [**Hospital1 18**].
.
In [**Hospital1 18**] ED, his vitals were T 97.8, HR 82, BP 126/73, HR 18,
97%
RA. Pt. was seen by plastics, would was open, and debrided the
wound removing clots, they found "viable muscles" w/o active
bleeding. Exam post debridement revealed a soft left leg with
palpable distal pulse on the R and dopplerable L. It was felt
not to be consistent with compartment syndrome by orthopedics
who will follow. In the ED SBP nadired at 82 (although lowest
recorded is 94), HR 80-90s. Pt. received 2L NS, 10mg IV Vitamin
K, morphine IV and Zofran. At time of transfer VS were 96/61
86 100% 2 LNC. Left leg Xrays revealed no fracture on
preliminary read.
.
Of note, he was recently admitted to [**Hospital **] hospital for a cat
bite infection, treated w/ IV ABx and sent home on Penicillin.
Past Medical History:
# Pulmonary embolism x2 ([**2143**] and dx [**5-/2146**] in RML and RLL): on
warfarin
# Acute myeloid leukemia:
- [**3-/2143**]: diagnosed
- [**6-/2143**]: underwent a matched unrelated allogeneic stem cell
transplant.
- post-transplant course c/b bx-proven GVHD of the liver and an
intermittent skin rash, s/p management with cyclosporine,
mycophenolate, rituximab, and currently, steroids.
# type 2 DM: steroid-induced
# hyperlipidemia
# bilateral hip AVN
# HTN
# nephrolithiasis: s/p lithotripsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
# BCC s/p excision
# SCC left cheek, s/p Mohs' [**5-/2144**]
# multiple back surgeries: L5-S1 surgery x 3, and cervical spine
fusion (bone graft, no hardware)
# anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]
# chronic numbness, neuropathic pain in left upper extremity
# multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4
# OSA: on BIPAP at home
Social History:
Lives with his wife, and [**Name2 (NI) **]. [**Name2 (NI) **] is retired, worked as a
[**Company 22957**]
technician
Tobacco - 40 pk year hx, quit 5 yrs ago.
EtOH - denies
Drug use - denies.
Family History:
Mother died suddenly in her 70s.
Father died of unknown cancer.
One sister has thyroid cancer.
One brother has diabetes.
One sister has [**Name (NI) 5895**].
Physical Exam:
T 97.8, HR 82, BP 126/73, HR 18, 97%RA
General: Eyes closed, opens to voice, awakens but is sleepy at
rest. Oriented, no acute distress
HEENT: Sclera anicteric, dMM, pale conjunctiva, oropharynx clear
Neck: supple, JVD not assessed, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: Cool [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l, L and R equally, there is 1+ edema at L foot,
trace in R foot. Echymoses on R toes. Extensive echymoses on
UEs. R hand w/ mark of old cat bite, no purulence, no
fluctuance.
Pulses: 2+ femoral b/l, DP 2+ on R, dopplerable on L.
Neuro: MS - see above.
Motor:
RLE: full at IP/Q/H/TA, [**Last Name (un) 938**] and EDB 5-/5.
LLE: full at IP/Q/H (magnitude of movement limited by pain), [**3-21**]
TA/[**Last Name (un) 938**]/EDB, full G. DTRs depressed at b/l achilles.
Sensory: sensate LT bilaterally, but decresed on L vs. R, intact
proprioception.
Pertinent Results:
[**2146-9-20**] 08:44PM COMMENTS-GREEN
[**2146-9-20**] 08:44PM K+-4.3
[**2146-9-20**] 08:43PM GLUCOSE-137* UREA N-19 CREAT-1.2 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11
[**2146-9-20**] 08:43PM estGFR-Using this
[**2146-9-20**] 08:43PM WBC-10.2# RBC-2.45*# HGB-9.5*# HCT-28.3*#
MCV-116* MCH-38.8* MCHC-33.5 RDW-15.0
[**2146-9-20**] 08:43PM NEUTS-81.9* LYMPHS-13.3* MONOS-4.2 EOS-0.3
BASOS-0.3
[**2146-9-20**] 08:43PM PLT COUNT-168
[**2146-9-20**] 08:43PM PT-26.0* PTT-26.6 INR(PT)-2.5*
IMAGING:
[**2146-9-21**]
XR of L femur
IMPRESSION: No fracture.
[**2146-9-21**]
b/l lower ext doppler
IMPRESSION: Normal appearance of the common femoral, superficial
femoral, and
popliteal veins bilaterally.
No below knee venous thrombus on the right side.
[**2146-9-21**]
FINDINGS: In comparison with study of [**5-23**], there is little
change and no
evidence of acute cardiopulmonary disease. No pneumonia,
vascular congestion,
or pleural effusion. Of incidental note is a cervical fusion
device.
LABS at [**Date Range **]:
[**2146-9-30**] 05:30AM BLOOD WBC-6.0 RBC-3.05* Hgb-9.9* Hct-31.1*
MCV-102* MCH-32.3* MCHC-31.8 RDW-20.5* Plt Ct-293
[**2146-9-29**] 05:25AM BLOOD Neuts-68 Bands-0 Lymphs-20 Monos-7 Eos-4
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2146-9-30**] 05:30AM BLOOD Plt Ct-293
[**2146-9-30**] 05:30AM BLOOD PT-15.7* PTT-34.4 INR(PT)-1.4*
[**2146-9-30**] 05:30AM BLOOD
[**2146-9-30**] 05:30AM BLOOD Glucose-106* UreaN-15 Creat-1.0 Na-139
K-3.9 Cl-98 HCO3-34* AnGap-11
[**2146-9-30**] 05:30AM BLOOD ALT-12 AST-11 LD(LDH)-192 AlkPhos-100
TotBili-0.4
[**2146-9-30**] 05:30AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.1 Mg-2.1
Brief Hospital Course:
56-year-old man with history of acute myeloid leukemia, status
post allogeneic stem cell transplant complicated by
graft-versus-host disease, and history of pulmonary embolism
(most recent [**5-/2146**]) now on warfarin presents with bleeding from
a leg wound s/p fall/trauma.
.
# Left leg ruptured hematoma: The patient's lowest hematocrit
was 22. After being transfused 3 units PRBCs, his hct rose to 31
and remained stable thereafter. Plastics reassessed the wound
the day after admission and found it to be clean with viable
muscle. Plastics recommended continued packing of the wound and
healing by second intention. They will consider a skin graft in
the future if required. His pain was controlled with IV
morphine and Dilaudid as well as his home regimen for chronic
pain (see below). When the patient's hct was stable and there
were no signs of further bleeding, he was transfered out of the
ICU to the BMT service. On the floor, he received daily dressing
changes. He did not receive a skin graft.
.
# Chronic pain: Home regimen of gabapentin 300 mg qhs,
hydromorphone 2-4 mg q4-6h prn
pain, and oxycodone SR 60 mg morning, 20 mg afternoon, 60 mg
evening. His home regimen was restarted prior to transfer from
the ICU. He was eventually place on Dilaudid PCA with standing
oxycontin. This was titrated for pain. On [**Year (4 digits) **], he lfet
with oxycontin 80mg TID and Dilaudid PO for breakthrough.
.
# H/o PE: History of bilateral PE on lifelong anticoagulation.
Coumadin held while in ICU. He has not done well with SQ
therapy in the past ( both lovenox and heparin given how fragile
his skin is). Restarted Coumadin with Lovenox bridge until
therapeutic. Goal INR is 2-2.5. His INR on [**Year (4 digits) **] was 1.4.
.
# Recent cat bite infection. Unclear hx and course of ABx or
organisms. He was on Penicillin on admission. He was switched
to augmentin on [**9-21**] to cover the cat bite as well as wound ppx.
He will continue Augmentin for 2 more days following [**Month/Day (4) **].
.
# AML: s/p SCT, now with chronic GVHD. Continued prednisone 10
mg daily. Continued prophylaxis with acyclovir 400 mg [**Hospital1 **].
Restarted sulfamethoxazole-trimethoprim 400-80 mg daily on
[**Hospital1 **].
.
# Hyperlipidemia: Continued atorvastatin 20 mg daily.
.
# Hypertension: Held BB in ICU.
.
# Type 2 DM: Continued insulin Humalog sliding scale and
insulin NPH 12 units SC bid
Medications on Admission:
--acyclovir 400 mg [**Hospital1 **]
--atorvastatin 20 mg daily
--budesonide SR 3 mg tid
--folic acid 1 mg daily
--gabapentin 300 mg qhs
--hydromorphone 2-4 mg q4-6h prn pain
--insulin Humalog sliding scale
--insulin NPH 12 units SC bid
--metoprolol succinate 50 mg daily
--oxycontin SR 60 mg morning, 20 mg afternoon, 60 mg evening
--pantoprazole 40 mg [**Hospital1 **]
--prednisone 10 mg daily
-sulfamethoxazole-trimethoprim 400-80 mg daily - stopped taking
unknown amount of time ago.
--warfarin 3.5mg MWF, otherwise 5mg daily.
--cholecalciferol 400 units daily
--Pen VK 500mg QID.
[**Hospital1 **] Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
3. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
Disp:*30 Tablet(s)* Refills:*2*
13. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
Disp:*30 syringe* Refills:*2*
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
18. oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*0*
19. zolpidem 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as
needed for sleep.
20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
21. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
22. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
[**Hospital6 **] Diagnosis:
Left lower leg bleeding wound.
[**Hospital6 **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Hospital6 **] Instructions:
Dear Mr. [**Known lastname 47367**],
It was a pleasure participating in your health care. You were
admitted to the hospital with a leg wound after falling. The
bleeding from your wound was severe enough to necessitate blood
transfusions. After being transfused, your blood levels
(hematocrit) rose and stabilized. Your coumadin was held while
bleeding was aconcern. The Plastic Surgery team assessed your
wound and dressed it appropriately. You were started on an
antibiotic called augmentin for the [**Last Name (un) **] bite and to prevent
infection of your leg. You were transferred out of the ICU to
the BMT floor for continued care. On the floor your red blood
cell count was followed closely but you did not require
transfusions. You were started on coumadin and lovenox to thin
your blood. Your pain was controlled with a combination of
dilaudid pca and oxycontin. Your pain was not fully under
control but lessened by this regimen.
The following changes were made to your medications:
START Augmentin (until - [**10-1**])
START Coumadin 7.5 mg daily
START Lovenox inj 100mcg daily
Followup Instructions:
Please follow-up with Plastic surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1
weeks. Please call [**Telephone/Fax (1) 6331**] to schedule this appointment.
|
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[
[
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,219
| 187,133
|
51065
|
Discharge summary
|
report
|
Admission Date: [**2174-5-13**] Discharge Date: [**2174-6-5**]
Service: General Surgery
CHIEF COMPLAINT: Nausea and vomiting.
HISTORY OF PRESENT ILLNESS: Patient is an 81 year-old
gentleman with the history of bladder cancer with spread to
the rectum who is currently being treated with chemotherapy
who presents with two to three weeks of progressively
worsened nausea nd vomiting. The nausea and vomiting is
worse after meals. He has developed a dysphagia originally
to solids and more recently now to liquids. He describes a
pressure in his chest after eating which lasts for several
minutes to hours followed by vomiting which relieves that
pressure. He presented to an outside hospital for evaluation
and it was thought that due an admission CT scan for bladder
cancer follow up work he might have retained contrast in his
gastrointestinal system. He was prescribed magnesium citrate
for bowel clean out. The symptoms persisted and the patient
then presented to the [**Hospital1 69**]
for further work up.
Regarding the patient's bladder cancer it was discovered in
[**2173**] when he presented with enuresis. Prior to this patient
had been followed for abnormal digital rectal examination and
he underwent a transrectal biopsy which showed poorly
differentiated carcinoma positive for CEA cytokeratin 7 and
20 but negative for PSA for PSAP. Patient has had further
work up including a negative bone scan and MRI which revealed
an asymmetric bladder wall thickening and thickening of the
rectum. He was started on gemcitabine and Ciscarboplatin
chemotherapy which has improved his symptoms and on follow up
CT scan the disease appears stable on [**2174-5-4**].
REVIEW OF SYSTEMS: Patient just reports a ten pound weight
loss over the last two to three weeks. He denies any fevers,
chills, shortness of breath, chest pain.
PAST MEDICAL HISTORY: Significant for 1) hypertension, 2)
paroxysmal atrial fibrillation, 3) bladder cancer.
PAST SURGICAL HISTORY: None.
MEDICATIONS: On admission include Coumadin 5 mg/5 mg/2.5 mg
repeated. Parnate 10 mg p.o. q.d. Dyazide 37.5/25 p.o.
q.d., Elavil 50 mg p.o. q.h.s., Bioptic GGT b.i.d. and
Lopressor 50 mg p.o. b.i.d.
ALLERGIES: Patient has no known drug allergies.
SOCIAL HISTORY: Patient is married, lives with his wife in
[**Name (NI) **].
PHYSICAL EXAMINATION: Patient is in no acute distress, blood
pressure 110/80, heart rate 66, respirations 14. Oropharynx
is clear, no lymphadenopathy in neck. Lungs are clear to
auscultation bilaterally. He is regular rate and rhythm with
a II/VI systolic ejection murmur. Abdomen is soft and
nontender, no palpable hepatosplenomegaly, no abdominal
distention. There is no inguinal lymphadenopathy. Rectal
examination revealed narrow canal with firmness on the left
side of the prostate. No peripheral edema.
LABORATORY DATA: On admission included white count of 9.4,
hematocrit of 36.4, platelets 224. PT 13.3, INR of 1.2.
Sodium of 134, potassium 3.3, chloride of 90, bicarbonate of
33, BUN 19, creatinine 1.5, glucose 101, ALT 15, AST of 39,
alk phos of 88, total bilirubin of 0.6, calcium 8.3,
magnesium 2.0. Electrocardiogram showed sinus tachycardia
with a rate of 100, no acute ischemia. Chest x-ray was
significant for elevated left hemidiaphragm and minimal
subsegmental atelectasis of the left lung. CT scan done on
[**2174-5-4**] was significant for no bladder wall or rectal wall
thickening of any significance. Bilateral moderate
hydronephrosis which is stable and increased atrophy of the
left kidney.
HOSPITAL COURSE: Patient was admitted to Medicine, made
n.p.o. and patient underwent a barium swallow [**2174-5-13**]. It
showed irregular erosions of the esophageal wall, elevation
of the left hemidiaphragm and abnormal position of the
stomach. Patient then underwent esophagogastroduodenoscopy
by the gastrointestinal service on [**2174-5-16**] which was
significant for grade 2 esophagitis of the lower third of the
esophagus and open pylorus and an extrinsic stenosis of the
second part of the duodenum. The patient felt
symptomatically better after several days of bowel rest.
Patient was restarted on liquid diet, was on Protonix for his
gastritis and subsequently developed nausea and vomiting once
again and intolerance to any p.o. intake. At this point
patient had a PICC line placed. Total parenteral nutrition
was started. A second esophagogastroduodenoscopy with
biopsies was performed. The esophagogastroduodenoscopy was
significant for gastric inlet patch, gastritis of the stomach
and extrinsic stenosis of the second part of the duodenum
once again. The biopsies were negative for any malignancy.
Surgery was consulted and once being cleared by cardiology
due to his history of paroxysmal atrial fibrillation patient
was taken to the operating room on [**2174-5-27**] for planned
gastrojejunostomy. During rapid induction for intubation
patient became hypotensive with systolic blood pressure in
the 60s and the monitor showed an eight beat run of
ventricular tachycardia. Patient was intubated, started on
pressors and was taken to the Intensive Care Unit without
undergoing any procedure. Patient in the Intensive Care Unit
remained hemodynamically stable. He was weaned off pressors
and extubated without incident. CKs were flat. Troponin Is
were 1.9 and 1.8 respectively. There were no
electrocardiographic changes post event. After spending
several days in a closely monitored setting it was decided
the patient would once again return to the operating room on
[**5-30**]. Patient was inducted without any incident. Patient on
[**2174-5-30**] underwent a gastrojejunostomy, anal dilatation and a
biopsy of intraoperative finding of a retroperitoneal mass
which was compressing the duodenum. Patient tolerated this
procedure well, was transferred to the post anesthesia care
unit extubated and in stable condition. He was then
transferred to the Surgical Intensive Care Unit for close
monitoring and after spending one night patient was then
transferred to the floor for the remainder of his recovery.
Postoperatively cardiology-wise patient remained stable with
no postoperative electrocardiogram changes. Postoperatively
the patient has remained afebrile. He received a five day
course of Levaquin. On postoperative day number one after
being transferred to the floor patient received rapid atrial
fibrillation with a stable blood pressure. He was treated
with intravenous Lopressor and became rate controlled.
Patient then converted spontaneously to sinus. On
postoperative two the patient once again had an episode of
rapid atrial fibrillation which was rate controlled and
patient converted back to normal sinus. Patient has remained
on beta blockade with adjustments as appropriate. Patient
was restarted on his Coumadin on postoperative day number
three and his current INR is 1.7. The patient received 5 mg
of Coumadin for tonight and will be followed by Dr. [**Last Name (STitle) 2539**] as
he has been doing in the past. Patient's respiratory status
has remained stable. He has been weaned off oxygen with O2
saturations in the high 90 percents. Patient's nasogastric
tube was discontinued on postoperative day number two and he
has been advanced to a soft diet which he is tolerating.
Patient's total parenteral nutrition was weaned and the PICC
line was removed. Patient has been cleared by physical
therapy for discharge to home and has been ambulating without
problem. Patient's hematocrit has remained stable at 30.
Patient's electrolyte balance has remained sable and kidney
function has remained stable with his last BUN and creatinine
being 33 and 1.0. Patient is stable and ready for discharge
to home.
The biopsy of the retroperitoneal mass pathology has returned
result of poorly differentiated adenocarcinoma, signet cell
features, positive for keratin and cytokeratin 7 and 20.
This is the same staining properties as the mass biopsied
from the bladder and is likely metastatic disease. Patient
was seen by the oncology service and outpatient chemotherapy
and will continue.
Patient will follow up with Dr. [**Last Name (STitle) 1305**] in one week and will
follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**] in one week for Coumadin
adjustment and atrial fibrillation management.
DISCHARGE DIAGNOSES:
1. Duodenal obstruction secondary to metastatic bladder
cancer, status post gastrojejunostomy.
2. Anal stenosis, status post anal dilatation.
3. Hypertension.
4. paroxysmal atrial fibrillation.
5. Hypertension.
6. Gastritis.
DISCHARGE MEDICATIONS: Include Protonix 40 mg p.o. q.d.,
Dilaudid 2 mg p.o. 1 to 2 p.o. q 4 hours p.r.n., Colace 100
mg p.o. b.i.d., Parnate 10 mg p.o. q.d., Dyazide 37.5 mg/25
p.o. q.d., Elavil 50 mg p.o. q.h.s., Coumadin 5/5/2.5 p.o.
repeated, Bioptic GGT b.i.d. and Lopresor 50 mg p.o. b.i.d.
CONDITION N DISCHARGE: Stable.
Patient will be discharged to home to follow up with Dr.
[**Last Name (STitle) 1305**] in one week and Dr. [**Last Name (STitle) 2539**] in one week, and oncology
service which patient will call for appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2174-6-5**] 10:21
T: [**2174-6-5**] 10:53
JOB#: [**Job Number 106061**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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8379, 8643
|
8667, 9465
|
3577, 8358
|
1990, 2249
|
2351, 3559
|
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|
118, 140
|
169, 1691
|
1878, 1966
|
2266, 2328
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,221
| 124,628
|
6131
|
Discharge summary
|
report
|
Admission Date: [**2106-3-17**] Discharge Date: [**2106-4-3**]
Date of Birth: [**2037-4-28**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Chills, fatigue.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 68 year-old man with high grade follicular lymphoma dx
in [**2105-6-26**] resistant to multiple chemotherapeutic regimens,
now 8 days s/p R-CHop (first cycle) admitted to [**Hospital Unit Name 153**] with
sepsis. He presents to the [**Hospital1 18**] ED complaining of fatigue,
shortness of breath, 1 day of chills, and abdominal fullness. He
was feeling more or less in his usual state of health when
presented to [**Hospital 478**] clinic on [**3-15**] for a count check. He only
complained of fatigue and foot swelling. He was given an
additional lasix 20mg iv and kcl 20meq. He was also given a PRBC
transfusion via his PICC line
.
In ED bp initially 100's but then to 60's-70's, non-rebreather
throughout in low to mid 90's, heart rate 90-110's. He got 5
liters fluids, fem line placed, started on two
pressors-levophed, neosynephrine, given cefipime, vancomycin,
ambisome. Pan-cultured, PICC line d/ced and sent for culture.
Chest CTA showed multi-focal pneumonia. Patient asked not to be
intubated unless tehre was no other option.
Past Medical History:
1. High grade follicular lymphoma: He was diagnosed with a high-
grade lymphoma in [**Month (only) 205**] of this year when he presented with night
sweats, diffuse bone pain, and bulky diffuse adenopathy. He was
initially treated with CHOP to which he initially had a good
response. He has also been treated with R-[**Hospital1 **], and ICE. He has
had numerous neurological complications from his lymphoma. He
developed blurred vision, for which he responded well to
radiation therapy. He also developed a C3-5 mass that resulted
in left arm weakness such that he is unable to raise his arm. He
also has a medial nerve palsy and decreased sensation on the
left forearm. He underwent radiation therapy to the C3-5 lesion
with no effect.
He is now undergoing R-CHOP-day #8 of cycle 1
2. Melanoma-in-situ on left foot: Resected in [**2099**], no evidence
of recurrence on [**2100**] biopsy.
3. Hypertension.
4. hx of prostatitis
5. Neuropathy secondary to vincristine
6. Recent hospitalization for MRSA high grade bacteremia from
port-a-cath
7. More recent hospitalization (d/c on [**2106-2-18**]) for chord
compression-radiation and high dose steroids.
8. Focal dorsal epidural mass centered at T9-10 levels with
extension through the neural foramen, with a moderate degree of
cord compression
Social History:
He lives in [**Location 23962**], is married, and has two children. He is
a math professor [**First Name (Titles) **] [**Last Name (Titles) 15559**]. He is a non-smoker and
used to drink 2 wine with dinner but has stopped once he was
diagnosed with lymphoma.
Family History:
There is no history of cancer in his immediate family. He has
three healthy siblings.
Physical Exam:
VS: Temp: BP: / HR: RR: O2sat
.
general: pleasant, comfortable, NAD
HEENT: PERLLA, EOMI, anicteric, no scleral icterus, 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/no splinters
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing
on finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
Microbiology:
[**3-17**] Urine culture: no growth.
[**3-17**] Blood culture: [**3-30**] blood cultures positive for oxacillin
resistant staph aureus.
[**3-17**] R PICC catheter tip culture: no growth.
[**3-18**], [**3-19**] Blood culture: pending.
All subsequent blood and urine cultures were negative.
Images:
[**3-17**] CT
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Multifocal areas of consolidation in the lungs, worrisome for
multifocal pneumonia.
3. Numerous foci of presumed lymphomatous disease involving both
axilla, the kidney, the retroperitoneum, and the osseous
structures.
...........................................
[**2106-3-19**]
CXR
FINDINGS: The heart size is normal. The mediastinal and hilar
contours are normal. There are new heterogenous opacities in
both lower lobes indicative of pneumonia. Upper lung fields are
clear. No pleural effusions or pneumothorax.
IMPRESSION: Bilateral lower lobe pneumonia/aspiration.
Brief Hospital Course:
This is a 68 year-old man with high grade follicular lymphoma dx
9 months ago s/p multiple chemotherapeutic regimens currently
day #8 of cycle 1 R-CHOP, known epidural mets-thoracic chord
compression, pancytopenic, on levoquin, fluconazole, acyclovir
prophylaxis admitted to [**Hospital Unit Name 153**] septic, likely secondary to
multi-focal pneumonia.
.
# MRSA Sepsis: Likely source of bacteremia leading to sepsis was
pneumonia vs. PICC line infection. Patient was treated with
broad spectrum antibiotics including cefipime, vanc, ambisome
(changed to cefepime), and flagyl. Aggressive ivf's and
pressors needed to maintain BP. Patient recovered from sepsis
and was transferred to BMT floor where broad spectrum
antibiotics were continued. Fevers resolved and patient was
tapered off all antibiotics (finished 14 day course of
vancomycin).
.
# PNA - Felt to have PNA by CXR. Once above antibiotics were
tapered off, patient was started on levofloxacin for presumed
PNA. Had continuous 02 requirement, low grade.
.
# HEME/ONC: Patient recieved r-chop as above, but had extremely
poor prognosis. He was given decadron for chord involvement (no
new acute sxs during this admission) as well as frequent
transfusions for anemia and thrombocytopenia. Dr. [**First Name (STitle) 1557**]
followed the patient, and repeated discussions were had with the
patient and the family regarding the poor overall prognosis of
the patient. D/T the aggressive nature of his follicular
lymphoma and his multiple comorbidities and concommitant medical
problems, the patient was made DNR/DNI and shortly thereafter
the family moved to CMO. The patient was started on morphine
for comfort and passed away approximately 48hrs after from
respiratory depression.
Medications on Admission:
Medications on discharge [**2106-2-18**]:
1. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous
twice a day for 3 doses: To finish tomorrow night, [**2-19**]. .
Disp:*3 doses* Refills:*0*
2. PICC line care
PICC line care per protocol
3. PICC line removal
Please remove PICC line tomorrow night ([**2-19**]) after last dose of
vancomycin.
4. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO four times a
day: Take 2 tabs QID x 6 days, then 1 tab QID x 3 days, then 1
tab [**Hospital1 **] x 3 days, then 1 tab QD x 3 days. .
Disp:*69 Tablet(s)* Refills:*0*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Senna 8.6 mg Capsule Sig: [**12-28**] Capsules PO once a day.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every [**4-1**]
hours.
Disp:*30 Tablet(s)* Refills:*0*
Now:
1. oxycontin 10 po bid
2. levoquin
3. acyclovir 200 tid
4. fluconazole
5. procrit
6. neulasta
7. lasix 20 po qday
8. allopurinol 100 [**Hospital1 **]
9. decadron
10. ativan
11. magic mouthwash
12. colace
13. senna
14. protonix
15. tamsulosin
16. atenolol
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis, PNA, Aggressive follicular lymphoma
Discharge Condition:
Deceased
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
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8085, 8094
|
4837, 6589
|
305, 311
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8181, 8192
|
3862, 4814
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3008, 3095
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8056, 8062
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8115, 8160
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6615, 8033
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3110, 3843
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249, 267
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339, 1395
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1417, 2715
|
2731, 2992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
585
| 123,154
|
22613
|
Discharge summary
|
report
|
Admission Date: [**2142-11-10**] Discharge Date: [**2142-12-5**]
Date of Birth: [**2082-6-25**] Sex: F
Service: PLASTIC
Allergies:
Demerol / Morphine / Penicillins
Attending:[**First Name3 (LF) 16920**]
Chief Complaint:
Left shoulder pain
Left arm pain
Right leg pain
Major Surgical or Invasive Procedure:
[**2142-11-10**] : Irrigation & Debridement of Open Right Tibia
Fracture, External fixation placement of Right Lower Extremity
[**2142-11-11**]: Flexible Bronchoscopy, Esophagogatroduodenoscopy,
Right thoracotomy, repair of tracheal laceration, intercostal
pedicled muscle flap.
[**2142-11-19**] : Intramedullary nail, right tibia, ORIF of right tibia,
removal of external fixator, incision & drainage of open wound,
right lower leg; Application of VAC dressing
History of Present Illness:
[**2142-11-10**]: This 60 year old African American female pedestrian
was struck by a car and found with altered mental status and
multiple fractures. She was transported by EMS to [**Hospital 1474**]
Hospital. A right open tib/fib fracture was identified as well
as a left humurus fracture. The patient was electively intubated
due to polytrauma and mental status changes, although
hemodynamically stable. Patient was transported to [**Hospital1 771**] via [**Location (un) 7622**] for additional care.
Past Medical History:
Osteogenesis Imperfecta
Depression
Hypertension
Hysterectomy
Social History:
This 60 year old African American female denies alcohol use,
tobacco use and use of recreational drugs. No history of
physical abuse. The patient does not work, is on disability and
lives with her sister in [**Location (un) 686**], MA. She also recieves
family support from a nephew. She has 2 daughters who live in
[**Name (NI) 4565**], and her husband died 4 years ago.
Family History:
Noncontributory
Physical Exam:
VS: BP 152/101, HR 80, RR 12, SPO2 100%, patient intubated upon
arrival.
Constitutional: intubated, sedated
Head/eyes: Left periorbital ecchymosis.
Ear/Nose/Throat: Tympanic membranes clear bilaterally. Dried
blood in nares.
Chest/Respiratory: Clear to auscultation bilaterally, Good
color.
Cardiovascular: Regular rate & rhythm.
Gastrointestinal/Abdominal: Soft, FAST negative. Positive rectal
tone.
Genitourinary/Flank/Pelvic: Stable
Musculoskeletal/Extremities/Back: Right open tibula/fibula
fracture
Skin: multiple abrasions
Pertinent Results:
[**2142-11-10**] 07:58PM WBC-16.0* RBC-2.46* HGB-7.8* HCT-22.9* MCV-93
MCH-31.5 MCHC-33.9 RDW-13.8
[**2142-11-10**] 07:58PM PLT COUNT-177
[**2142-11-10**] 07:58PM PT-14.1* PTT-31.2 INR(PT)-1.2*
[**2142-11-10**] 07:58PM FIBRINOGE-160
[**2142-11-10**] 05:41PM TYPE-ART PO2-236* PCO2-33* PH-7.32* TOTAL
CO2-18* BASE XS--8 COMMENTS-GREEN TOP
[**2142-11-10**] 04:06PM GLUCOSE-170* LACTATE-2.4* NA+-144 K+-3.2*
CL--120* TCO2-18*
[**2142-11-10**] 04:04PM UREA N-13 CREAT-0.7
[**2142-11-10**] 04:04PM AMYLASE-83
RADIOLOGY Final Report
CHEST (PA & LAT) [**2142-11-22**] 10:56 AM
CHEST (PA & LAT)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
60 year old s/p trauma, tracheal repair
REASON FOR THIS EXAMINATION:
interval change
AP UPRIGHT AND LATERAL FILM
INDICATION: Status post trauma. Tracheal repair. Assess interval
change.
COMPARISONS: [**2142-11-20**].
A right-sided PICC line is again seen with its tip within the
mid to distal SVC. There is mild blunting of the left posterior
pleural surface which is essentially unchanged. The lungs are
clear. The pulmonary vascularity is normal. There is no
pneumothorax.
IMPRESSION: No significant interval change compared to [**2142-11-20**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 2618**] [**Doctor Last Name **]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2142-11-22**] 8:57 PM
RADIOLOGY Final Report
TIB/FIB (AP & LAT) RIGHT [**2142-11-19**] 2:59 PM
TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT
Reason: TIBIA NAILING
HISTORY: Tibial nailing.
Fluoroscopic assistance provided to the surgeon in the OR
without the radiologist present. 15 spot views were obtained. No
fluoro time was recorded on the electronic requisition. Views
demonstrate steps related to placement of an intramedullary rod
and interlocking screws traversing a tibial fracture. Fibular
fractures are also present. Skin staples noted.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: MON [**2142-11-19**] 7:16 PM
Brief Hospital Course:
Upon arrival to [**Hospital1 69**],
Ortho-Trauma, neurosurgery, thoracic surgery and plastic surgery
consults were obtained for multiple injuries. She underwent
surgical repair of open right tibia/fibula fracture with
external fixation on [**2142-11-10**] by Dr. [**Last Name (STitle) 7376**]. She recovered in
the PACU, remained intubated, and was transferred to Trauma
Surgical Intensive Care Unit. On [**2142-11-11**] she underwent repair
of tracheal rupture by Dr. [**Last Name (STitle) **], which included placement
of 3 chest tubes and a cervical collar. The patient remained
intubated and recovered well in the PACU. She was then
transferred back to Trauma Surgical Intensive Care unit.
Physical Therapy and Occupational Therapy were consulted on
[**2142-11-11**], and have followed her throughout her admission.
She was extubated on [**2142-11-12**]. Gentamycin and Cefazolin were
started post-operatively, as well as anticoagulation. A PICC
line was placed by interventional radiology for intravenous
access. Acute pain service was consulted and an epidural was
placed. Her pain was controlled through epidural analgesia and
intravenous Dialudid via patient controlled analgesia. PCA
dialudid was continued until [**2142-11-23**] when she was transitioned
to oral dilaudid, which she has tolerated well.
The tracheal injury prohibited further intubation for surgical
ORIF of Tibula/fibula fracture. On [**2142-11-13**], spinal clearance
was obtained. On [**2142-11-14**] 2 chest tubes were removed, and the
remaining chest tube was left to water seal.
On [**2142-11-19**] she recieved ORIF of the right tibula/fibula under
spinal anesthesia, removal of ex-fix and placement of wound vac
by Dr. [**Last Name (STitle) **]. Plastic surgery is consulted regarding the
wound vac of the right lower extremity, and for closure of the
leg flap. She is projected to have closure of the flap during
the middle of the week of Decemeber 11th. On [**2142-11-20**] she was
touch down weight bearing on RLE and the [**Doctor Last Name **] drain was d/c by
thoracic surgery. The vac dressing remained in place. ON
[**2142-11-21**], she had her PICC line TPAd with success. On [**2142-11-22**]
orthopedics changed the VAC dressing and she continued to wait
for a flap. On [**2142-11-23**] the PCA was stopped and she tolerated
oral pain medication well. On [**2142-11-24**], there were no issues.
On [**2142-11-25**], the vac was changed again by orthopedics. On
[**2142-11-26**], she was preoped for flap placement on RLE. PT saw her
as well and thought patient had great rehab potential when
eligable. The patient ended up going to the OR on [**2142-11-28**] for
RLE Gastro flap with full thickness skin graft. Please see
operative note for full details. She had no intra or
postoperative complications. On [**2142-11-29**], there were no major
issues as her pain was well controlled. The JP drain put out
29cc of serosang fluid. On [**2142-11-30**], the [**Last Name (un) 32019**] remained in
place the JP continued to drain serosanguinous fluid. On
[**2142-12-1**], she there were major issues and her pain was well
controlled with po tylenol. She remained on bed rest and on
[**2142-12-3**], we changed the dressing. The wound was intact and
looked good. Occupational therapy saw here on [**2142-12-4**] and
recommended OT and rehab 3 hours per day 5-7 days/week to
maximize patient function. She also stared a dangle protocol at
5 minutes TID and the JP remained in. ON [**2142-12-5**], we changed
the dressing again and took out the JP. She was advanced to a
15 minute dangle protocol TID and was due for discharge to
Spaling facility this afternoon.
Medications on Admission:
Home meds reported: Ambien, Depression meds, Hypertension meds.
No doses or names of medications provided.
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
4. Labetalol 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): Hold for HR < 65, or SBP < 110.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for HR < 60, SBP < 110.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Open Right comminuted displaced tib/fib fracture
Tracheal rupture
Left proximal humerus fracture
Left zygomatic arch fracture
Left parietal skull fracture
C2 spinous process fracture
Trace pneumomediastinum
Discharge Condition:
Stable
Discharge Instructions:
Do not bear weight on your left arm.
You may touchdown weight bear on your Right Lower Extremity.
Please continue to dangle the right lower extremity for 30
mintutes TID. Continue to increase this time for three times a
day.
Followup Instructions:
Follow up appointment with your throacic surgeon, Dr.
[**Last Name (STitle) **], in 2 weeks, call # [**Telephone/Fax (1) 170**] for appointment.
Follow up with plastic surgery clinic on [**12-14**] for
outpatient management of Left zygomatic fracture electively,
call [**Telephone/Fax (1) 4652**] for an appointment. Dr. [**First Name (STitle) 3228**] is the
attending MD.
Follow up with your orthopedic Surgeon, Dr. [**Last Name (STitle) **] in 2 weeks,
call # [**Telephone/Fax (1) 1228**] for an appointment.
Follow up with the Trauma Clinic as needed, call [**Telephone/Fax (1) 6429**] if
you have any concerns.
Completed by:[**2142-12-5**]
|
[
"285.9",
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"401.9",
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"823.32",
"756.51",
"800.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.63",
"93.59",
"03.90",
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"79.36",
"31.79",
"79.66",
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"99.04",
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icd9pcs
|
[
[
[]
]
] |
9343, 9413
|
4646, 8322
|
342, 808
|
9664, 9673
|
2415, 3052
|
9948, 10599
|
1832, 1849
|
8480, 9320
|
3089, 3129
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9434, 9643
|
8348, 8457
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9697, 9925
|
1864, 2396
|
255, 304
|
3158, 4623
|
836, 1342
|
1364, 1427
|
1443, 1816
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,710
| 153,302
|
31819
|
Discharge summary
|
report
|
Admission Date: [**2138-10-22**] Discharge Date: [**2138-10-30**]
Service: NEUROLOGY
Allergies:
Enalapril / Quinolones
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Transfer from OSH with left ICA occlusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo woman PMH atrial fibrillation off Coumadin x 10 days due
to hemorrhagic hemorrhoid who was transferred from OSH after
presenting with transient vision loss in left eye and subsequent
aphasia and right hemiparesis.
Patient called daughter at 10am yesterday complaining of blurry
vision of the left eye only. 911 called.
At OSH ED, noted to be aphasic with a right hemiparesis. Head
CT negative for bleed. No TPA d/t recent GIB. Patient was
started on IV heparin and admitted to the medicine floor where
she was noted to be lethargic. A repeat head CT was negative
for bleed and IV heparin was resumed at and patient was
transferred to ICU where her deficits reportedly improved
(speech & weakness) but did not completely resolve. Carotid US
showed near occlusion of the left carotid artery and moderatley
60% stenosis on the right.
On OSH neurologist exam (Dr. [**Last Name (STitle) 5017**], +right carotid bruit,
AXO3, some naming and word finding difficulties, right drift and
3+ proximal and 4+ distal weakness. R LE proximal 4+.
Patient was transferred to [**Hospital1 18**] vascular service to consider of
emergent endarterectomy versus endovascular stenting. Family
and patient are reportedly open to any possible procedures.
At baseline per daughter, patient has iADLs and lives on her
own.
Past Medical History:
- atrial fibrillation
- hypertension
- congestive heart failure
- chronic renal insufficency
- hypercholesterolemia
- s/p CABG [**2105**]
- LGIB likely hemorrhoidal bleed, colonoscopy [**2138-10-15**] sm polyp
right colon and left sided diverticulum
Social History:
Lives alone with family in the area and very supportive.
Family History:
NA
Physical Exam:
T- 98.1 BP- 133/51 HR- 52 RR- 22 98 O2Sat 2LNC
Gen: Sleeping soundly in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple, right carotid bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Sleepy and fluctuating alertness. Partially
cooperative with exam. Follows midline commands, less
consistent with axial commands. Nonfluent speech only saying
"no, yup" otherwise aphasic. Intact comprehension.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Blinks to threat bilaterally. Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1- V3. Right UMN facialweakness. Palate elevation
symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue
midline, movements intact.
Motor/Sensation:
Normal bulk bilaterally. Flaccid right arm. No observed
myoclonus or tremor. Motor impersistance. Right arm biceps
4+/5 but otherwise unable to give resistance, does not protect
face. Left arm and leg 5-/5 throughout. Right lower leg IP at
least [**4-7**] but does not cooperate with rest of resistance exam.
Withdraws to noxious stim, decreased in right leg and least in
right arm.
Reflexes:
+2 brisker on the right throughout. Right upgoing and left
downgoing.
Coordination: not cooperative enough.
Gait/Romberg: deferred
Pertinent Results:
[**2138-10-23**] 12:00AM BLOOD WBC-8.0 RBC-3.02* Hgb-9.3* Hct-27.6*
MCV-92 MCH-30.8 MCHC-33.7 RDW-14.7 Plt Ct-226
[**2138-10-24**] 02:41AM BLOOD WBC-10.1 RBC-3.03* Hgb-9.3* Hct-27.3*
MCV-90 MCH-30.5 MCHC-33.9 RDW-14.7 Plt Ct-248
[**2138-10-25**] 01:04AM BLOOD WBC-8.6 RBC-2.93* Hgb-9.0* Hct-26.6*
MCV-91 MCH-30.7 MCHC-33.8 RDW-14.8 Plt Ct-213
[**2138-10-26**] 05:12AM BLOOD WBC-8.6 RBC-2.90* Hgb-8.8* Hct-26.4*
MCV-91 MCH-30.4 MCHC-33.4 RDW-14.9 Plt Ct-176
[**2138-10-27**] 02:46AM BLOOD WBC-8.8 RBC-2.67* Hgb-8.0* Hct-24.0*
MCV-90 MCH-30.0 MCHC-33.3 RDW-15.1 Plt Ct-159
[**2138-10-27**] 08:01PM BLOOD Hct-24.3*
[**2138-10-28**] 02:22AM BLOOD WBC-7.9 RBC-2.66* Hgb-8.4* Hct-24.6*
MCV-93 MCH-31.4 MCHC-34.0 RDW-15.2 Plt Ct-199
[**2138-10-29**] 01:53AM BLOOD WBC-9.9 RBC-2.70* Hgb-8.3* Hct-24.4*
MCV-90 MCH-30.7 MCHC-34.0 RDW-15.1 Plt Ct-223
[**2138-10-23**] 12:00AM BLOOD Glucose-115* UreaN-34* Creat-2.5* Na-141
K-4.3 Cl-104 HCO3-24 AnGap-17
[**2138-10-24**] 02:41AM BLOOD Glucose-135* UreaN-21* Creat-2.0* Na-136
K-3.3 Cl-99 HCO3-30 AnGap-10
[**2138-10-25**] 01:04AM BLOOD Glucose-110* UreaN-18 Creat-1.8* Na-138
K-4.0 Cl-105 HCO3-23 AnGap-14
[**2138-10-26**] 05:12AM BLOOD Glucose-175* UreaN-27* Creat-1.8* Na-142
K-4.6 Cl-108 HCO3-23 AnGap-16
[**2138-10-27**] 02:46AM BLOOD Glucose-150* UreaN-38* Creat-2.0* Na-140
K-4.2 Cl-102 HCO3-28 AnGap-14
[**2138-10-28**] 02:22AM BLOOD Glucose-139* UreaN-47* Creat-2.0* Na-141
K-4.8 Cl-103 HCO3-29 AnGap-14
[**2138-10-28**] 05:56PM BLOOD Glucose-186* UreaN-52* Creat-2.1* Na-139
K-4.8 Cl-101 HCO3-30 AnGap-13
[**2138-10-29**] 01:53AM BLOOD Glucose-132* UreaN-59* Creat-2.0* Na-143
K-4.8 Cl-104 HCO3-30 AnGap-14
[**2138-10-30**] 01:07AM BLOOD Glucose-153* UreaN-62* Creat-2.0* Na-142
K-5.3* Cl-103 HCO3-29 AnGap-15
[**2138-10-23**] 02:02PM BLOOD Lipase-42
[**2138-10-30**] 03:02PM BLOOD Lipase-27
[**2138-10-23**] 02:02PM BLOOD ALT-9 AST-14 CK(CPK)-32 AlkPhos-99
Amylase-148* TotBili-0.3
[**2138-10-28**] 05:56PM BLOOD CK-MB-5 cTropnT-0.96*
[**2138-10-30**] 01:07AM BLOOD CK-MB-NotDone cTropnT-1.29*
[**2138-10-30**] 02:32PM BLOOD CK-MB-NotDone cTropnT-2.21*
[**2138-10-23**] 12:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2138-10-23**] 02:02PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2138-10-24**] 02:41AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2138-10-30**] 03:07PM BLOOD Hgb-8.2* calcHCT-25
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the ICU and managed for her stroke.
She was intubated for airway protection and had a stroke work-up
with an echo, carotid dopplers, MRI and A1c. She was initially
treated with heparin and then started on coumadin via NG. Her BP
was allowed to autoregulate. After a prolonged hospital course
involving an MI and a failed extubation her family decided to
make her CMO. She was extubated and started on morphine. She
died shortly thereafter.
Medications on Admission:
- ambien 5mg QHS
- lipitor 10mg QD
- atenolol 50mg QD
- lasix 40mg QD
- coumadin as above
- nitroglycerin 0.4mg SL PRN
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Stroke
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
|
[
"285.9",
"V45.81",
"403.90",
"410.71",
"599.0",
"585.9",
"112.0",
"427.31",
"414.00",
"434.11",
"428.0",
"428.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6542, 6551
|
5861, 6344
|
275, 282
|
6601, 6605
|
3514, 5838
|
6656, 6753
|
2009, 2014
|
6514, 6519
|
6572, 6580
|
6370, 6491
|
6629, 6633
|
2029, 2345
|
194, 237
|
310, 1644
|
2615, 3495
|
2384, 2599
|
2369, 2369
|
1666, 1917
|
1934, 1993
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,261
| 144,662
|
5855+55704
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-3-16**] Discharge Date: [**2111-4-3**]
Date of Birth: [**2033-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
[**3-26**] Redo Coronary Artery Bypass Graft x 4 (Left internal
mammary artery to left anterior descending, Saphenous vein graft
to Diagonal, Saphenous vein graft to Obtuse marginal, Saphenous
vein graft to posterior descending artery)
[**3-19**] Cardiac Cath
History of Present Illness:
78 year old male with a history of coronary artery bypass
surgery [**39**] years ago, remote myocardial infarction, chronic
Atrial fibrillation, and Diabetes type 2 presented to outside
hospital with fatigue, weakness, cough and subjective fever.
The week prior he was admitted to an outside facility for
weakness which was thought to be secondary to inderal dosing.
The patient saw his outpatient cardiologist following discharge,
asked to wear a holter monitor which showed 3 second pauses. He
was scheduled to return to Dr.[**Name (NI) 23188**] office this coming
Wednesday.
.
On the day of admission to [**Hospital3 417**] Hospital, the
patient's daughter found him lying on the floor, unable to stand
on his own. He denies any LOC at that time. His initial vital
signs were T 100.7, HR 102 (irregular) and BP 158/90. He had a
CXR which showed evidence of a LUL opacity. He was admitted for
suspected pneumonia. He initially received levaquin and given
IV fluids. As the patient became more wheezy on exam, a BNP was
checked found to be 405. He was then treated with IV lasix X 1
(unclear dose). He became more dyspneic and hypoxic, then
transferred to the ICU. He was found to be in a rapid
ventricular rate with A fib, and treated with IV lopressor. In
the ICU, a TTE showed an EF of 20-25% with severe global
hypokinesis, dilated LA, mild TR, and no other valvular
dysfunction. CE's were sent and the initial set showed CK 353,
MB 20, Trop I 15.5, then repeat at 2 am CK 395, MB 55, Trop I
9.0, then prior to transfer was CK 1506, MB 299, Trop I 43.3.
He was given high dose aspirin, loaded with 600mg of plavix, and
put on IV heparin for transfer. He was treated with IV
lopressor for his rapid rate.
.
The patient on arrival to [**Hospital1 18**], was asymptomatic. He was
initially transferred to the cath lab for suspected cardiac
catheterization, but given his elevated INR, the decision was
made to postpone cardiac cath until the AM.
Past Medical History:
Coronary Artery Disease with histoy of myocardial infarction
[**2069**] and coronary artery bypass surgery [**2073**]
Diabetes Mellitus
Hypertension
Chronic atrial fibrillation and right bundle branch block
Acute on chronic renal failure
Transient ischemia attack [**2-8**]
Status post Cholecystectomy
Chronic thrombocytopenia
Social History:
Pt married, has 3 children, lives at home with his wife
-[**Name (NI) 1139**] history: quit smoking 40 years ago
-ETOH: none
-Illicit drugs: none
Family History:
Multiple family members with CAD
Physical Exam:
On dmission at CCU
VS: T= 99 BP=124/67 HR=97 RR=18 O2 sat= 97%
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular rhythm, 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. Rhonchi heard in [**Doctor Last Name **]
segment, no crackles or wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Left
upper extremity hematoma.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
[**3-31**]- INR 1.3
[**3-19**] CARDIAC CATH: 1. Coronary angiography of this right
dominant system demonstrated severe native three vessel disease.
The LMCA had no stenosis. The LAD was heavily calcified and
had serial long stenoses ~85% in the proximal to mid vessel.
The LAD was a large and patent in its mid to distal pole. The
LCX was occluded. The RCA was occluded. 2. Venous conduit
arteriography showed SVG/RCA and SVG/OM occlusion. 3.
Angiography of the LIMA for upcoming re-do CABG showed a large
non-obstructed vessel. 4. Resting hemodynamics revealed
elevated right and left ventricular enddiastolic filling
pressures at 14 and 15 mmHg, respectively. The PCWP was 20
mmHg. The mean PA pressure was 27 mmHg (phasic 40/16 mmHg). The
cardiac index was depressed at 1.6 L/min/m2. The mean systolic
arterial pressure was 71 mmHg (phasic 105/51 mmHg).
[**3-20**] Chest CT: 1. Multifocal areas of ground-glass opacities
involving mainly the upper lobes. Differential diagnosis is
broad and includes pneumonia and ARDS, although the distribution
is not typical. Edema is less likely due to lack of other signs.
2. Atherosclerotic changes as described above. 3. Cardiomagaly.
4. Mediastinal lymphadenopathy.
[**3-20**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%.
[**3-26**] Echo: PRE-BYPASS: 1. The left atrium is moderately dilated.
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 left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. 2. Left ventricular wall thicknesses are normal.
The left ventricular cavity is mildly dilated. There is mild to
moderate regional left ventricular systolic dysfunction with .
Overall left ventricular systolic function is moderately
depressed LVEF= 30 %). 3. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. 4. There are
simple atheroma in the descending thoracic aorta. 5. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Trace aortic regurgitation is seen. 6. The
mitral valve leaflets are moderately thickened. Moderate (2+)
mitral regurgitation is seen. POST-BYPASS: For the post-bypass
study, the patient was receiving vasoactive infusions including
milrinone and norepiepinephrine and is being AV paced. 1. LV
ventricular function and RV function are unchanged. 2. MR is
still moderate 3. Aortic contours appear intact. 4. Other
findings are unchanged
Brief Hospital Course:
As mentioned in the history of present illness, Mr. [**Known lastname 7363**] was
transferred from outside hospital to ICU at [**Hospital3 **] for
further cardiac work-up. In addition to being medically managed
for a non-ST elevation myocardial infarction, he received
treatment for congestive heart failure, atrial fibrillation and
pneumonia. On [**3-19**] he was brought for a cardiac cath which
revealed severe three vessel disease and totally occluded
saphenous vein grafts. Cardiac surgery was consulted for redo
bypass surgery. He underwent further work-up which included
chest CT and carotid U/S prior to surgery. His status slowly
improved while receiving medical management over the next week.
During this time, both his kidney and liver function showed
improvement with continuous lab work. On [**3-26**] he was brought to
the operating room where he underwent a redo coronary artery
bypass graft x 4. Please see operative report for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
His chest tubes and temporary pacing wires were removed per
cardiac surgery protocol. He was started on betablocker,
diuretic, statin and aspirin therapy. He was transferred from
the ICU on POD#2. His post op course was uneventful with the
exception of failing to void. the foley was replaced and he was
started on flomax. Coumadin was resumed for afib but at a lower
dose than his home regimen. He was seen by physical therapy and
reab was recommended.
Medications on Admission:
Lasix 20mg daily, coumadin 2.5mg Tue, [**Last Name (un) **], Sat, Sun and 5mg on
Mon, Wed, Fri, Allopurinol 100mg daily, Propranolol 10mg QID,
Amlodipine 5mg daily, Glyburide 2.5mg daily, Aspirin 81mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-5**] Sprays Nasal
QID (4 times a day) as needed.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): needs follow up LFT's in one month.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily) as needed for atrial fibrillation : INR goal 2-2.5
rec'd 2.5 mg [**2111-3-31**].
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation TID ().
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: then decrease to 20mg daily ongoing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
Coronary Artery Disease
Myocardial Infarction
Systolic Congestive heart failure
Pneumonia
status post Coronary artery bypass graft [**2073**]
Chronic atrial fibrillation and right bundle branch block
Diabetes Mellitus
Acute on chronic renal failure
Transient ischemia attack [**2-8**]
Chronic thrombocytopenia
Discharge Condition:
deconditioned
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
please call and schedule the following appointments.
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] in [**1-6**] weeks
Dr. [**Last Name (STitle) **] in [**12-5**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2111-3-31**] Name: [**Known lastname 3936**],[**Known firstname 3937**] Unit No: [**Numeric Identifier 3938**]
Admission Date: [**2111-3-16**] Discharge Date: [**2111-4-3**]
Date of Birth: [**2033-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 265**]
Addendum:
Just prior to transfer to rehabilitation Mr [**Known lastname **] became
increasing somnolent and was having difficulty following
commands. He was able to move all extremities but was weakened
when compared to an exam earlier in the day, speach was garbled.
He had an emergent head CT that was negative and upon return to
the cardiac surgery floor a check of his finger stick blood
sugar revealed it to be 19. He was treated with 25gm of D50 and
somnolence resolved and neurological exam returned to baseline.
His blood sugars were followed closely over the next 18 hours.
His Lantus had been discontinued earlier in the day. His
glyburide was held and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 616**](endocrine) consult was called.
He remained in the hospital for another 4 days due to
hypoglycemia and hyponatremia. His lasix was d/c'd and he was
placed on a fluid restriction. His sodium stabilized. He was
discharged to rehabilitation on POD #9.
Pertinent Results:
INR 1.9
NA 131
Discharge Medications:
THESE ARE THE MOST UPDATED MEDIACTIONS [**2111-4-3**]
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-5**] Sprays Nasal
QID (4 times a day) as needed.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): needs follow up LFT's in one month.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily)
as needed for atrial fibrillation : INR goal 2-2.5
rec'd 2.5 mg [**2111-4-3**].
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. Sitagliptin 100 mg Tablet Sig: One (1) Tablet PO daily ().
14. Outpatient Lab Work
monitor INR daily until stable
monitor serum sodium unitl stable.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 371**] Rehabilitation and Nursing Center - [**Hospital1 328**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2111-4-10**]
|
[
"403.90",
"348.39",
"276.1",
"412",
"486",
"426.4",
"996.72",
"250.80",
"V12.54",
"410.71",
"428.21",
"585.9",
"428.0",
"427.31",
"414.01",
"584.9",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"88.52",
"36.15",
"36.13",
"37.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
14318, 14539
|
6741, 8341
|
285, 546
|
10681, 10696
|
12891, 12907
|
11235, 12872
|
3066, 3100
|
12930, 14295
|
10349, 10660
|
8367, 8575
|
10720, 11212
|
3115, 4060
|
237, 247
|
574, 2537
|
2559, 2887
|
2903, 3050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,231
| 148,348
|
37965+58180
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-10-10**] Discharge Date: [**2111-11-3**]
Date of Birth: [**2037-9-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Phenergan
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Bright red blood per rectum, dizziness, lightheadedness
Major Surgical or Invasive Procedure:
1. Mesenteric angiography on [**2111-10-26**]
2. Colonoscopy on [**10-11**] and [**10-15**]
History of Present Illness:
Ms. [**Known lastname 84830**] is a 74F with a PMH s/f CAD (s/p CABG), and atrial
fibrillation recently diagnosed and started on coumadin about 4
weeks ago. She was in her usual state of health until about 10
days ago when she developed lethargy and dizziness with
standing. Over the past two days she developed abdominal pain
with BRBPR. Abdominal pain is described as a sharp pain in the
middle of her abdomen, associated with nausea, no vomiting.
Non-radiating. She began to have BRBPR yesterday, when her aide
noticed it. She cannot recall the color or consistency of her
stools prior to this.
.
In the emergency department her presenting vital signs were:
T=98.7, BP=151/72, HR=84, O2sat=100%RA. On exam she was noted
to have BRBPR. Laboratory data was significant for a HCT of
16.6 (baseline is 26), and INR of 2.9, and a lactate of 4.9.
The patient was given 2 L NS, 2 units of FFP, 2 units of pRBCs,
10mg IV vitamin K, and factor 9 ([**2041**] units) per protocol. A CT
of the abdomen and pelvis with contrast was obtained which
showed no colitis, and trace ascites. A surgical consultation
was obtained, they felt there was no urgent surgical issues.
Gastroenterology was made aware of the admission, and
recommended IV PPI, which was given. She was hemodynamically
stable in the ED with SBPs 103-120, with adequate urine output,
and reporting mild dizziness. She has two large bore PIVs. She
also had two episodes of sinus bradycardia with dropped QRS
complexes, which was transient.
Past Medical History:
#. CAD- s/p CABG- Received outside reports of CABG X 2 on
[**2108-12-26**]. Had saphenous vein graft of diagonal and OM1
sequentially
#. S/p AVR, bioprosthetic
#. Mitral stenosis
#. Atrial fibrillation- On coumadin/ amiodarone
#. Hypothyroidism
#. Chronic diastolic dysfunction
#. Diabetes type II
#. HTN
#. ORIF right ankle fracture, [**2101**]
#. Left proximal humerus fracture [**2108**]
.
Social History:
Denies EtOH, tobacco and lives in [**Hospital3 **] elder housing.
She is part of the [**Hospital **] medical system and has regular home
visits from Dr [**Last Name (STitle) 19434**] and his nursing staff.
Family History:
non contributory
Physical Exam:
ON ADMISSION:
GENERAL: Pleasant, answers questions appropriately, in no acute
distress
HEENT: Normocephalic, atraumatic. Left cataract. No scleral
icterus. Right pupil responds to light. Very dry mucous
membranes.
CARDIAC: Regular rhythm, normal rate. [**1-16**] low-pitched systolic
ejection murmur, high-pitched S2
LUNGS: Diffuse bilateral inspiratory crackles and expiratory
wheezes
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
EKG: Sinus rhythm at 82 bpm, normal axis, normal intervals, old
TWI in I and AVL, new STD in V4-V6
.
Chest XR: Worsening airspace disease on the right lower lung
.
CT abdomen and pelvis with contrast: [**2111-10-10**]
IMPRESSION:
1. No evidence of acute colitis. No bowel obstruction.
2. Thickened urinary bladder wall, raising the concern for
cystitis.
3. Dilated CBD measuring 15mm, of uncertain significance. MRCP
may be
considered if concern for biliary pathology.
4. Evidence of prior renal insults vs ongoing
pyelonephritis--correlate
clinically.
5. Small right-sided pleural effusion.
.
Tagged RBC study: Detailed results:
RADIOPHARMACEUTICAL DATA:
16.4 mCi Tc-[**Age over 90 **]m RBC ([**2111-10-10**]);
HISTORY: Patient is a 74 year old female with brisk
gastrointestinal bleeding, evaluate for location.
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for 90 minutes were obtained. A left
lateral view of the pelvis was also obtained. Blood flow images
show arterial flow in the abdominal aorta and iliac vessels.
Dynamic blood pool images show a quick appearance of radiotracer
overlying the right upper quadrant likely within the hepatic
flexure that could be duodenal, though given history of brisk
bleeding, is thought to be colonic in origin. There is no
significant accumulation of radiotracer on subsequent images in
the dynamic series.
Bleeding was first noticed within the first several minutes of
the examination.
IMPRESSION: Gastrointestinal bleeding seen in the right upper
quadrant likely within the hepatic flexure of the colon, with
duodenal origin thought to be less likely. The bleeding appears
soon after tracer injection but does not continue throughout the
study.
.
ECHO results from [**2111-10-12**]:
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. The estimated right atrial pressure is 0-5 mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Regional left ventricular wall motion is normal.
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. A bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets aand supporting
structures are thickened. There is mild valvular mitral stenosis
(area 2.0cm2). No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Normal functioning aortic bioprosthesis. Mild mitral
stenosis with thickened leafles and supporting structures. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. No evidence for an
intracardiac shunt.
.
[**2111-10-12**]: CT HEAD: no evidence of acute intracranial process.
.
[**2111-10-12**]: CT head perfusion study: There are no focal perfusion
abnormalities. 1. Mild to moderate atherosclerotic disease
without high-grade stenoses. 2. Pleural-parenchymal disease as
detailed which should be correlated with the patient's pulmonary
history and imaging.
.
[**2111-10-12**]: CTA Head/Neck: There is a two-vessel aortic arch with a
normal variant bovine configuration. There is mild
atherosclerotic disease of the aortic arch and origins of the
great vessels. Other than mild atherosclerotic disease at the
carotid bifurcations bilaterally, the common and cervical
internal carotid arteries are normal. The middle and anterior
cerebral arteries are normal. Incidental note is made of a small
posterior communicating artery infundibulum on the right.
There is left vertebral artery dominance with the right
vertebral artery
effectively ending at the level of PICA and the vessel origins
are not well evaluated. There is moderate atherosclerosis of the
distal left vertebral artery. There is mild mucoperiosteal
thickening within the maxillary and ethmoid sinuses. There are
small bilateral pleural effusions, right greater than left with
minimal associated consolidation and bilateral interlobular
septal thickening. There are multilevel degenerative changes of
the cervical spine.
.
[**2111-10-20**]: MRCP: 1. Dilation of the common hepatic duct, common
bile duct, and proximal pancreatic duct to the level of the
ampulla without evidence of stricture or mass. These findings
may be secondary to ampullary stenosis versus a small ampullary
lesion below the level of detection of MRI. An ERCP is
recommended for further characterization.
2. Interlobular septal thickening noted in the lung bases likely
representing pulmonary edema.
Brief Hospital Course:
HOSPITAL COURSE:
#. GI bleed and TIA: Presented with BRBPR and significant Hct
drop to 16 from her baseline of approximately 26. She received
6 units of pRBC on the first two days of hospitalization and her
hematocrit bumped appropriately and was stable for the remainder
of her ICU course. She remained hemodynamically stable
throughout the stay in the ICU. She had a tagged RBC scan which
localized the bleed to the RUQ likely hepatic flexure vs
duodenum. She had two colonoscopies that were nondiagnositic
secondary to lots of blood seen in colon with difficulty
visualizing lesions. She did not require angiography because
the bleeding was felt to be too slow for localization on angio.
Surgery was consulted and followed, however the patient decided
she would not like to pursue a surgical option. Coumadin and
aspirin were held in setting on acute GI bleed and patient
developed a TIA (see below) which resolved within 24 hours. Ms
[**Known lastname 84830**] was restarted on heparin and a CT revealed no perfusion
deficits. She was transferred to the floor where she continued
to intermittently ooze in the setting of continued
anticoagulation. It was deemed important for her to continue
heparin given her high CHADS score in the setting of paroxysmal
atrial fibrillation. She received transfusions as necessary for
her slowly decreasing HCT. She remained hemodynamically stable
on the floor.
On the nights of [**10-25**] and [**10-26**] in the setting of preparing for
colonoscopy she again developed increased bleeding. She was
initially stable and continued prep, but then [**10-26**] she
developed hypotension and tachycardia that persisted after being
transfused blood. She was transferred back to the ICU and
agreed to go with interventional radiology for angiography and
embolization. A small 5mm, right colonic artery with a
non-bleeding pseudoaneurysm was embolized. The patient
tolerated the procedure well and was afterwards hemodynamically
stable with stable hematocrits initially upon retransfer to
floor. Over the next several days, she continued to have bright
red bowel movements although she remained hemodynamically
stable. At this point we had a goals of care discussion; Ms
[**Known lastname 84830**] began to refuse transfusions feeling that she no longer
wants to suffer. We addressed the issue of considering
restarting amiodarone and withdrawing anticoagulation in the
setting of active bleed, however given her TIA, we felt that
continued anticoagulation was important to prevent her high risk
of stroke. We considered performing a TEE to evaluate for
presence of clot but thought this would not alter management as
continued anticoagulation was necessary for paroxsymal atrial
fibrillation and her high risk score. After explaing to her
that she could likely continue to remain stable if she continued
to receive transfusions intermittently, she decided that she
would be compliant with receiving further transfusions as an
outpatient on an as-needed basis. We developed a plan with her
outpatient primary care physician in which the following outline
was developed:
(1) HCT checks twice a week by her primary care team and nursing
staff who will both visit her home as well as provide for her
care at the office.
(2) If her blood count was less than 25, she would receive a
transfusion at [**Hospital1 2177**] as directed by her primary care team.
(3) If she became symptomatic, she would contact her primary
care team for a blood check and if low, she would receive a
transfusion at [**Hospital1 2177**].
(4) If she developed significant bleeding or felt very sick, she
would be readmitted for transfusions and further work-up as
necessary.
We decided to continue her coumadin and bridge her using
lovenox. At time of discharge, her INR was 1.3 and she was on
lovenox 100 mg [**Hospital1 **] (dosed at 1.5 mg/kg [**Hospital1 **]). We did continue to
hold her aspirin. She did have several bleeding events that we
felt were relatively small in total volume; her HCT remained
stable between 26 - 30. Her neurological status was at baseline
and her TIA had completely resolved with normal strength testing
on right side and normal language testing.
.
#. Stroke: See above for details. On [**10-12**] had a code stroke
called for new R-sided paralysis and aphasia. She had a
negative CT and CTA head and neck and symptoms resovled in
approximately three hours with no residual effects since. She
was started on a heparin gtt, however was having resolution of
symptoms prior to the initiation of the gtt. She had an ECHO
which was negative as well as a CTA which showed only mild
atherosclerotic disease. However since she developed a TIA in
the setting of stopping coumadin less than a week prior,
neurology recommended heparin gtt with a bridge to coumadin
despite bleeding risks. Anticoagulation was discussed with the
patient and she determined that she would rather risk bleeding
than have another stoke. IV heparin was restarted; just prior
to discharge, she was started on lovenox and coumadin with goal
to discharge home on lovenox with bridge to therapeutic INR.
INR was 1.3 at time of discharge, and as noted above, had
resolution of her neurologic symptoms.
.
#. Cardiac: H/o a fib and chronic diastolic dysfunction. In the
[**Name (NI) **], pt with a transient epidsode of possible Mobitz type II
heart block, resolved and did not reoccur throughout
hospitalization. In the MICU was noted to be in sinus rhythm.
Anti-hypertensive medications were initially held and then
restarted on the floor (metoprolol tartrate 12.5 [**Hospital1 **] daily).
Amiodarone was held given its interactions with coumadin and
that we didn't want two nodal agents operating simultaneously in
the setting of lower GI bleed. On the floor she was noted to be
in continued sinus rhythm however anticoagulation was continued
given above risk scores and development of TIA. She was
discharged in sinus rhythm on metoprolol succinate 25 mg daily
as per her home regimen and on lovenox and coumadin as above.
Amiodarone was held given above reasons. Aspirin was held and
can be restarted when underlying pattern of bleeding when Ms
[**Known lastname 84830**] is an outpatient is observed.
.
#. R knee effusion: Developed right knee effusion [**10-13**] that was
painful but without evidence of erythema. Not thought to be a
septic joint. Ultrasound revealed a prepatellar fluid
collection. Effusion improved with heat packs and Tylenol.
# Abnormal LFTs: Transaminitis and elevated TBili on admission
with some evidence of ascites on CT. No known liver disease.
CT demonstrated CBD dilatation to 15mm. Seen by ERCP,
recommended stabilizing the pt from a GIB perspective and then
consider MRCP to assess whether a mass at the ampulla could be
causing the bleed. However LFTs were improving, negative
hepatitis panel. However [**Doctor First Name **] positive but reflex titers were
not obtained. MRCP was performed which did not reveal any
stenotic mass at the periampullary area. If a mass was there,
it was thought to be smaller than the limit of detection. This
made the possibility of a periampullary bleeding mass unlikely.
Further ERCP was recommended to assess but given her above goals
of care, we decided not to perform ERCP, with continued
monitoring of LFTs as an outpatient. The most likely cause of
her abnormal LFTs and dilated CBD we thought could be secondary
to a passed stone given that her LFTs trended back down.
Periodic monitoring of LFTs as an outpatient recommended.
.
#CAD: Stable during hospitalization. We continued her on her
beta blocker, statin, and warfarin (aspirin was held). She was
relatively normotensive during most of her hospitalization; an
Ace inhibitor could be added as an outpatient as tolerated.
.
#Urinary tract infection: On the day prior to discharge,
developed urinary frequency and dysuria. Was started on bactrim
to be continued for a 3 day course until [**2111-11-4**] as her last
day.
.
#Hypothyroidism: Continued her on thyroid replacement.
.
#Type II diabetes: Covered her with sliding scale.
.
#Diastolic dysfunction: Was not overloaded during
hospitalization. Had normal O2 saturations on room air.
.
#Hypertension: Held anti-hypertensives initially in the setting
of gastrointestinal bleeding and then restarted metoprolol
following initial transfusions.
.
#Code Status: Refer to goals of care above. Is DNR/DNI at time
of discharge. Accepting transfusions on an as needed basis but
has been reluctant to get further colonoscopies or surgeries or
other invasive procedures, however, this should be reassessed
when needed, as her desire to receive such procedures often
depends on the immediacy of the situation. For example, during
a massive GI bleed, its possible that she may want intervention.
For this reason, these possibilities should be continually
reassessed with determination of patient capacity to make these
decisions.
Medications on Admission:
Alendronate 70mg weekly
ASA 81mg daily
Fiber powder
Glucerna supplements
Humalog mix 50/50- 30 units [**Hospital1 **]
Levothyroxine 100mcg daily
Metoprolol succinate 25mg daily
MVI
Omeprazole 20mg daily
Pravastatin 40mg daily
Tums 1000mg daily
Vitamin D 1000 units daily
Acetaminophen prn
Sorbitol 70% solution 3 tablespoons daily as needed
Warfarin 5mg daily
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
6. Fiber Powder 3 gram/3.5 gram Powder Sig: One (1) PO once a
day.
7. Glucerna Bar Sig: One (1) PO once a day.
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Tums 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO once a day.
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*3 Tablet(s)* Refills:*0*
15. Lovenox 100 mg/mL Syringe Sig: One (1) mL Subcutaneous twice
a day: please give 100 mg SC BID.
Disp:*1 1* Refills:*2*
16. insulin
Humalog mix 50/50- 30 units [**Hospital1 **]
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
1. Gastrointestinal bleed of unclear source, likely lower GI
2. Paroxysmal atrial fibrillation, rate controlled with
metoprolol and anticoagulated with lovenox bridge to coumadin,
last INR of 1.3.
3. TIA while in ICU presenting as aphasia and rt extremity
weakness which has resolved
.
Prior PMH
1. CAD- s/p CABG
2. S/p AVR, bioprosthetic
3. Mitral stenosis
4. Chronic diastolic dysfunction
5. Hypertension
6. Diabetes
7. Hypothyroidism
Discharge Condition:
Stable for home. Last HCT from [**11-2**] stable at 28. On room
air. Ambulating with no distress or symptoms.
Discharge Instructions:
Dear Ms [**Known lastname 84830**],
It was a pleasure caring for you while you were at [**Hospital1 18**]. You
had a long hospital course and, as you are aware, was quite
complicated by a combination of your gastrointestinal bleeding
and the TIA that you experienced. We performed several tests to
look for the source of your gastrointestinal bleeding, including
a "tagged red blood cell scan," "angiography," and 2
colonoscopies. All of these tests failed to definitively find a
source. During angiography, a suspicious area had a coil placed
in it which may have helped stop some of your bleeding, however,
its unclear if this was the main source, especially since your
bleeding continued afterwards. Giving you bowel preps prior to
colonscopy tended to worsen your bleeding, so we felt that
repeated colonoscopies would not improve the situation. Given
that you had atrial fibrillation, the heart rhythm that gave you
the TIA, it was important to keep your blood thin. Stopping
anticoagulation puts you at high risk for stroke. Thin blood
however, would lead to continued bleeding. The only solution to
this difficult situation was to give you transfusions on an
as-needed basis. As a result, after discussing the benefits and
risks of continued anticoagulation in the face of continued
gastrointestinal bleeding, we decided that we could discharge
you on lovenox and coumadin with a plan coordinated by your
primary care doctor to ensure your blood counts did not fall too
low. Your primary care doctor will describe this plan further
to you but a brief outline is as follows:
(1) Initially, you will get your blood checked twice a week by
your primary care doctor and his staff.
(2) If your blood count falls less than 25, or a number set by
your PCP, [**Name10 (NameIs) **] you will receive a transfusion at [**Hospital1 2177**].
(3) If you feel dizzy or lightheaded, you can get your blood
checked and if its low, you will receive a transfusion at [**Hospital1 2177**].
(4) If you have significant bleeding or if you feel very sick,
you will be readmitted for transfusions and further work-up as
necessary.
.
The above is only an outline and it will likely require further
clarification and editing as the pattern of your bleeding over
time emerges. There is a possibility that your bleeding could
improve despite your anticoagulation or there is even a
possibility that your bleeding may never improve. The above
plan will help take both possibilities into account so that a
follow-up plan can be tailored to each.
.
We made the following changes to your medication regimen during
this hospitalization:
(1) Lovenox 100 mg injected subcutaneously twice a day - you
will receive this medicine daily along with your usual coumadin
until your INR reaches 2.0. At this time, the lovenox will be
stopped. Your primary care team will know when to stop the
lovenox.
(2) You should not take aspirin any longer since you are taking
coumadin. Your primary care doctor will tell you when to
restart this.
(3) Bactrim double strength tablet - you should take this twice
a day to finish a three day course. You need to take one more
pill today ([**11-3**]) and two tomorrow ([**11-4**]) and then you can
stop this. We started you on this because of a urinary tract
infection.
(4) You should not take amiodarone until your primary care
doctor feels its safe to restart this drug.
Other than the above changes, you can continue to take your
other medications, including 5 mg coumadin daily, as per your
home regimen.
.
If you experience worsening bleeding, start to feel dizzy or
lightheaded, or experience any limb weakness, changes in mental
status, difficulty speaking, or any other concerning symptoms,
please call your primary care physician immediately or return to
the emergency department.
Followup Instructions:
1. Your primary care doctor and his nursing staff will visit
you at your home tomorrow [**11-4**] in the morning to see you. At
that time, you will get much of the information on how your care
will be coordinated from here on out.
Name: [**Known lastname 13476**],[**Known firstname **] Unit No: [**Numeric Identifier 13477**]
Admission Date: [**2111-10-10**] Discharge Date: [**2111-11-3**]
Date of Birth: [**2037-9-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Phenergan
Attending:[**First Name3 (LF) 3870**]
Addendum:
Correction to above: Patient being discharged on Lovenox 100 mg
once a day (1.5 mg/kg dosing) for bridge until therapeutic level
of coumadin (goal INR [**1-13**]).
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
[**Name6 (MD) **] [**Name8 (MD) 3872**] MD [**MD Number(2) 3873**]
Completed by:[**2111-11-3**]
|
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"428.0",
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"794.8",
"401.1",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.79",
"45.23",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
24332, 24511
|
8293, 8293
|
341, 437
|
19578, 19693
|
3251, 6458
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2629, 2647
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19717, 23527
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2662, 2662
|
246, 303
|
465, 1972
|
6467, 8270
|
2676, 3232
|
1994, 2389
|
2405, 2613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,825
| 138,225
|
29288
|
Discharge summary
|
report
|
Admission Date: [**2108-11-5**] Discharge Date: [**2108-11-27**]
Date of Birth: [**2065-7-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
pain/shortness of breath
Major Surgical or Invasive Procedure:
sternal wound debridement /VAC placement [**11-14**]
sternal wound debridement /VAC placement [**11-14**]
sternal wound debridement /VAC placement [**11-14**]
History of Present Illness:
This 43 year old white female underwent mechanical mitral valve
replacement, closure of patent foramen ovale and ligation of
left atrial appendage three weeks previously. She was doing well
post-operatively until Saturday([**11-3**])when she had nausea and
after an episode of vomiting developed acute sternal incision
pain that makes it difficult to breath. She presented to [**Hospital1 3343**] ER and was subsequently transferred to [**Hospital1 18**] for further
management.
Past Medical History:
Hypertension
Pulmonary Hypertension
Possible Rheumatic heart disease
[**Hospital1 70393**] [**Hospital1 **]
Asthma
chronic obstructive pulmonary disease
Migraines
Obstructive sleep apnea
Depression/Bipolar disorder
Possible Fibromyalgia on Percocet
Osteoarthritis
History of Bells Palsy
s/p mechanical mitral valve replacement)/closure foramen
ovale/resection left atrial appendage/talon
closure sternum [**2108-10-11**]
s/p cervical spine surgery in [**2103**] at [**Hospital1 1774**]
s/p TAH for excessive bleeding in [**2105**]
s/p C-section x 2
Social History:
She currently lives in [**Location 8985**], [**State 350**]. She is
married with two daughters who are healthy. She smokes one to
two packs per day for the past 21 years. Social alcohol use.
No drug use. She is currently unemployed and not on disability
Family History:
Significant for fibromyalgia in her brother, mother and maternal
aunt. History of ovarian, breast, and colon cancer in maternal
side. Congenital heart dz in niece. Mother with RHD and MVR as
well as MI in her 40s. MGF with stroke in 80s.
Physical Exam:
Admission:
Temp 98.6 Pulse: 122-reg Resp: 24 O2 sat: 95% 3LNP
B/P Right: 143/87 Left:
Height:5'6" Weight:155.5 Kg
General:
Skin: Dry [x] intact [] small scabbed over area at base of
sternal incision, minimal surrounding erythema. Incision tender
to touch
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: diminished at bases, rhonchorous throughout
Heart: RRR [x] tachycardic, sharp click
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: lymphedema with 4+bilateral pedal edema
Neuro: A&Ox3: Grossly intact
Pulses:
Femoral Right: NP Left: NP
DP Right: NP Left: NP
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 1+ Left: 1+
Carotid Bruit Right:No Left:No
Pertinent Results:
[**2108-11-9**] 03:52AM [**Month/Day/Year 3143**] WBC-11.3* RBC-3.05* Hgb-8.0* Hct-25.0*
MCV-82 MCH-26.2* MCHC-32.0 RDW-16.9* Plt Ct-455*
[**2108-11-5**] 04:08PM [**Month/Day/Year 3143**] WBC-20.2* RBC-3.92* Hgb-9.9* Hct-31.7*
MCV-81* MCH-25.1* MCHC-31.1 RDW-16.8* Plt Ct-662*
[**2108-11-9**] 03:52AM [**Month/Day/Year 3143**] Glucose-92 UreaN-32* Creat-1.2* Na-132*
K-4.5 Cl-96 HCO3-27 AnGap-14
[**2108-11-5**] 04:08PM [**Month/Day/Year 3143**] Glucose-140* UreaN-12 Creat-0.6 Na-133
K-4.5 Cl-97 HCO3-23 AnGap-18
[**2108-11-5**] 04:08PM [**Month/Day/Year 3143**] %HbA1c-6.2*
IMPRESSION:
Increase in size of fluid collection noted immediately anterior
to the
sternum, now measuring 3.8 cm x 3.4 cm x 7.5 cm. Extensive
adjacent fat
stranding. Some of these changes may be postsurgical; however
supperimposed
infection cannot be excluded.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: TUE [**2108-11-13**] 10:15 AM
Imaging Lab
Brief Hospital Course:
She was transferred from [**Hospital1 1774**] on [**11-5**]. The sternum was stable
on exam with a quarter sized eschar at the lower end, without
surrounding cellulitis. There was 2+ lower extremety edema with
cellulitis. [**Month/Year (2) **] cultures were drawn and the sets from the
16th and 17th grew Staph aureus. Vancomycin and Clindamicin
were started and her white count fell. She was rehydrated as
her creatinine rose to 2 after diuresis and sepsis and
coagulopathy corrected with fresh frozen plasma and Vitamen K
for an INR of 10. Infectious disease saw the patient.
On [**11-8**] the eschar was excised and the wound was solid, without
tracking. The wound was packed, wet to dry. Cultures grew coag
negative staph. The cellulitis of the lower extremeties
improved quickly and her creatinine improved.
A PICC was placed for a 4 week course of Vancomycin and the
Clindamicin stopped. Local wound care to the sternum was
continued. CT scan done and she was taken to the OR for sternal
wound debridement on [**11-14**]. Cultures from the operating room
grew rare growth of coag + staph aureus. Transferred to the
CVICU after extubation in the OR. A wound VAC was left in place
and pain was controlled with Dilaudid, Oxycontin and Tramadol.
She was resumed on a heparin drip and coumadin was held for a
future flap surgery with plastics. She was continued on
vancomycin with adjustments in doses based on trough levels.
On [**2108-11-21**] she was taken to the operating room with Dr. [**First Name (STitle) **]
and Dr. [**Last Name (STitle) 914**] for removal of Talon plating, sternal
debridement and plating with pec flap advancement.
Please refer to operative note for details. Post operatively she
remained intubated and was admitted to the ICU. She was weaaned
and extubated without any difficulty. She was maintained on IV
vancomycin for MRSA with consultation and management by
infectious disease . Her pain was managed with oxycodone SR and
dilaudid for breakthrough pain. Her lopressor was titrated to
control her heart rate and was agressively diuresed. She was
discharged to home on 80mg lasix [**Hospital1 **]- home dose 120mg [**Hospital1 **]- dose
change discussed with Dr. [**Last Name (STitle) 3649**]. Coumadin dosing and follow up
confirmed with Dr. [**Last Name (STitle) 3649**].
Medications on Admission:
Warfarin: currently taking 10mg QD INR goal
3.0-3.5 daily
Metoprolol Tartrate 75 mg [**Hospital1 **], Aspirin 81 mg DAILY
Atorvastatin 20 mg DAILY, Ipratropium-Albuterol 1-2 Puffs Q4H
Alprazolam 1 mg [**Hospital1 **] -prn, Aripiprazole 15 mg QHS, Docusate
Sodium
100 mg [**Hospital1 **], Venlafaxine 225 mg QHS, Advair 250-50 [**Hospital1 **],
Nortriptyline 40 mg QHS, Lisinopril 2.5 mg DAILY, Potassium
Chloride 20 mEq Tab Daily, Furosemide 40 mg [**Hospital1 **]
Oxycontin 30 [**Hospital1 **]
and dilaudid 2-4mg Q3-prn on discharge, recent note from PCP
states pain regime changed to:
Percocet 7.5/325-up to 8 pills per day. One dose of extra
strength Tylenol-1000 mg allowable which w will keep total daily
Tylenol under 4000 mg. However patient states she is still
taking
oxycontin and dilaudid
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. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nortriptyline 10 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 72 doses: start date
[**11-21**] x 6 weeks- end date [**2109-1-2**].
Disp:*72 doses* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
Disp:*1 tube* Refills:*2*
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-23**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezes.
Disp:*1 mdi* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Hydromorphone 4 mg Tablet Sig: 1/2-1 Tablet PO Q4H (every 4
hours) as needed for pain: 2 weeks supply.
Disp:*100 Tablet(s)* Refills:*0*
13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Five (5)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): 2 week
supply.
Disp:*140 Tablet Sustained Release 12 hr(s)* Refills:*0*
14. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: Take as directed by DR. [**Last Name (STitle) 3649**].
Disp:*60 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Next INR draw is [**2108-11-28**] then everyother day or as advised by
Dr. [**Last Name (STitle) 3649**] please fax result to ATTENTION -Dr. [**Last Name (STitle) 3649**] or coverage or
[**First Name9 (NamePattern2) 70395**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7518**] [**Telephone/Fax (1) 18820**].
16. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
18. Outpatient Lab Work
CBC with diff, BUN/CREAT, Vanco trough weekly and fax to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**].
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Bacteremia
lower extremity cellulitis
s/p Mitral Valve replacement (mechanical),closure patent Foramen
Ovale,ligation of left atrial appendage [**9-28**]
Pulmonary Hypertension
Possible Rheumatic heart disease
[**Month/Year (2) 70393**] [**Month/Year (2) **]
Asthma
chronic obstructive pulmonary disease
Migraines
Obstructive sleep apnea
Depression/Bipolar disorder
Fibromyalgia
Osteoarthritis
History of Bells Palsy
Discharge Condition:
Vital signs stable,walking
wounds clean
Discharge Instructions:
no lotions creams or powders on any incision
shower daily and pat incision dry
no lifting greater than 10 pounds for 10 weeks
no driving for one month
call for fever,redness or drainage.
CALL Dr. [**Last Name (STitle) 5543**] or DR. [**Last Name (STitle) 3649**] for weight gain or 2 pounds in 2
days or 5 pounds in one week.
INR check every other day or as directed by Dr. [**Last Name (STitle) 3649**] for
coumadin dosing.
Weekly labs CBC/Diff, BUN/CREAT, and vanco trough- results faxed
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (infectious disease) [**Telephone/Fax (1) 70396**]
Ace wraps daily to bilateral lower extremities.
Followup Instructions:
see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] (PCP) on [**2108-12-10**] at 12:30pm ([**Telephone/Fax (1) 3070**])
see Dr. [**Last Name (STitle) 5543**] (cardiologist) [**2108-12-6**] at 11:40
see Dr. [**Last Name (STitle) 914**] (surgeon) in 2 weeks ([**Telephone/Fax (1) 170**])
see Dr. [**First Name (STitle) **] in one week from discharge for drain removal-
[**Telephone/Fax (1) 1416**].
Follow up with Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 2688**] in infectious disease clinic
on [**2108-12-3**] at 3:50pm ([**Telephone/Fax (1) 15920**])
Dr. [**Last Name (STitle) 3649**] [**Telephone/Fax (1) 3070**] will follow your INR and dose your
coumadin. Your next INR [**Telephone/Fax (1) **] draw is [**2108-11-28**].
Completed by:[**2108-11-27**]
|
[
"682.2",
"401.9",
"998.31",
"346.90",
"998.59",
"327.23",
"278.01",
"E878.1",
"416.8",
"493.20",
"V43.3",
"584.9",
"041.11",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"34.4",
"93.57",
"34.79",
"78.51",
"83.82",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
9996, 10071
|
4090, 6414
|
304, 467
|
10532, 10574
|
2890, 4067
|
11284, 12095
|
1841, 2081
|
7266, 9973
|
10092, 10511
|
6440, 7243
|
10598, 11261
|
2096, 2871
|
239, 266
|
495, 976
|
998, 1549
|
1565, 1825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,276
| 165,137
|
48983
|
Discharge summary
|
report
|
Admission Date: [**2168-2-19**] Discharge Date: [**2168-2-22**]
Date of Birth: [**2097-4-5**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Lopressor
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Hypotension, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 yo M with CAD s/p CABG and PCI x 3 (EF 44%), DM, HTN who was
sent to MICU from ED for hypotension. He presented to the ED
from an outpatient pain clinic with hypotension with BP 70/40
(per pt: normal BP 120/80) while being seen in pain clinic. In
pain clinic, was not given any extra narcotics or treatment that
would have dropped his BP. Patient had recent admission from
[**Date range (1) 12052**] at [**Hospital6 **] for back pain, and sent home on
vicodin prn which the patient didn't take. Also had ARF thought
to be [**12-21**] NSAID use, and some confusion with normal neuro eval
and MRI/MRA. No documentation of patient's BP trend during this
hospitalization. Since that admission, patient noted 1 week h/o
lightheadedness, subjective fever, decreased PO intake, and
fatigue. Then had onset of 1 day of profuse watery diarrhea. He
is on 80mg PO lasix at home and has continued to take this. FS
at home in 130s. No sick contacts or recent travel.
.
Denies abdominal pain, chills, diaphoresis, nausea, vomiting,
shortness of breath, wheezing, increased LE edema, chest pain
palpitations. No confusion, numbness, tingling, difficulties
with speech or coordination. Other ROS negative.
.
In ED, initial vitals were 100.2 64 82/60 18 94. Mental status
was intact. He received 5L of fluids, and SBPs went up to 110s.
Also given levaquin 750mg IV x 1 for guiac positive stool, and
ASA 325mg PO for reported chest pain while in ED which resolved
with 2mg IV morphine. ekg unchanged, cardiac enzymes flat. Guiac
positive stool. Lactate 1.8, no leukocytosis. UA negative, CXR
clear. No recent abx. On transfer, vitals were 112/60, 79, 20,
99% on 2L. Patient was admitted to ICU for further monitoring
given hypotension.
Past Medical History:
CAD s/p CABG ([**2148**]), s/p 2 PCI, one not patent per patient:
-[**2136**] Inferoposterior MI treated medically
-[**2148**] CABG: SVG to PDA, SVG to OM1, SVG to OM2, LIMA to the LAD
Hypertension
Hyperlipidemia
NIDDM (dx 7 years ago)
Angioedema
Social History:
Sells real estate. Lives alone.
Smoking 6 pack year h/o
Few drinks/week, no IVDU
Family History:
Mother passed away of MI at 76, Father passed away of MI at 75,
FH of DM.
Physical Exam:
VITAL SIGNS:
T=97.5 BP=131/67 HR=76 RR=22 O2=96% on 2L
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing man 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 difficult to assess
LUNGS: trace crackles right lung base
ABDOMEN: NABS. Soft, obese,
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-20**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Labs on admission:
[**2168-2-19**] 01:30PM BLOOD WBC-8.8 RBC-4.21* Hgb-12.2* Hct-35.4*
MCV-84 MCH-29.0 MCHC-34.4 RDW-13.5 Plt Ct-254
[**2168-2-19**] 01:30PM BLOOD Neuts-78.5* Lymphs-16.8* Monos-3.0
Eos-1.5 Baso-0.2
[**2168-2-19**] 01:30PM BLOOD Glucose-137* UreaN-30* Creat-1.7* Na-131*
K-3.9 Cl-90* HCO3-26 AnGap-19
[**2168-2-19**] 01:30PM BLOOD CK(CPK)-43
[**2168-2-19**] 02:10PM BLOOD CK(CPK)-40
[**2168-2-19**] 07:33PM BLOOD CK(CPK)-43
[**2168-2-19**] 02:10PM BLOOD cTropnT-<0.01
[**2168-2-19**] 07:33PM BLOOD CK-MB-3 cTropnT-<0.01
[**2168-2-20**] 05:21AM BLOOD CK-MB-3 cTropnT-<0.01
[**2168-2-19**] 07:33PM BLOOD Albumin-3.2* Calcium-7.2* Phos-2.8
Mg-1.4*
[**2168-2-19**] 01:31PM BLOOD Glucose-129* Lactate-1.8
.
ECG on admission: NSR at 77, old Q wave and TWI in III. No
significant changes from prior 7/[**2161**]. No ST changes.
.
MICROBIOLOGY:
[**2-19**], [**2-20**] Blood culture - no growth to date
[**2-19**] urinalysis - negative, culture pending
.
IMAGING:
[**2-19**] Chest x-ray:
IMPRESSION: Low lung volumes with basilar atelectasis. No acute
cardiopulmonary process.
.
[**2-20**] Chest x-ray:
INDICATION FOR STUDY: Evaluate for edema or infiltrate in
patient with
coronary artery disease, low ejection fraction and hypertension.
Comparison made with most recent prior study from [**2168-2-19**].
Cardiac and mediastinal contours remain unchanged in size and
appearance. Linear
atelectasis is present in the left lower lobe. The remaining
lungs are clear with no consolidation, no pneumothorax is noted.
Bony structures are
unremarkable.
IMPRESSION: Unchanged left lower lobe atelectasis.
Brief Hospital Course:
70 yo M with CAD s/p CABG and PCI x 3 (EF 44%), DM, HTN admitted
to MICU for hypotension which resolved after fluid resuscitation
likely secondary to dehydration, and diarrhea.
.
#. Hypotension: Patient with hypotension in clinic and also on
admission to ED. He was fluid responsive to 5L in ED and his
hypotension resolved upon arrival in ICU. He did not meet any
other SIRS criteria when admitted to the ICU: lactate normal
(1.8->1.4), afebrile, no leukocytosis, no tachycardia. He was
likely hypovolemic in the setting of a possible gastrointestinal
infection. He had no evidence suggesting a cardiac etiology of
his hypotension as there was no evidence of ACS by EKG or
cardiac enzymes x3. He required no further fluids while in the
ICU and he maintained this MAP >65. Blood cx, urine cx were
sent with no growth to date at time of discharge. AM cortisol
was checked and was low at 4.1 He underwent [**Last Name (un) 104**] stim test with
1 hr post-[**Last Name (un) 104**] level of 20.5 (nl response).
.
#. Diarrhea: Likely viral gastroenteritis. Pt had no further
diarrhea while here, so no stool studies could be sent
.
#. Acute renal failure: Creatnine up to 1.7 from recent baseline
of 1.3 on adission. This resolved to normal with IV fluid
hydration. Of note, he was also recently admitted to an outside
hospital for acute renal failure for excess NSAID use.
Creatinine was 0.9 at time of discharge. On day of discharge pt
was restarted on his lasix but on [**11-20**] dose (40 mg a day).
Tekturna still on hold and can be resumed as outpatient.
.
# Guaiac positive stool: Likely related to diarrhea above. Hct
has been stable. Patient has follow up with his
gastroenterologist in [**Month (only) 116**], and may need repeat colonoscopy (last
one 1 year ago per patient) and possible EGD.
.
#. Chronic systolic CHF/CAD: Patient with known CAD status post
CABG and PCI in past, with baseline EF of 44%. His EKG was
unchanged from his baseline. While he did have some chest pain
when put supine in the ED, the was not his anginal equivalent.
His enzymes were cycled and were negative. He was continued on
his ASA, statin, and plavix. His carvedilol and lasix were held
given that he was hypotensive. On day of discharge his
carvedilol was resumed and lasix was resumed at 1/2 home dose
(40 mg a day). His Tekturna will be held until follow up with
his PCP (BP currently does not warrant initiation of it--SBP
110s prior to discharge).
.
#. Diabetes Mellitus II, controlled, no complications: He was
not hyperglycemic in setting of possible infection, His oral
hypoglycemics were held and he was maintained on an ISS. His
metformin was restarted upon normalization of his creatinine and
his glyburide was restared on discharge.
.
# Anemia: Hct 33 prior to discharge. Iron studies were checked
and were normal. As per above, has had guaiac positive stool.
.
#. HTN: As above, his BP meds were held given that he presented
with hypotension. Carvedilol resumed prior to discharged.
Resumed 1/2 dose home lasix (40 mg) prior to discharge. Tekturna
held until follow up with PCP.
.
#. Hyperlipidemia: He was continued on his crestor.
Medications on Admission:
Lasix 80mg PO daily
Plavix 75mg PO daily
Crestor 20mg PO daily
Carvedilol 25mg [**Hospital1 **]
Glyburide 10mg [**Hospital1 **]
Metformin 1gm [**Hospital1 **]
Tekturna (HCTZ/aliskiren) 100mg PO daily
KCL 25mEq daily
ASA 81mg PO daily
(not taking) Vicodin 1tab PO Q4hr prn pain
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Discharge Condition:
stable
Discharge Instructions:
You were admitted with low blood pressure. This is likely due to
diarrhea that you had before coming in. We performed a cortisol
stimulation test, in which you responded normally.
.
You did have some noted blood in your stool while you were here.
This may have been related to infectious diarrhea. You need to
discuss this finding with your GI doctor and your primary care
doctor (to see if you need any further work up like an upper
endoscopy or repeat colonoscopy). You should have stools studies
resent when you see your primary care doctor to ensure the blood
in your stools is resolved.
.
Medication Changes: Your carvedilol was restarted. Your lasix
was decreased to 40 mg a day for now in light of your recent
dehydration. Do not increase back up to 80 mg a day until you
see your doctor. [**First Name (Titles) 2172**] [**Last Name (Titles) 102850**] and aliskiren
(Tekturna) have been held until you follow up with your doctor.
You will need to be seen by the end of this week to ensure that
your blood pressure is still in good range. We would recommend
you go to the grocery store or pharmacy and have your blood
pressure checked this week (Wednesday). If your systolic blood
pressure is over 160, then please call your doctor to discuss
which blood pressure medications to resume.
.
Call your doctor or go to the ER for blood pressure greater than
200 (upper number) or 110 (lower number). Also call your doctor
for any lightheadedness, dizziness, chest pain, dehydration,
diarrhea, abdominal pain, fever, or any other concerning
symptoms.
Followup Instructions:
Your doctor's office (Dr. [**Last Name (STitle) 102851**] will be calling you this week
to arrange for an urgent care visit by the end of this week. You
will need to have your blood pressure checked at that visit and
decide which medications should be restarted. You should discuss
having stool cards done to see if you still have blood in your
stool.
|
[
"250.00",
"285.9",
"272.4",
"412",
"584.9",
"276.51",
"V45.81",
"401.9",
"008.8",
"428.22",
"578.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9042, 9048
|
5025, 8173
|
319, 325
|
9104, 9113
|
3391, 3396
|
10713, 11068
|
2461, 2536
|
8500, 9019
|
9069, 9083
|
8199, 8477
|
9137, 9731
|
2551, 3372
|
9751, 10690
|
258, 281
|
353, 2077
|
4127, 5002
|
2099, 2347
|
2363, 2445
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,987
| 177,287
|
15987+56718
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-12-22**] Discharge Date: [**2167-12-30**]
Date of Birth: [**2123-12-7**] Sex: F
Service: MICU GREEN TEAM
CHIEF COMPLAINT: Hypoxia, status post right middle lobe
wedge resection.
HISTORY OF PRESENT ILLNESS: This is a 44-year-old female,
with a history of primary pulmonary hypertension diagnosed in
[**2167**], presenting with progressive dyspnea on exertion over
the past year. The patient states that the dyspnea has
worsened since [**2167-3-7**], for which she was admitted four
months later with a diagnosis of dyspnea. She was initially
treated with Flolan, given her diagnosis of primary pulmonary
hypertension. Echo and cardiac catheterization were notable
for increased pulmonary artery hypertension. At that time,
the patient also had a normal wedge pressure, normal LV
function, normal biventricular diastolic function, and a
normal ejection fraction.
The patient was admitted primarily for work-up of new chest
x-ray and chest CAT scan findings which were diffuse
bilateral ground glass opacities, bibasilar thickening of the
interlobar septa with honeycombing. The concern was that the
patient may have had a secondary diagnosis in addition to her
primary pulmonary hypertension. Therefore, the patient was
admitted to have a right lobe wedge resection performed for
pathologic studies. The differential at the time of this
surgery primarily included pulmonary [**Last Name (un) **]-occlusive disease
versus pulmonary capillary hemangiomatosis. At the time of
admission, the patient was status post chest tube removal.
She complained of pleuritic right-sided chest and back
discomfort. She also noted feeling short of breath. She was
persistently nauseated, and she had vomited bilious emesis x
1 on the day of transfer to the MICU. The patient also noted
a cough productive of dark blood 2-3 times a day.
Additionally, the patient felt orthopneic. Chest x-ray upon
transfer to the MICU was notable for a new right lower lobe
infiltrate consistent with air space disease, most likely
lung injury.
PAST MEDICAL HISTORY:
1. Primary pulmonary hypertension.
2. Herniated disk at L4-L5 diagnosed in [**2166-3-7**].
3. Rosacea.
4. Status post ex. lap 2 years ago to evaluate abdominal
pain.
5. History of negative Holter evaluation.
ALLERGIES: Penicillin causes hives.
MEDICATIONS ON TRANSFER:
1. Flolan continuous infusion.
2. Potassium chloride 60 mEq qd.
3. Lasix 240 mg po qd.
4. Vitamin D 800 U qd.
5. Digoxin 0.125 po qd.
6. Elavil 50 mg po q hs.
7. Coumadin had been discontinued as of [**2167-12-9**].
SOCIAL HISTORY: The patient is an ex-tobacco user of
approximately 28-pack year. She quit in [**2166-11-4**]. She
works as a registered nurse [**First Name (Titles) **] [**Hospital3 **]. She lives
with her children and husband. She reports occasional
alcohol use, but denies IV drug abuse. At baseline, the
patient is on 4 liters nasal cannula at home. Her code
status is full.
FAMILY HISTORY: Negative for any pulmonary processes.
Father is deceased from Alzheimer's disease and pneumonia.
Mother is alive and well. There is a family history of
coronary artery disease.
PHYSICAL EXAM ON TRANSFER TO MICU: Notable for vital signs -
T-max 99.8??????F, blood pressure ranged systolic 84-123/45-91,
heart rate range 103-140, respiratory rate 24, 89-95% on 4 L
nasal cannula and shovel mask. Her intake and output history
upon transfer: She had 2,050 ml/3,425 ml. Exam was notable
for anicteric sclerae. Her oropharynx was clear. Her neck
exam - JVP approximately 10 cm at 45??????, no bruits. Pulmonary
exam - decreased breath sounds at bases, no crackles, no
wheezes. Cardiac exam - regular, tachycardia, S1, S2, II/VI
systolic murmur at the left sternal border. Abdominal exam
benign. Extremity exam - 1+ pretibial edema, 2+ dorsalis
pedis bilaterally, positive clubbing of the upper digits, no
calf tenderness, no swelling. Neurologic exam grossly
intact.
STUDIES [**2167-10-5**]: Echocardiogram - ejection fraction
55-60%, right ventricular dilatation, moderate global right
ventricular hypokinesis, moderate pulmonary systolic
hypertension.
[**2167-11-4**] CARDIAC CATHETERIZATION: Right ventricular
filling pressures 55/7, pulmonary artery pressure 55/26, with
a mean of 39, mean wedge 6, left ventricular pressure 81/10,
cardiac output 4.9, cardiac index 2.8, pulmonary vascular
resistance 536.
RADIOGRAPHIC STUDIES: As mentioned, CAT scan notable for
ground glass opacities bibasilar. Chest x-ray notable for a
new right lower lobe infiltrate.
HOSPITAL COURSE BY PROBLEM - 1) PRIMARY PULMONARY
HYPERTENSION, STATUS POST RIGHT LOWER LOBE WEDGE RESECTION
FOR WORK-UP OF NEW RADIOGRAPHIC LUNG FINDINGS AND PROGRESSIVE
DYSPNEA ON EXERTION: The patient was initially treated with
Flolan with a short course of inhaled nitric oxide treatment
in the setting of her acute dyspnea. Symptomatically, the
patient improved and was able to be weaned off nitric oxide
after a 48-hour course. The patient's pathology was notable
for evidence of pulmonary capillary hemangiomatosis. Given
the overall poor prognosis in this diagnosis, the patient was
maintained on supportive regimen including Flolan,
doxycycline for its presumed effects on decreased
metalloproteinase activity, and lasix to further reduce
preload in the setting of increased filling pressures on the
right side. The patient's chest x-ray did not change
remarkably. However, symptomatically she improved. Her
cough became dry without any evidence of hemoptysis. The
patient's hematocrit was stable. Her oxygen saturation
improved while weaning her O2 requirement. Additionally, the
patient's exercise tolerance increased during her hospital
course, and upon transfer to the regular floor, the patient
was able to ambulate without feeling short of breath.
2) CARDIAC: From an ischemia standpoint, the patient did not
have any active issues. She, however, did remain tachycardic
throughout her hospital course, but denied any symptoms of
chest discomfort, and did not have any evidence of ischemia
on her EKG. The patient did have a recent cardiac
catheterization from [**2167-11-4**] which did not reveal any
evidence of critical stenoses in her coronary arteries.
From a pump perspective, the patient's ejection fraction was
55-60%. She did have evidence of increased right ventricular
filling pressures and moderate right ventricular hypokinesis.
The patient was maintained on lasix with very impressive
diuresis. She was maintained on her PO regimen and was
approximately negative 10 liters for her length of stay in
the ICU. The patient was continued on her digoxin with her
dig level at 0.6 on transfer to the MICU. Follow-up level is
pending.
From a rhythm perspective, the patient was persistently sinus
tachycardic. This was presumed to be in relation to
diuresis, as well as her Flolan treatment which is a common
side-effect. The patient was asymptomatic, however.
Therefore, she was not aggressively treated for this, and her
EKG did not reveal any abnormalities. For this reason, the
patient was maintained on tele.
3) HEMATOLOGIC: The patient initially was on Coumadin for
her primary pulmonary hypertension. However, in the setting
of an acute bleed in the right lung, her Coumadin was held
and continues to be held upon transfer to the floor. Her
hematocrit remained stable, and her chest x-ray did not
change in appearance.
4) GI: The patient did not have any active issues. She was
maintained on a bowel regimen with normal bowel movements
which were reportedly guaiac negative.
5) POSTOPERATIVE PAIN AND BACK PAIN: The patient, at
baseline, has back pain in relation to her disk disease for
which she takes amitriptyline. In the setting of having had
her chest surgery, she was given morphine sulfate on a prn
basis, as well as po percocet, to which the patient reported
adequate pain control. Thereafter, the patient was
maintained on Tylenol treatment prn for her pain.
6) PROPHYLAXIS: The patient was maintained on a proton pump
inhibitor, as well as heparin subcu tid.
DISPOSITION: To the floor with follow-up with Dr. [**Last Name (STitle) **]
for potential treatment of her primary pulmonary hypertension
and pulmonary capillary hemangiomatosis. Additionally, the
patient is on the lung transplant waiting list. Addendum to
follow with the team on service.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**], M.D. [**MD Number(1) 1178**]
Dictated By:[**Last Name (NamePattern1) 1600**]
MEDQUIST36
D: [**2167-12-30**] 10:56
T: [**2167-12-30**] 12:01
JOB#: [**Job Number 45782**]
Name: [**Known lastname 8417**], [**Known firstname **] Unit No: [**Numeric Identifier 8418**]
Admission Date: [**2167-12-22**] Discharge Date: [**2168-1-2**]
Date of Birth: [**2123-12-7**] Sex: F
Service: [**Location (un) 571**]
ADDENDUM: [**2167-12-30**], through [**2158-1-2**].
The patient was transferred from the Medical Intensive Care
Unit to the general medical floor and remained in stable
condition. She was weaned from her oxygen 50% face mask and
nasal cannula to four liters nasal cannula. The patient was
able to ambulate well on four liters nasal cannula with
oxygen saturation above 90%. The patient was also continued
on her home Flolan dose as well as the Doxycycline for
pulmonary capillary hemangiomatosis. For further diuresis,
the patient was placed on her home dose of Lasix 120 mg twice
a day as well as her potassium repletion of 30 meq twice a
day. Given the patient's improvement in her oxygen
requirement, the patient was stable for discharge on
[**2168-1-2**]. She will be discharged with her home oxygen
requirement of four liters nasal cannula.
CONDITION ON DISCHARGE: Stable to home requiring four liters
of oxygen nasal cannula on exertion.
DISCHARGE STATUS: To home with VNA services for Flolan and
home oxygen.
DISCHARGE DIAGNOSES:
1. Pulmonary hypertension.
2. Congestive heart failure.
3. Hypoxia.
4. Pulmonary capillary hemangiomatosis.
MEDICATIONS ON DISCHARGE:
1. Vitamin D 800 once daily.
2. Digoxin 0.125 mg once daily.
3. Amitriptyline 50 mg q.h.s.
4. Furosemide 120 mg twice a day.
5. Epoprostenol, Flolan, 20 ng/kg/min continuous infusion.
6. Doxycycline 100 mg twice a day.
7. Colace 100 mg twice a day.
8. Percocet one to two tablets q4-6hours p.r.n. incisional
pain.
9. Potassium Chloride 30 meq twice a day.
10. Coumadin 2.5 mg tablets once daily to be adjusted further
as an outpatient.
11. Miconazole Powder.
12. Home oxygen.
FOLLOW-UP PLANS: The patient will follow-up with her primary
care physician to have an INR checked and Coumadin dose
changed as needed early in the week following discharge. In
addition, the patient will follow-up with her pulmonologist,
Dr. [**Last Name (STitle) 2306**].
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 2334**], M.D. [**MD Number(1) 2335**]
Dictated By:[**Name8 (MD) 2450**]
MEDQUIST36
D: [**2168-1-2**] 10:20
T: [**2168-1-2**] 12:31
JOB#: [**Job Number 8419**]
|
[
"E878.8",
"V58.61",
"998.11",
"228.09",
"285.1",
"428.0",
"416.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.28",
"00.12"
] |
icd9pcs
|
[
[
[]
]
] |
2983, 9785
|
9980, 10093
|
10119, 10605
|
10623, 11144
|
167, 224
|
253, 2069
|
2363, 2580
|
2091, 2338
|
2597, 2966
|
9810, 9959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,026
| 146,621
|
21451
|
Discharge summary
|
report
|
Admission Date: [**2174-10-23**] Discharge Date: [**2174-12-6**]
Date of Birth: [**2146-7-2**] Sex: M
Service: SURGERY
Allergies:
Cefotetan / Cefepime
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Motor vehicle accident -> ran over by car
Major Surgical or Invasive Procedure:
Exploratory laparotomy & abdominal packing ([**10-23**])
Re-exploration of abdomen & removal of packing ([**10-24**])
Exploratory laparotomy & evacuation of hematoma ([**11-3**])
ERCP with stent placement ([**11-4**])
Abdominal washout & closure ([**11-6**])
CT-guided drainage of abdominal fluid collections ([**11-15**] & 20)
US-guided thoracentesis ([**12-1**])
History of Present Illness:
28yo M brought to [**Hospital1 18**] via [**Location (un) **] from [**Hospital **] hospital. Pt
was reportedly stuck & pinned under car driven by girlfriend.
Upon presentation to outside hospital, was hypotensive with
tender abdomen. Blood products were started & transferred via
[**Location (un) **] - pt became unstable enroute & was intubated. Upon
arrival, pt was taken directly to OR for ex lap.
Past Medical History:
Prematurity & low-birth weight
Developmental delay
Social History:
Living with girlfriend prior to admission.
Parents are health care proxy.
Family History:
Non-contributory
Physical Exam:
General - intubated, sedated, hypothermic @ 34.0 Celsius
HEENT - no signs of external trauma
Neck - c-collar in place
Lungs - equal BS bilat
Abd - distended, +DPL with gross blood, R groin scar
Back - no deformity/obvious injury
Ext - no deformity
Pertinent Results:
[**2174-10-23**] 08:12PM BLOOD WBC-9.5 RBC-5.68 Hgb-17.1 Hct-48.6 MCV-86
MCH-30.2 MCHC-35.3* RDW-13.6 Plt Ct-178
[**2174-10-23**] 08:12PM BLOOD PT-14.6* PTT-40.6* INR(PT)-1.4
[**2174-10-23**] 08:12PM BLOOD Glucose-175* UreaN-14 Creat-0.9 Na-145
K-4.5 Cl-115* HCO3-15* AnGap-20
[**2174-10-24**] 03:57AM BLOOD ALT-2180* AST-1723* LD(LDH)-2545*
Amylase-119* TotBili-2.4*
[**2174-10-24**] 03:57AM BLOOD Lipase-61*
[**2174-10-23**] 08:12PM BLOOD Calcium-11.4* Phos-4.1 Mg-2.0
[**2174-10-23**] 06:50PM BLOOD Type-[**Last Name (un) **] Temp-34.2 pO2-57* pCO2-39
pH-7.22* calHCO3-17* Base XS--11 Intubat-INTUBATED
[**2174-10-23**] 08:37PM BLOOD Lactate-4.2*
[**2174-12-4**] 05:30AM BLOOD WBC-10.8 RBC-3.27* Hgb-9.5* Hct-28.3*
MCV-86 MCH-29.0 MCHC-33.5 RDW-15.1 Plt Ct-505*
[**2174-12-6**] 05:05AM BLOOD PT-21.7* PTT-41.8* INR(PT)-3.0
[**2174-12-3**] 05:30AM BLOOD Glucose-111* UreaN-18 Creat-0.4* Na-135
K-4.9 Cl-100 HCO3-24 AnGap-16
[**2174-12-3**] 05:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.6
Brief Hospital Course:
[**10-23**] - Admitted to [**Hospital1 18**], taken directly to OR for ex lap,
repair of liver lac & packing of abdomen, taken to T/SICU for
further resuscitation, significant skin rash suggestive of
allergy to cefotetan given in OR.
[**10-24**] - Taken back to OR for removal of packing & closure of
abdomen, CT head/CTL-spine negative.
[**10-25**] - Pt extubated.
[**10-27**] - Transferred from T/SICU to surgical [**Hospital1 **].
[**10-28**] - Psych consult for ? of depression -> diagnosed with
adjustment d/o & multifactorial delirium.
[**10-29**] - Pt noted to have large biloma on CT scan, clinical
findings suggestive of peritonitis & started on antibiotics.
[**10-30**] - Percutaneous drainage of biloma by IR.
[**11-3**] - Pt became hypotensive with severe abdominal pain, JP with
grossly bloody output. Pt taken back to OR for ex lap &
evacuation of hematoma. Pt had angiography demonstrating a
pseudoaneurysm in R lobe of liver, coiling performed. [**Hospital **]
transferred to T/SICU paralyzed & intubated with open abdomen.
[**11-4**] - ERCP performed with placement of a stent in the common
bile duct.
[**11-6**] - Pt taken back to OR for abdominal washout & closure.
[**11-9**] - Pt extubated.
[**11-10**] - Transferred form T/SICU to surgical [**Hospital1 **].
[**11-14**] - Pt had HEIDA & CT scan to evaluate recent fevers/abd
pain/tenderness -> demonstrated multiple intra-abdominal fluid
collections.
[**11-15**] - CT guided drainage of fluid collections & placement of 2
drains.
[**11-16**] - Pt transferred back to T/SICU following episode of
tachypnea/tachycardia suggestive of early sepsis. Repeat CT
guided drainage of fluid collections.
[**11-18**] - Transferred from T/SICU to surgical [**Hospital1 **].
[**11-21**] - CT scan of abd/pelvis with interval improvement of
intra-abdominal collections.
[**11-22**] - Dobhoff feeding tube placed by IR & started on
tube-feeds. Started on antifungal for [**Female First Name (un) **] cultured from
drains, in addition to pt's antibiotics.
[**11-25**] - Pt with LUE pain/swelling, u/s demonstrated L
axillary/subclavian vein DVT, started on therapeutic lovenox.
[**11-27**] - Pt started on coumadin for completion of anticoagulation
therapy for LUE DVT.
[**11-28**] - CT scan of abd/pelvis with continued interval improvement
of intra-abdominal collections.
[**12-1**] - Pt has had persistent tachycardia for weeks, R pleural
effusion thought to be possibly contributing to tachycardia. Pt
underwent u/s guided thoracentesis with removal of 200cc fluid -
significant improvement in respiratory & cardiovascular
symptoms.
[**12-5**] - Pt's calorie counts well above requirements, dobhoff &
tube feeds d/c'd. Pt's INR therapeutic for last 2 days, d/c'd
lovenox.
[**12-6**] - D/C to home on coumadin, will f/u with internal medicine
on [**12-9**] for management of coumadin, f/u in trauma clinic on
[**12-13**].
Medications on Admission:
None
Discharge Medications:
1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*15 Tablet(s)* Refills:*0*
2. Megestrol Acetate 40 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone HCl 2 mg Tablet Sig: 0.5-1 Tablet PO Q3-4H ()
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
6. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) for 6 months.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Motor vehicle accident
Liver laceration
Hepatic pseudoaneurysm
Left upper extremity DVT
Right pleural effusion
Intra-abdominal abcess
[**Female First Name (un) 564**] albicans infection
Wound infection
Discharge Condition:
Good, stable
Discharge Instructions:
-Abdominal drain in place with daily dressing changes
-Home physical therapy for strenghtening/conditioning
-Coumadin dosage & blood level monitoring by primary care
physician
[**Name10 (NameIs) 56640**] with Trauma Clinic in 1 week
[**Hospital **] clinic or return to ER for fevers, pain, shortness of
breath or other concerns.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) 55668**] [**Name (STitle) **] on Friday [**12-9**] @ 3:30 for
monitoring & adjusting of your coumadin dosage. The office is
located in the South Suite on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building of [**Hospital1 18**]. The phone number is [**Telephone/Fax (1) 250**] if there
are any questions.
Follow-up in Trauma Clinic on Tuesday [**12-13**], call ([**Telephone/Fax (1) 376**]
for appointment time & questions/directions.
|
[
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"567.2",
"570",
"041.19",
"997.4",
"112.89",
"453.40",
"442.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"96.72",
"50.61",
"54.91",
"34.91",
"50.12",
"54.63",
"99.04",
"54.12",
"51.87",
"96.59",
"96.08",
"39.79",
"99.15",
"54.11",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6265, 6340
|
2612, 5498
|
321, 688
|
6586, 6600
|
1603, 2589
|
6977, 7477
|
1302, 1320
|
5553, 6242
|
6361, 6565
|
5524, 5530
|
6624, 6954
|
1335, 1584
|
240, 283
|
716, 1121
|
1143, 1195
|
1211, 1286
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,550
| 131,324
|
39043
|
Discharge summary
|
report
|
Admission Date: [**2177-3-9**] Discharge Date: [**2177-3-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
GI bleeding, PNA
Major Surgical or Invasive Procedure:
- Intubation and Mechanical Ventilation
- Blood transfusions (6 units packed red blood cells, 1 unit
fresh frozen plasma)
- Colonoscopy
History of Present Illness:
The patient is an 85y/o F with a PMH of severe aortic stenosis,
recent OSH admission for pulmonary embolism ([**Date range (1) 86563**]) admitted
with lower GI bleed in setting of supratherapeutic INR.
Per patient??????s daughter, her mother [**Name (NI) 653**] her for left arm
pain this afternoon. While visiting daughter noticed [**Name2 (NI) 86564**]
staining on her clothes. Reportedly patient has been having
[**Name2 (NI) 86564**]-colored stools x 3 days. Pt's daughter took her to OSH
where gross blood was seen in rectal vault and supratherapeutic
INR of 4.7 with Hct 25. Pt had been taking Coumadin 5mg QD for
pulmonary embolus diagnosed [**2-23**] (though had held for 3 days
given supratherapeutic INR >3 on routine lab check), as well as
Ascriptin (ASA 325 + maalox) for arm pain. NG lavage showed
flecks of blood, but cleared with NS. At OSH, given pantoprazole
40mg IV and 2U FFP, then transferred to our ED.
ED vitals were T97, HR 80, BP 97/70, RR 24, 90% and exam
revealed gross blood in rectal vault. Stat Hct 23 and INR 2.3.
Received 1U O neg blood, 700 mL NS. Overload from transfusion
caused acute hypoxia. Patient was given Lasix 120mg IV and
intubated.
On the floor, vitals T:98.6 BP: 93/61 P: 72 R: 16 O2: 99% on AC.
Transfused additional 1 unit PRBCs and 3U FFP.
Per discussion with the patient??????s family, was mostly complaining
of left arm pain. This had been ongoing for weeks and was
attributed to ?bursitis. Apparently had cardiac work-up without
evidence that it was contributing.
Past Medical History:
Pulmonary embolism of small and subsegmental arteries on
coumadin (discharged from OSH [**2177-2-28**])
HTN
HL
Type 2 DM
AS, severe. OSH echo [**2177-2-25**] showed EF 55%-60%, no regional WMAs
LBBB
CAD--diagnosed on echo by echo and nuclear aress test [**2174**];
never had MI or catheterization
Severe left ICA stenosis by ultrasound
Anemia
GERD
Depression
Osteoporosis
Spinal stenosis
Chronic back pain on opiates
S/p bilateral knee replacement
Social History:
Lives independently. No tobacco/EtOH/drugs. Close relationship
with daughter [**Name (NI) 11229**].
Family History:
NC
Physical Exam:
Physical Exam:
Vitals: T:98.6 BP: 93/61 P: 72 R: 16 O2: 99% on AC
General: Sedated, appeared comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear. PERRL
Neck: supple, JVP flat, no LAD
Lungs: Rhonchi bilaterally at bases bilaterally.
CV: Regular rate and rhythm, normal S1 and S2. IV/VI
crescendo-decrescendo murmur heart diffusely but most
prominently at RUSB with radiation to carotids. II/VI systolic
murmur at apex.
Abdomen: soft, non-tender, bowel sounds present, some
distension. No tenderness or guarding, no organomegaly. Midline
abdominal scar.
Ext: warm, well perfused, 2+ R DP pulse, 1+ DP pulse, 2+ radial
pulses bilaterally. No clubbing, cyanosis or edema
Pertinent Results:
[**2177-3-9**] 04:00PM WBC-8.8 RBC-2.67* HGB-7.4* HCT-22.7* MCV-85
MCH-27.8 MCHC-32.7 RDW-13.9
[**2177-3-9**] 04:00PM PT-24.3* PTT-48.7* INR(PT)-2.3*
[**2177-3-9**] 04:00PM cTropnT-0.11*
[**2177-3-9**] 04:00PM GLUCOSE-172* UREA N-29* CREAT-0.9 SODIUM-137
POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-31 ANION GAP-12
Brief Hospital Course:
#) GI bleeding--admission hematocrit 23. Patient was transfused
1 unit O negative blood in the ED and one more unit once brought
on to the floor with a hematocrit goal of 28-30. Nasogastric
lavage of 1L was negative for blood. On HD2 she was transfused
two more units of packed red blood cells. Her INR was 2.7 on HD2
and she was subsequently transfused two more units of fresh
frozen plasma. During the second unit of FFP, she became
febrile, and the transfusion was stopped due to concern for a
transfusion reaction. On HD3 she was transfused one more unit,
and thereafter her hematocrit remained stable at 29-31 and her
INR remained stable at 1.2. She was not actively bleeding while
in the unit. GI followed the patient during her stay on the unit
and deferred their plan for colonoscopy until her more immediate
medical problems resolved (CHF, myocardial ischemia), given the
fact that she was not actively bleeding. On HD5 she had a bloody
bowel movement but Hct remained stable at 29 with no further
signs of active bleeding. In this setting her heparin (DVT
prophylaxis), which had been started once she stopped showing
signs of active bleeding and INR reversed, was stopped. In
addition, her aspirin, which had been started for myocardial
ischemia, was changed to a baby dosing.
.
Once on the floor, pt underwent a colonoscopy, which showed
nonspecific inflammation, but no specific source for her bleed.
The colonoscopy was limited, reaching only to the distal
ascending colon, due to an abdominal hernia. At this point,
since the patient's hct remained stable, GI signed off, and will
plan to further work this up on an outpatient basis.
.
#) Respiratory Distress--patient was intubated in the emergency
department due to flash pulmonary edema from heart
failure/aortic stenosis in the setting of receiving 700cc's of
normal saline and 1 unit of packed red blood cells. She was
given lasix after this fluid load but remained intubated on the
unit. On HD4 she was weaned from assist control to CPAP/pressure
support. On HD5 she was extubated successfully. To avoid further
pulmonary edema while receiving blood transfusions, lasix was
administered gingerly with transfusions for a goal for euvolemia
to -500cc's negative daily. Once on the floor, she no longer
required transfusions, and remained euvolemic.
.
#) Fever--spiked during FFP transfusion to 102.5; transfusion
stopped and patient remained febrile with low-grade temps (100.1
--> 101) for remainder of evening and into the next day. Her
white blood cell count also bumped to 13, which was concerning
for infection. She was noted to have an abscess at the back and
base of her lower neck which was incised and drained and packed.
Blood and urine cultures were sent in the context of the fever
and abscess. She was started on unasyn after I&D. However, her
chest X-ray the next morning showed a new lower left lung
opacity that may have been consistent with pulmonary edema or
developing infection. Respiratory cultures were sent and she was
treated empirically for ventilator-associated pneumonia with
vancomycin and cefepime, and the unasyn was discontinued.
.
#) Pneumonia--As noted above, during her ICU stay pt was found
to have a LLL pneumonia. She received a weeklong course of
vancomycin and cefepime.
.
#) Neck abscess--As also noted above under fever heading, Ms.
[**Known lastname 86565**] was found to have an abscess at her upper back/base of
neck. It was I&Ded, and irrigated and repacked daily, and
appeared to be well-healing on exam. She was discharged with VNA
for continued daily packings, and given a 10 day course of oral
Keflex.
.
#) Myocardial ischemia: troponin bumped from 0.11 --> 1.12 after
12 hours, then peaked at 1.50 before down-trending. This was
initially treated with simvastatin 80mg (heparin and ASA held in
setting of bleeding; beta-blocker held in setting of severe AS
and congestive heart failure). Transthoracic echocardiogram
noted distal septal wall motion abnormalities which were
presumably new (TTE performed at OSH from [**Date range (1) 86566**] showed no
regional wall motion abnormalities, according to OSH discharge
summary). Overnight on HD3, troponins increased again to 1.35,
which was concerning for a repeat event. Cardiology was
consulted on HD4, and they felt that her troponin trend was
consistent with demand ischemia in the setting of a GI bleed.
They recommended to continue high-dose statin therapy, start
aspirin 325mg, and a low-dose beta-blocker if blood pressure
permitted. Aspirin was started since at that point of the
hospitalization she showed no signs of active bleeding, her
hematocrit and INR had remained stable. Metroprolol was given
for a few days; however the patient was noted to have increased
sinus pauses on EKG, so it was discontinued. Her discharge
medications included aspirin, simvastatin, and lisinopril.
.
#) Aortic stenosis--patient's flash pulmonary edema in ED felt
to be secondary to diastolic heart failure and aortic stenosis.
Patient given lasix gingerly (10mg IV doses) with transfusions
for daily volume balance goal euvolemic to 500cc's negative.
Repeat chest X-rays showed gradual resolution of pulmonary
edema. Transthoracic echocardiogram revealed severe AS with
valve area of 0.8cm, normal LV cavity size with regional
systolic dysfunction consistent with CAD in mid-LAD
distribution, PA systolic hypertension, amd mild-moderate mitral
regurgitation. Cardiology consulted and planned to discuss
option of percutaneous valve replacement with patient on an
outpatient basis.
.
#) Pulmonary embolus--OSH PE CTA scans obtained and reviewed
with [**Hospital1 **] radiology, who felt that study was limited due to motion
artifact but there was no clear indication of PE in small and
subsegmental arteries. Radiology did note interstitial pulmonary
edema on PE CT, which may have been causing this patient's
shortness of breath when she presented to OSH on [**2-22**]. Bilateral
lower extremity ultrasounds were negative for DVT. In setting of
GI bleeding, patient's coagulopathy was reversed with FFP and
vitamin K (5mg IV x1). After detailed discussion with patient
and family as to the risks and benefits of anticoagulation in
the setting of only questionable PE, and certain GI bleed, it
was decided that the patient would remain off of coumadin.
.
#) Left upper extremity pain--this was the patient's primary
concern in presenting to the hospital. Her symptoms were
concerning for ischemia (discussed above). She may have bursitis
or this may be arthritic pain, and this should be pursued on
outpatient follow-up. Her pain was treated with fentanyl during
intubation. On extubation, and throughout stay on floor, she
remained pain free without pain medication requirement.
.
#) Intrahepatic biliary ductal dilatation--noted on OSH
discharge summary and confirmed on review of OSH imaging with
radiologist here. Liver function tests revealed ALT, AST and
alkaline phosphatase within normal range but initially elevated
bilirubin to 1.9 (Direct 0.5; indirect 1.4). Repeat liver
function tests revealed normal bilirubin. Radiology felt degree
of dilatation was significant enough to be of concern for
possible pancreatic mass, so I/O+ abdominal CT ordered which
showed significant intrahepatic and extrahepatic biliary ductal
dilatation (common bile duct dilated to 3.5cm) but no definite
pancreatic mass. Differential included ampullary strictire or
pancreatic mass. Recommended follow-up with ERCP or, less
invasively, MRCP, to definitively rule-out pancreatic mass.
Biliary ductal dilatation is likely chronic, and the patient had
no abdominal pain to suggest cholangitis or cholecystitis. This
will be further addressed with GI on an outpatient basis.
.
#) Type II Diabetes--Home glipizide (2.5mg QD) held and patient
was originally maintained on a sliding scale with humalog.
However, her finger-sticks remained within appropriate range
without insulin administration and this was discontinued during
ICU stay. It was re-started when her diet was advanced after
extubation. She was restarted on home glipizide upon discharge.
.
#) Hypercholesterolemia--treated with high-dose simvastatin for
myocardial ischemia.
Medications on Admission:
Ascriptin (dose unknown)
Prilosec 20mg QD
ASA 81mg QD
Diltiazem long acting 360mg QD
Glipizide 2.5mg QD
Lipitor 20mg QD
Oxycontin 10mg [**Hospital1 **]
Hydrocodone 500 mg twice daily
Sertraline 50mg QD
Miralax 17mg PO QD
Coumadin 5mg PO QD (held x 3 days)
Furosemide 40 mg daily
Colace [**1-4**] daily
MVI
Calcium 500 mg daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
9. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day.
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. M-Vit 27-1 mg Tablet Sig: One (1) Tablet PO once a day.
12. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
14. Doxycycline Monohydrate 100 mg Capsule Sig: One (1) Capsule
PO twice a day for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Northeast Home Care
Discharge Diagnosis:
Primary: GI bleed, pneumonia, NSTEMI, neck abscess
Secondary: aortic stenosis, high blood pressure, high
cholesterol, diabetes, shoulder pain, biliary ductal dilatation
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 hospitalized at the [**Hospital3 **] for several medical
problems.
1. Gastrointestinal bleeding
At home, you noticed some [**Hospital3 86564**] colored stool; in the hospital
we found that you had a low blood count (hematocrit). You were
transfused with blood products, and your blood count stabilized.
Due to your bleeding, your blood-thinning medicine (Warfarin)
was stopped. You had a colonoscopy which showed some
non-specific inflammation. Your bleeding has stopped for several
days, and you will follow up with the gastrointestinal doctors
as [**Name5 (PTitle) **] outpatient.
2. Respiratory distress
In the emergency department, you had difficulty breathing due to
something called "flash pulmonary edema," in which fluid backs
up into your lungs. You were intubated, and put on a ventilator
in the intensive care unit. After 5 days, we were able to remove
your breathing tube, and you breathed well on your own.
3. Pneumonia
While you were in the ICU, you developed fevers, and were found
on chest xray to have a pneumonia in your left lung. This can
often happen to patients on ventilators. You received
antibiotics called vancomycin and cefepime to treat this.
4. Heart injury
You had lab tests that showed that your heart may have suffered
some injury after not getting enough oxygen. You had a test
called an echocardiogram which also showed this. You were
started on medicines for this, including aspirin, simvastatin,
and lisinopril. You briefly took a medicine called metoprolol,
however this may have caused your heartbeat to have some pauses,
so it was stopped. You have done well on these medicines and had
no more problems.
5. Neck abscess
You were found to have an infection called an abscess on the
back on your neck. It was drained and is healing well. You will
need to have your dressing changed daily; a nurse will visit you
at home for this. You will also take a course of oral
antibiotics.
6. Possible pulmonary embolism (clot in your lung)
You had a CT scan at the outside hospital which was thought to
show some small clots in your lung. However, the radiologists
here thought that these clots may not really have been there.
Your shortness of breath at that time may instead have been due
to a little fluid in your lungs. An ultrasound of your legs (a
common place for clots to come from) showed no signs of clots.
Due to all this, we reversed your thin blood, and stopped your
blood thinning medicine.
7. Aortic stenosis
You have a narrow valve in your heart, which you have had for
some time. This likely contributed to the fluid filling your
lungs. You will follow up with cardiology doctors in the future,
to disucuss the pros and cons of having valve replacement
surgery.
8. High blood pressure
You have had some high blood pressure in the past, for which you
take medicine. You are now taking lisinopril and lasix to
control your pressure.
9. Shoulder pain
You have been having pain in your left shoulder for some time,
which could be due to several causes, such as bursitis or
arthritis. This can be further evaluated and treated as an
outpatient with your primary care doctor.
10. Biliary ductal dilatation (enlarged ducts in and around your
liver)
This was noticed on your CT scan, and you may need a test called
an ERCP or MRCP as an outpatient. Your gastrointestinal doctors
[**Name5 (PTitle) **] follow this with you.
You have had several changes made to your medications. A current
list of your medicines is attached; you should take these, and
disregard your previous list.
Followup Instructions:
Please follow up with your primary care doctor within 1 week.
You should also follow up with gastroenterology. You can keep
the appointment below, or your primary care doctor can help you
find a new GI doctor more convenient to you.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2177-4-16**]
2:30
Completed by:[**2177-3-27**]
|
[
"414.01",
"272.4",
"518.81",
"997.31",
"729.5",
"578.1",
"530.81",
"E934.2",
"250.00",
"V43.65",
"338.29",
"682.1",
"401.9",
"433.10",
"576.8",
"285.1",
"724.5",
"518.4",
"410.71",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"48.24",
"38.91",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13430, 13480
|
3624, 11808
|
278, 415
|
13694, 13694
|
3285, 3601
|
17435, 17826
|
2571, 2575
|
12186, 13407
|
13501, 13673
|
11834, 12163
|
13874, 17412
|
2605, 3266
|
222, 240
|
443, 1967
|
13709, 13850
|
1989, 2438
|
2454, 2555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,908
| 173,009
|
7534
|
Discharge summary
|
report
|
Admission Date: [**2157-6-23**] Discharge Date: [**2157-7-1**]
Date of Birth: [**2081-1-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cefazolin / Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Coronary Artery Disease
Major Surgical or Invasive Procedure:
[**2157-6-23**] CABGx3
[**2157-6-30**] Cardioversion
History of Present Illness:
Mr. [**Known lastname 27534**] is a 76 year old male with a history of
hypertension and hyperlipidemia. He was seen by Dr. [**First Name (STitle) **]
for a [**3-10**] week history of chest discomfort with exertion. An EKG
revealed non-specific inferior T wave changes. He was referred
for a stress test which was positive. A cardiac catheterization
was performed which revealed severe 3 vessel coronary artery
disease.
Past Medical History:
Hypercholesterolemia
Hypertension
Lumbar disc herniation
Bilateral hearing aids
Retinal artery occlusion of left eye - legally blind
Chronic renal insufficiency
Social History:
Married with several children. Lives in [**Location 4310**]. Retired.
Family History:
Brother had CABG in early 60's.
Physical Exam:
5' 9" Wt: 164
BP (R) 120/76 (L) 121/80 HR 50
GEN: No acute distress
HEART: RRR, no Murmur
LUNGS: Clear
ABD: Benign
EXT: No edema, 2+ pulses, no varicosities
NEURO: Non-focal
Pertinent Results:
[**2157-6-28**] 06:58AM BLOOD WBC-9.9 RBC-3.09* Hgb-9.5* Hct-28.3*
MCV-91 MCH-30.6 MCHC-33.5 RDW-14.1 Plt Ct-257
[**2157-6-30**] 06:50AM BLOOD Hct-30.4*
[**2157-7-1**] 07:05AM BLOOD PT-15.2* PTT-99.3* INR(PT)-1.5
[**2157-7-1**] 07:05AM BLOOD Glucose-102 UreaN-18 Creat-1.5* K-3.9
[**2157-6-27**] CXR
Interval removal of chest tubes, ET tube and NG tube. There is a
faint linear opacity at the left lung apex, which may possibly
represent a tiny apical pneumothorax.
[**2157-6-17**] Cardiac Catheterization
Left main 60-70%, LAD 80%, Second Diagonal 70%, Circumflex 80%,
obtuse marginal 80%, occluded right coronary artery.
Brief Hospital Course:
Mr. [**Known lastname 27534**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2157-6-23**] and taken to the operating room where he
underwent coronary artery bypass grafting to three vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr. [**Known lastname 27534**] [**Last Name (Titles) **]e neurologically intact and was extubated. He was transfused
with packed red blood cells for postoperative anemia. On
postoperative day two, he was transferred to the Cardiac
Surgical Step down unit for further recovery. He was gently
diuresed towards his preoperative weight. Beta blockade was
titrated for optimal heart rate and blood pressure support. He
had some mild postoperative confusion which resolved without
issue. The physical therapy service was consulted for assistance
with his postoperative strength and mobility. Mr. [**Known lastname 27534**]
developed atrial flutter on postoperative day four for which
amiodarone was started. The electrophysiology service was
consulted for assistance in his care. Coumadin was started for
anticoagulation. On [**2157-6-30**], Mr. [**Known lastname 27534**] was taken to the
electrophysiology lab where he underwent cardioversion to normal
sinus rhythm. Several hours later, Mr. [**Known lastname 27534**] went back into
atrial flutter and the electrophysiology service recommended
ablation in the future after follow-up with Dr. [**Last Name (STitle) **].
Amiodarone and Coumadin were continued and Mr. [**Known lastname 27534**] again
converted back into a normal sinus rhythm. He continued to make
steady progress and was discharged home with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 27535**]e day eight. He will follow-up with Dr. [**Last Name (STitle) **]
for further management his paroxysmal atrial flutter in [**2-6**]
weeks. Dr. [**First Name (STitle) **] will manage his Coumadin dosing for a goal
INR of 2.0-2.5. Mr. [**Known lastname 27534**] will follow-up with Dr. [**Last Name (STitle) **] in
4 weeks.
Medications on Admission:
Atenolol 25mg daily
Dyazide 37.5mg daily
Zocor 40mg daily
Lisinopril 40mg daily
Adalat 60mg daily
Aspirin 81mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
2. 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*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO twice a
day: Take 400mg (two 200MG tablets)twice daily for one week,
then starting [**2157-7-8**], take 400mg once daily.
Disp:*70 Tablet(s)* Refills:*2*
6. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO Once daily or
as instructed by Dr. [**First Name (STitle) **]: Take 3mg daily or as instructed
by Dr. [**First Name (STitle) **]. Dose may change based on blood INR.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
Atrial Flutter
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Monitor vital signs. Report any fever greater then 100.5.
3) No lifting greater then 10 pounds for 1 month.
4) No driving for 1 month.
5) Do not apply lotions or creams to incision.
6) Please monitor INR for a goal between 2.0-2.5 for atrial
flutter. Dr. [**First Name (STitle) **] will monitor your blood work and dose your
coumadin accordingly. Take coumadin as instructed by Dr.
[**First Name (STitle) **]. Your discharge dose will start at 3mg daily and may
change based on your blood levels. Please have your blood
checked (PT/INR) with Dr. [**First Name (STitle) **] on Tuesday [**2157-7-5**] (in
[**Location (un) **]) and then as instructed by him. Take 3mg daily until
that time however do not take Tuesdays dose until you have been
instructed as to a dose by Dr.[**Name (NI) 11574**] office. The visiting
nurse may draw blood and report it to Dr.[**Name (NI) 11574**] office
Sunday or Monday if your are seen.
7) Take amiodarone 400mg twice daily for 1 week, then (Starting
[**2157-7-8**]) take 400mg once daily thereafter until instructed by Dr.
[**Last Name (STitle) **].
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] (Surgeon) in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**First Name (STitle) **] (PCP/Cardiologist) for coumadin
dosing and blood draw ([**2157-7-5**]) and for routine post-surgical
follow-up in 2 weeks. [**Telephone/Fax (1) 250**]
Please have blood draw in [**Location (un) **] on [**2157-7-5**] (PT/INR) for
coumadin dosing and have results faxed to Dr.[**Name (NI) 11574**] office.
Follow-up with Dr. [**Last Name (STitle) **] (Cardiologist/Electrophysiologist)
in [**2-6**] weeks. Call to schedule appointment. [**Telephone/Fax (1) 285**]
Completed by:[**2157-7-1**]
|
[
"362.30",
"433.10",
"593.9",
"272.4",
"285.1",
"427.32",
"722.10",
"401.9",
"414.01",
"411.1",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"36.15",
"99.04",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5311, 5386
|
1995, 4152
|
312, 367
|
5469, 5475
|
1346, 1972
|
6702, 7340
|
1103, 1136
|
4319, 5288
|
5407, 5448
|
4178, 4296
|
5499, 6679
|
1151, 1327
|
249, 274
|
395, 816
|
838, 1000
|
1016, 1087
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,365
| 149,670
|
10660
|
Discharge summary
|
report
|
Admission Date: [**2200-12-17**] Discharge Date: [**2200-12-24**]
Date of Birth: [**2129-2-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Respiratory Difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71M who is well known to our service who was recently discharged
to [**Hospital 34967**] rehab on [**10-9**] after a long hospital course for
management of cystgastrostomy, G-tube and J-tube placement c/b
PNA/effusion s/p L chest tube placment at rehab. The patient
was doing well with passe muir valve on O2 cannula until
approximately 2 weeks ago when he had an aspiration event.
Patient developed a RLL infiltrate and he was started on
antibiotics and needed vent support at nights for CO2 retension.
Patient then developed increase in secretion and developed a
LLL pneumonia. Sputum culture showed MRSA/GNR. Patient then
needed a full vent support. Patient presented on [**12-4**] with
vague abdominal pain and had a CT of chest at that time.
Past Medical History:
HTN
CAD, s/p angioplasty
s/p AVR [**7-6**]
Respiratory failure
tracheostomy
Failure to thrive
s/p R knee surgery
ventilator associated pneumonia
pancreatic pseudocyst
Atrial fibrilation
galstone pancreatitis
picc line placement
cholelithiasis
COPD
CHF
sepsis
Social History:
lives with his wife
former tobacco use
Physical Exam:
T 99, HR 84, BP 115/58, RR 22 and 95%
NAD, alert, follows commands
Neck supple, trach
MMM
RRR
coarse breath sounds bilaterally
soft, J tube placed, NT, ND, no rebound and no guarding
2+ edema
Pertinent Results:
[**2200-12-17**] 09:48PM GLUCOSE-86 UREA N-44* CREAT-0.6 SODIUM-150*
POTASSIUM-4.5 CHLORIDE-112* TOTAL CO2-31* ANION GAP-12
[**2200-12-17**] 09:48PM ALT(SGPT)-12 AST(SGOT)-22 ALK PHOS-1279*
AMYLASE-21 TOT BILI-0.4
[**2200-12-17**] 09:48PM ALBUMIN-2.5* CALCIUM-11.4* PHOSPHATE-3.2
MAGNESIUM-2.0 IRON-34*
[**2200-12-17**] 09:48PM LIPASE-37
[**2200-12-17**] 09:48PM calTIBC-125* TRF-96*
[**2200-12-17**] 09:48PM WBC-12.0* RBC-3.03* HGB-9.1* HCT-28.9* MCV-96
MCH-30.0 MCHC-31.4 RDW-16.1*
[**2200-12-17**] 09:48PM NEUTS-80.1* LYMPHS-11.6* MONOS-4.7 EOS-3.1
BASOS-0.4
[**2200-12-17**] 09:48PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2200-12-17**] 09:48PM PLT COUNT-360
Brief Hospital Course:
Patient was admitted to a ICU setting and underwent an
evaluation by orthopedic surgery for swollen knee to rule out
septic knee. Orthopedic surgery felt that there was no signs
consistent with septic knee. Thoracic surgery was also
consulted for his respiratory failure and they requested a CT
scan. Patient was continued on his antibiotic regiment of
Linezolid and Flagyl. We then added fluconazole to his regimen.
Patient was continued on his tube feeds, home medication and
full ventilatory support. A CT of the torso revieled an
improved lung consolidations and a small area in the abdomen
concerning for a abscess that was the reminent of the pseudocyst
that has unchanged in character in multiple CT scan. Patient
improved on HD3 with continuation of antibiotics and full
ventilatory support. Patient was started to ween from vent on
HD4 and continue to do well. On HD7 patient was discharged to
vent rehab in a good condition tolerating trach collar. Patient
was continued on Linzolid and Fluconazole for total of 14 days.
Medications on Admission:
Fragmen 6000"
Digoxin 0.125'
Synthroid 275 mcg'
Protonix 40'
Paxil 40'
Albuterol
Allopurinol 300'
Atenolol 100"
Tylenol
Spiriva
MVI
Neutrophos
Vit B12
Folate
Iron
Nystatin
Cefipime
Flagyl
Linezolid
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Chlorhexidine Gluconate 0.12 % Liquid Sig: 5-10 MLs Mucous
membrane TID (3 times a day) as needed.
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
check digoxin level once a week.
4. Levoxyl 75 mcg Tablet Sig: One (1) Tablet PO once a day:
total of 275 mcg per day.
5. Levoxyl 200 mcg Tablet Sig: One (1) Tablet PO once a day:
total of 275 mcg per day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
14. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
15. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
16. Fragmen
17. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Respiratory distress
Hypertension
Coronary artery disease s/p angioplasty
s/p R knee surgery
pancreatic pseudocyst
atrial fibrillation
h/o gallstone pancreas
h/o chronic obstructive pulmonary disease
h/o congestive heart failure
s/p ex lap, cystgastrostomy, G and J tube placement
s/p ex-lap, abdominal washout, ccy, G tube placement
L chest tube placement
s/p tracheostomy
anemia
Discharge Condition:
Good
Discharge Instructions:
Please call with fevers,nausea, vomiting, diarrhea, abdominal
pain and respitory distress
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 3628**] SURGICAL ASSOC [**Name11 (NameIs) 3628**]-3A (NHB) Where: LM
[**Hospital Unit Name 3665**] ASSOCIATES Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2200-12-31**] 10:00
Completed by:[**2200-12-23**]
|
[
"518.81",
"V44.0",
"496",
"414.01",
"285.9",
"599.0",
"V45.82",
"486",
"427.31",
"401.9",
"719.06",
"V44.4",
"569.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5211, 5281
|
2410, 3453
|
339, 345
|
5706, 5712
|
1692, 2387
|
5850, 6112
|
3701, 5188
|
5302, 5685
|
3479, 3678
|
5736, 5827
|
1479, 1673
|
277, 301
|
373, 1126
|
1148, 1408
|
1424, 1464
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,790
| 173,354
|
17188
|
Discharge summary
|
report
|
Admission Date: [**2123-10-20**] Discharge Date: [**2123-11-3**]
Date of Birth: [**2049-9-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Furosemide
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
OPCABx3(LIMA->LAD, SVG->[**Last Name (LF) 48199**], [**First Name3 (LF) **]) [**10-20**]
Cardiac catherization with intra aortic balloon pump insertion
[**10-20**]
History of Present Illness:
This is a 74 year old man who presented with 2 weeks of
exertional chest pain with an elevated troponin.
Past Medical History:
Hypertension, alcohol abuse, depression, Hepatitis C, PE-ex'd w/
coum, then [**Location (un) 260**] filter [**2-27**], PVD, s/p PTA of L SFA, s/p
colostomy for bowel obstruction, biliary tract disease, chronic
back pain, CVA with residual facial and left hand weakness, s/p
UGIB, + smoker 1 PPD
Social History:
Mr. [**Known lastname 48200**] is a 74 year old Russian man, widowered. He is
noted to have a significant alcohol history, with current
intake. He is a 1 PPD smoker.
Family History:
Father with MI in 70s
Physical Exam:
Deferred, patient taken emergently to OR
Discharge
Neuro alert, oriented x3 nonfocal
Cardiac RRR no m/r/g
Resp Clear to ausculation bilaterally
Abd soft, NT, ND +BS
Ext warm, pulses palpable +1 pulses
Inc sternal healing no erythema, sternum stable
Left EVH no erythema no drainage
Old chest tube sites with 1cm depth tissue pink - wet to dry
dressing
Rash on arms and abdomen improving had been total body rash
Sacral skin tears stage 1 left and sacral stage 2 right buttock
Pertinent Results:
[**2123-11-1**] 09:35AM BLOOD WBC-19.3* RBC-3.13* Hgb-9.7* Hct-30.4*
MCV-97 MCH-31.1 MCHC-32.0 RDW-15.1 Plt Ct-809*
[**2123-10-20**] 05:00PM BLOOD WBC-14.2* RBC-3.30* Hgb-11.3* Hct-31.8*
MCV-96 MCH-34.2* MCHC-35.6* RDW-13.0 Plt Ct-260
[**2123-11-1**] 09:35AM BLOOD Neuts-70.5* Lymphs-17.3* Monos-3.8
Eos-7.9* Baso-0.5
[**2123-10-24**] 03:00AM BLOOD Neuts-72.7* Lymphs-14.7* Monos-6.5
Eos-5.8* Baso-0.3
[**2123-10-29**] 04:53AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Burr-2+ Tear Dr[**Last Name (STitle) **]1+ Bite-OCCASIONAL Acantho-1+
[**2123-11-1**] 09:35AM BLOOD Plt Ct-809*
[**2123-10-20**] 05:00PM BLOOD PT-12.4 PTT-35.9* INR(PT)-1.1
[**2123-10-20**] 05:00PM BLOOD Plt Ct-260
[**2123-10-25**] 03:21AM BLOOD Fibrino-498*#
[**2123-11-1**] 09:35AM BLOOD Glucose-138* UreaN-21* Creat-1.3* Na-140
K-5.3* Cl-106 HCO3-24 AnGap-15
[**2123-10-22**] 03:19AM BLOOD UreaN-31* Creat-1.7* Na-139 Cl-116*
HCO3-15*
[**2123-10-20**] 03:35PM BLOOD Glucose-105 UreaN-24* Creat-1.3* Na-140
K-4.8 Cl-105 HCO3-28 AnGap-12
[**2123-10-23**] 02:00AM BLOOD ALT-30 AST-33 AlkPhos-42 TotBili-0.6
[**2123-11-1**] 09:35AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.3
[**2123-10-22**] 12:36PM BLOOD Lipase-12
[**2123-10-20**] 05:00PM BLOOD VitB12-431
[**2123-10-20**] 05:00PM BLOOD %HbA1c-5.9
Cardiology Report ECG Study Date of [**2123-11-1**] 10:04:58 AM
Normal sinus rhythm, rate 69. Right bundle-branch block.
Compared to
tracing [**2123-10-20**] no significant change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 148 138 444/459 42 49 10
RADIOLOGY Final Report
CHEST (PA & LAT) [**2123-11-1**] 1:16 PM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
s/p off pump cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
HISTORY: To evaluate pleural effusion.
FINDINGS: In comparison with the study of [**10-29**], there is little
change in the appearance of the costophrenic angles with small
pericardial effusions, more marked on the left. Atelectatic
streak is again seen at the right base. The right IJ catheter
has been removed.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: MON [**2123-11-1**] 2:03 PM
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2123-10-29**] 3:36 PM
CT CHEST W/O CONTRAST
Reason: evaluate for infection in pt with WBC of 28 thou
[**Hospital 93**] MEDICAL CONDITION:
74 year old man s/p OPCABGx3
REASON FOR THIS EXAMINATION:
evaluate for infection in pt with WBC of 28 thou
CONTRAINDICATIONS for IV CONTRAST: iodine allergy
INDICATION: 74-year-old man status post CABG. Evaluate for
infection. Elevated white blood cell count of 28,000.
COMPARISON: CT abdomen and pelvis [**2119-5-4**].
TECHNIQUE: MDCT acquired axial images of the chest were obtained
without IV contrast. Thin slice and coronal reformations were
performed.
FINDINGS: There are extensive coronary artery and aortic
calcifications. There is no mediastinal, hilar, or axillary
lymphadenopathy. The largest lymph node is within the right
lower paratracheal station, 8 mm. There is a moderate amount of
fluid within the retrosternal region, that given within 15 days
of the surgery is within normal limits. There is no CT evidence
suggestive of infection. Moderate bilateral pleural effusions,
left slightly greater than right with associated atelectasis,
are new. A stable 2 mm right middle lobe pulmonary nodule, is
unchanged compared to [**2119-5-4**], requiring no further
followup.
This examination was not intended for subdiaphragmatic
evaluation. Limited views of the upper abdomen demonstrate a
stable dilated extrahepatic biliary tree with the abnormal
aggregate of bile ducts containing a small amount of
pneumobilia. Aside from the pneumobilia, which is a normal post
sphincterectomy finding, this is unchanged compared to [**2119-4-27**].
There are multiple nonobstructive bilateral kidney stones. The
largest within the right mid pole, 5 mm. There are stable
bilateral simple renal cysts.
There are no suspicious lytic or sclerotic osseous lesions.
There is no evidence of sternal dehiscence or osteomyelitis.
IMPRESSION:
1. No evidence of sternal dehiscence.
2. Substernal fluid collections that within 15 days of surgery
are likely expected postoperative changes; infection is not
excluded, but there are no definitive signs to suggest this
possibility.
3. New bilateral moderate pleural effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SAT [**2123-10-30**] 11:03 AM
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 48201**],[**Known firstname **] [**2049-9-10**] 74 Male [**-6/4259**] [**Numeric Identifier 48202**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **], [**Last Name (un) 48203**],[**Doctor First Name **]/dif
SPECIMEN SUBMITTED: SKIN LEFT LATERAL HIP, RIGHT MEDIAL THIGH (2
JARS) - RUSH CASE.
Procedure date Tissue received Report Date Diagnosed
by
[**2123-10-26**] [**2123-10-27**] [**2123-10-28**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/bef??????
Previous biopsies: [**-6/2931**] SKIN RIGHT ANTIHELIX,
MID-ABDOMEN (2 JARS).
[**-2/3175**] AMPULLARY BX.
[**Numeric Identifier 48204**] SMALL BOWEL, SIGMOID COLON (STITCH ON PROXIMAL END)
DIAGNOSIS:
1. Skin, left lateral hip; punch biopsy (A):
Superficial to mid dermal perivascular mononuclear cell
infiltrate with perivascular and interstitial eosinophils (see
comment).
2. Skin, right medial thigh; punch biopsy (B):
Superficial to mid dermal perivascular mononuclear cell
infiltrate with perivascular and interstitial eosinophils (see
comment).
Comment. The appearances in both biopsies are similar although
more developed in the biopsy from the left lateral hip. They are
consistent with a hypersensitivity reaction such as that to a
drug. There is some mild focal epidermal spongiosis. No
bacterial or fungal organisms are identified on Gram or PAS
stains, performed on both biopsies. Preliminary findings phoned
to Dr. [**Last Name (STitle) 40510**] by Dr. [**Last Name (STitle) **] on [**2123-10-27**]. Final results sent by
internal email to Dr. [**Last Name (STitle) **] on [**2123-10-28**].
Clinical: 74 year old man, status post coronary artery bypass
graft with diffuse confluent erythema for 3 days involving
medial thighs, perineum, back, buttocks, abdomen, and posterior
legs. Suspect dermal hypersensitivity reaction (to antibiotics
versus iodine) versus infectious process. Please rule out early
necrotizing fasciitis and Fournier's gangrene. Please do gram
stain and PAS.
Gross: The specimen is received in two formalin-filled
containers, each labeled with the patient's name "[**Known firstname **] [**Known lastname 48200**],"
and the medical record number.
Part 1 is additionally labeled "A left hip" and consists of a
0.4 cm punch biopsy of white skin excised to a depth of 0.5 cm.
The specimen is black inked at its resection margin, bisected
and entirely submitted in A in histo wrap.
Part 2 is additionally labeled " B left medial high" and
consists of a 0.5 cm punch biopsy of skin excised to a depth of
0.7 cm. The specimen is black inked, serially sectioned and
entirely submitted as follows; B = tips in histo wrap, C= body
in histo wrap.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 48205**] (Complete)
Done [**2123-10-20**] at 8:18:09 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2049-9-10**]
Age (years): 74 M Hgt (in): 67
BP (mm Hg): 160/60 Wgt (lb): 180
HR (bpm): 78 BSA (m2): 1.94 m2
Indication: EmergentCABG for left main disease
ICD-9 Codes: 424.0, 440.0, 786.05
Test Information
Date/Time: [**2123-10-20**] at 20:18 Interpret MD: [**Name6 (MD) 3892**]
[**Name8 (MD) 3893**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
Emergency CABG for tight left main disease with a IABP. IABP is
atleast 8 cm below the left main to be adjusted. IABP was placed
prophylactically.
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch. Normal descending aorta diameter. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild to moderate ([**12-29**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (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 ascending
aorta is thickened and calcified.
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 or flail segments. Mild to moderate ([**12-29**]+)
central mitral regurgitation with some posterior direction to
the jet is seen. The vena contracta is 0.3cm and there is no
blunting or reversal seeni n the pulmonary veins. There is no
pericardial effusion.
Post offpump anastomosis:
Preserved biventricular systolic function. LVEF 55%.
Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **].
Thoracic aortic contour is intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
[**2123-11-1**] 10:58 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2123-11-2**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2123-11-2**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2123-10-26**] 8:53 pm TISSUE Site: SKIN
Source: Skin biopsy SKIN BX, L MEDIAL THIGH PARTNER'S
PAGER [**Numeric Identifier 37088**] DR.
[**Last Name (STitle) **] OR #[**Numeric Identifier 48206**] TAN-[**Doctor Last Name **].
GRAM STAIN (Final [**2123-10-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2123-10-31**]):
REPORTED BY PHONE TO DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2123-10-27**] AT 13:00.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier **]Portable TTE
(Complete) Done [**2123-11-3**] at 12:05:32 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2049-9-10**]
Age (years): 74 M Hgt (in): 66
BP (mm Hg): 120/64 Wgt (lb): 180
HR (bpm): 65 BSA (m2): 1.91 m2
Indication: Abnormal ECG. Left ventricular function.
ICD-9 Codes: 410.92, 423.9
Test Information
Date/Time: [**2123-11-3**] at 12:05 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2007W036-0:38 Machine: Vivid [**7-2**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: *259 ms 140-250 ms
Pericardium - Effusion Size: 1.3 cm
Findings
This study was compared to the prior study of [**2123-10-20**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets. No TR.
Indeterminate PA systolic pressure.
PERICARDIUM: Moderate pericardial effusion. No echocardiographic
signs of tamponade.
Conclusions
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%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The pulmonary artery systolic
pressure could not be determined. There is a moderate sized
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: Normal left ventricular systolic function. There is
a small to moderate (maximum size 1.3cm) pericardial effusion
adjacent to the inferolateral wall. There are no
echocardiographic signs of tamponade.
Compared with the prior study (TEE - images reviewed) of
[**2123-10-20**], there is now a small to moderate pericardial
effusion.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Brief Hospital Course:
Mr. [**Known lastname 48200**] was admitted to [**Hospital1 18**] on [**2123-10-20**] and underwent an
emergent off-pump 3 vessel CABG. Please refer to the operative
note for details. An IABP was placed prior to his surgery. His
post-operative course was significant for oliguria requiring
fluid boluses. His IABP was removed POD1. He remained
ventilated and was noted to have a WBC of 24. His chest and
mediastinal tubes were removed on POD4. He was empirically
placed on Vancomycin and Zosyn on [**10-25**]. Also on POD 5, his
Cordis was removed, and a triple lumen catheter was placed over
a wire. His pacing wires were removed. He was extubated, and
his femoral arterial line was removed. He was transferred to
the floor on POD #6.
He was seen by chronic pain service and by psychiatry. He was
followed by ostomy care for his previous colostomy. He was seen
by dermatology who performed 2 skin biopsies for rash on trunk
and legs. He was started on betamethasone cream for presumed
hypersensitivity reaction, for a maximum of two weeks. The rash
and pruritis improved. A skin biopsy grew VRE and he was started
on linezolid. He was seen by electrophysiology for 1 - 14 beat
run of VT and beta blockers were increased. He had no further
episodes of VT and Echo done [**11-3**] with EF 55%. He was ready for
discharge to rehab [**11-3**].
Medications on Admission:
Lopressor 25mg PO bid, ASA 81 mg PO daily, Neurontin 300 mg PO
bid, Prilosec 20 mg PO daily, Motrin 800 PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
7. Betamethasone Dipropionate 0.05 % Cream [**Last Name (STitle) **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day) for 7 days.
8. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
9. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
for 6 months.
10. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
11. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
13. Linezolid 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
14. Bumex 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 2
weeks.
15. Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO
every eight (8) hours.
16. Lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Coronary Artery Disease s/p Off pump CABG w/ IABP
Atrial Fibrillation
Drug reaction rash
Myocardial Infarction
Hypertension, ETOH abuse, depression, Hep C, PE-ex'd w/ coum,
then [**Location (un) 260**] filter [**2-27**], PVD, s/p PTA of L SFA, s/p
colostomy for bowel obstruction, biliary tract disease, chronic
back pain, CVA w. resid facial and L hand weakness, s/p UGIB, +
smoker 1 PPD
Discharge Condition:
Good.
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Old chest tube sites above umbilicus - please pack with wet >
dry dressing and change [**Hospital1 **]
Lab CBC please draw [**2123-11-5**] and [**11-9**] to evaluate while on
Linezolid
Followup Instructions:
Please call to schedule all appointments
Dr. [**First Name (STitle) **] 2 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 250**]
Already scheduled appointments:
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2123-11-4**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2123-11-8**]
1:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1040**]
Date/Time:[**2123-11-30**] 4:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2123-11-3**]
|
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"410.71",
"V44.3",
"427.31",
"707.09",
"V10.83",
"V12.79",
"285.9",
"997.5",
"707.03",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"37.22",
"37.61",
"88.56",
"99.04",
"86.11",
"36.15",
"36.12",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
22008, 22051
|
18850, 20205
|
327, 493
|
22484, 22492
|
1683, 3445
|
23189, 24030
|
1146, 1169
|
20368, 21985
|
4206, 4235
|
22072, 22463
|
20231, 20345
|
22516, 23166
|
1184, 1664
|
266, 289
|
4264, 18827
|
521, 627
|
649, 945
|
961, 1130
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,481
| 180,735
|
7195
|
Discharge summary
|
report
|
Admission Date: [**2174-3-23**] Discharge Date: [**2174-3-29**]
Date of Birth: [**2097-6-18**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
bacteremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs [**Known lastname **] is a 76 yo patient with PMH of CAD s/p DES to prox
and mid LAD ([**2174-3-10**]), nephrolithiasis s/p stent, DM2, CVA and
likely dementia who presents on transfer from [**Hospital3 18201**] with MRSA bacteremia and MS changes. Pt
originally presented to OSH with weakness and near syncope in
the setting of dysuria, urgency and frequency complaints as well
as mental status changes and disorientation. Pt admitted with
UTI and started on Levaquin. Workup included UCx which grew
Klebsiella (ampicillin resistant) and [**4-18**] BCx that grew MRSA.
Pt started on Vancomycin with addition of Gentamicin for
synergy. MRSA bacteremia without clear source; endocarditis
considered but no documented echocardiogram. Additional
complaints include abdominal tenderness, distension and G+
stool, as well as painful right knee without effusion. Pt was
noted to have a Hct of 24 5 days ago and was transfused 2u
PRBCs, given G+ stool Pt was placed on protonix. On
presentation to [**Hospital1 18**], Pt disoriented and unable to clearly
express complaints. Pt with cries of pain with all palpation
and movement. Family in the room who says that her mental
status and confused has worsened over the past few days of
admission. Pt has a history of dementia and at times can be
confused especially with stress, but says that last week she was
having full comprehensible conversations with them
ROS: Unable to acquire
Past Medical History:
CAD (The LAD-70% stenosis in the proximal vessel and a 90%
stenosis in the mid vessel. The LCX had a tubular 70% stenosis
in the proximal vessel. The RCA had an ostial 80% stenosis.)
S/P DES to LAD ([**2174-3-10**])
DM2
mild dementia
h/o CVA with ? [**2-16**] aneursym with h/o craniotomy
nephrolithiasis s/p stent
? asthma
Depression
HTn
Hyperlipidemia
NASH, ?cirrhosis
Social History:
Pt lives at home with son and daughter. per history no
Tob/EtOH/IVDU.
Family History:
NC
Physical Exam:
vs: 99.1, 108/60, 88, 26 93%RA
PE:
gen-sitting still and appears comfortable. NAD
heent-NC/AT, PERRL, OP wnl, DMM
neck-supple, no JVD, no LAD
cvs-RRR, nl s1/s2, [**3-20**] SM best LSB but heard throughout
pulm-CTAB
abd-soft, diffuse tenderness, no reb/guard, distended, NABS
ext-no edema but vascular pretibial engorgement B/L, left knee
without effusin, slight ecchymosis, tender to touch. no femoral
bruit, +hematoma at cath site
neuro-A & O times 1, confused, answers questions with yes/no,
follows simple commands, [**5-19**] UE strength. Pt reluctant to move
LE, especially right so can't asses strength.
Pertinent Results:
OSH Data:
HCT 24->35->32->32
wbc 14 with 24%B
ESR 113
Cr 1.3-1.5
AlkP 178, ALT/AST 56/45
.
Abd U/S: no acute process, cirrhosis, no nephrolithiasis,
prominent CBD but no dilation, s/p CCY, stable splenomegaly
.
CXR: stable right pleural effusion, diffuse interstial alveolar
involvement
Brief Hospital Course:
76 yo female with h.o DM2, mild dementia, CVA and CAD s/p stents
to LAD ([**2174-3-10**]) presenting to OSH with UTI found to have MRSA
bacteremia.
MRSA ENDODCARDITIS: TEE on [**3-27**] with large mobile vegetation on
posterior leaflet and moderate eccentric MR with no PV flow
reversal. No abscess seen and nl LVEF-- while on amrinone. It
was felt she would need right groin hematoma removed as well as
may be source of continued bacteremia. CT surgery plans for MVR
on hold per family discussion, which would be after many weeks
of antibiotics.
VASCULAR: On arrival to MICU noted to have no dopplerable or
palpable right DP/PT pulses and seen by vascular and stat
ultrasound showed occlusive clot of right common femoral artery.
She went for stat CT angio of her LEs- with right hematoma,
segmental occlusion of CFA, severe disease of superficial
femoral, patent popliteal and three vessel flow. She was started
on heparin empirically.
GIB: Pt had BM's with mutliple bright red blots. Repeat Hct 27
down from 33 on admission. SBP in 90's when had been in 110's
130's and had received her regular metoprolol and diltiazem
dose. Was on asa, plavix. Heparin held and bolused 1L NS and
recieved 4uPRBC. Colonscopy prior to vascular surgery difficult
given pressor requirement and underlying cardiac disease.
CARDIOGENIC SHOCK: thought secondary to diastolic dysfunction
and moderate MR(2+) with large mobile vegetation and bilateral
pulm edema. She was intubated, and PA catheter in place with
initial low CO/CI and high SVR which improved on amrinone. [**3-27**]
started on dobutamine; required levophed for pressure support.
COMFORT CARE: It was felt that the patient had an extremely poor
prognosis given her complicated medical history. After lengthy
discussions with member of the MICU team and patients family, it
was decided that we should change to confort care. She was
extubated and pressors were discontinued. At 7pm on [**2174-3-29**] she
was pronounced dead. Immediate cause of death was respiratory
failure, with underlying cause of death endocarditis and
bacteremia. The family was notified, and the attending Dr.
[**Last Name (STitle) 26687**] was notified.
Medications on Admission:
RISS
Latanoprost
Lopressor 25 [**Hospital1 **]
Glipizide
Atrovent
advair
Gent 180 IV q24
Vanc 1gm qd
Lovenox
bowel regimen
Effexor
Zyrtec 10 qd
ASA 325
Plavix
Crestor
Protonix
Dilt 120 qd
singular
morphine
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Endocarditis
Bacteremia
Infected Hematoma
Cardiogenic Shock
GI Bleed
Discharge Condition:
Deceased
Completed by:[**2174-3-29**]
|
[
"038.11",
"294.8",
"421.0",
"578.1",
"V09.0",
"619.1",
"571.5",
"584.9",
"428.31",
"996.62",
"998.12",
"518.81",
"995.92",
"250.00",
"444.0",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"38.91",
"00.17",
"89.64",
"88.72",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5652, 5661
|
3218, 5396
|
279, 285
|
5793, 5832
|
2906, 3195
|
2254, 2258
|
5682, 5772
|
5422, 5629
|
2273, 2887
|
229, 241
|
313, 1754
|
1776, 2150
|
2166, 2238
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,522
| 188,720
|
18863
|
Discharge summary
|
report
|
Admission Date: [**2123-3-3**] Discharge Date: [**2123-3-11**]
Date of Birth: [**2061-3-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Cough and dyspnea on exertion
Major Surgical or Invasive Procedure:
Thoracentesis with chest tube placement ([**2123-3-4**])
History of Present Illness:
Mr. [**Known lastname **] is a 61 year old male with no significant past medical
history who presents with a ten day history of cough productive
of blood tinged sputum, right shoulder pain and dyspnea on
exertion. He felt entirely well until ten days ago. He has a
primary care doctor in the United States for the past three
years but has not been followed for any medical problems. [**Name (NI) **] has
not had routine health screening. He is unable to quantify the
amount of sputum production or blood in his sputum. He also was
experiencing pain in his right shoulder which was worsened with
cough or deep inspiration and dyspnea with mild exertion. He was
still able to perform his activities of daily living and go to
work but he was unable to sleep for the past two nights because
of cough and shoulder pain. He presented to his primary care
doctor with these symptoms ten days ago and was treated with
azithromycin without improvement. He presented again on [**2123-2-25**]
and had a CXR performed which showed a large right sided
mediastinal mass. He was seen again today and was referred for a
CT scan of the chest. Preliminary findings on the chest CT were
concerning and he was referred to the emergency room.
In the emergency room his initial vitals were T: 97.9 HR: 98 BP:
145/93 RR: 20 O2: 98% on RA. He had a Chest CT which showed a
large right sided lung mass with associated right middle and
right lower lobe collapse and large circumfrential right sided
pleural effusion. The mass is compressing the SVC to a slit.
There is also concern regarding possible involvement of the
pericardium and myocardium. He received 4 mg IV morphine in the
emergency room with resolution of his dyspnea and right sided
shoulder pain.
On review of systems he denies fevers, chills, left sided chest
pain, nausea, vomiting, abdominal pain, diarrhea, constipation,
dysuria, hematuria, leg pain, leg swelling, lightheadedness,
dizziness, numbness or tingling. He has had a 10 lb weight loss
over the past few weeks. All other review of systems negative in
detail.
Past Medical History:
Low Back Pain
Latent TB s/p treatment (unknown details)
Gastric Ulcer
Social History:
Originally from [**Country 651**]. Previously worked as a farmer of rice and
corn. Also worked for 2-3 years in the concrete industry. Since
coming to the United States he has worked in a super market. He
lives with his wife. [**Name (NI) **] has five children. He smoked [**12-4**] pack
per day for 40 years and quit 10 years ago. He does not drink or
use illicit drugs.
Family History:
History of hepatitis B in the family. No history of CAD or
diabetes. No history of lung disease or lung cancer.
Physical Exam:
Vitals: T: 100.2 HR: 81 BP: 123/85 RR: 20 O2: 99% on 2L
HEENT: PERRL, EOMI, sclera anicteric, MMM, oropharynx clear
Neck: External veins distended, JVP ~ 10 cm, no lymphadenopathy
Cardiac: Regular rate and rhythm, s1 + s2, no murmurs, rubs,
gallops
Lungs: Decreased chest wall expansion on right, absent breath
sounds on right, dullness to percussion on right, on left clear
to auscultation
GI: soft, non-tender, non-distended, + BS, no organomegaly
appreciated
GU: no foley
Ext: Warm and well perfused, 2+ pulses, trace clubbing, no
cyanosis or edema
Neurologic: Grossly intact
Pertinent Results:
[**2123-3-8**] 06:20AM BLOOD WBC-8.2 RBC-3.63* Hgb-10.6* Hct-31.9*
MCV-88 MCH-29.3 MCHC-33.4 RDW-12.1 Plt Ct-478*
[**2123-3-3**] 05:45PM BLOOD WBC-8.3 RBC-3.70* Hgb-11.3* Hct-32.0*
MCV-87 MCH-30.4 MCHC-35.2* RDW-12.3 Plt Ct-456*
[**2123-3-3**] 05:45PM BLOOD Neuts-78.7* Lymphs-11.5* Monos-8.6
Eos-0.7 Baso-0.5
[**2123-3-5**] 05:35AM BLOOD PT-14.2* PTT-30.2 INR(PT)-1.2*
[**2123-3-8**] 06:20AM BLOOD Glucose-112* UreaN-11 Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-32 AnGap-9
[**2123-3-3**] 05:45PM BLOOD Glucose-112* UreaN-14 Creat-0.9 Na-134
K-4.2 Cl-99 HCO3-25 AnGap-14
[**2123-3-3**] 05:45PM BLOOD ALT-61* AST-50* LD(LDH)-161 AlkPhos-143*
TotBili-0.3
[**2123-3-3**] 05:45PM BLOOD TotProt-6.5 Albumin-3.3* Globuln-3.2
Calcium-8.7 Phos-3.4 Mg-2.3 Iron-12*
[**2123-3-3**] 05:45PM BLOOD calTIBC-228* Hapto-397* Ferritn-697*
TRF-175*
[**2123-3-4**] 04:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-BORDERLINE
[**2123-3-5**] 05:35AM BLOOD CEA-1.7
[**2123-3-11**] Radiology FDG TUMOR IMAGING (PET-
[**Last Name (LF) **], [**First Name3 (LF) **] Approved
1. Large FDG-avid right perihilar mass, involving the middle and
upper lobes and associated with extensive right hilar,
mediastinal, retrocrural and right supraclavicular FDG-avid
lymphadenopathy.
2. Extensive multifocal FDG-avid right pleural disease
associated with a moderate sized pleural effusion increased in
volume from the prior study.
3. There is nodular airspace disease in the anterior right upper
lobe having low-level tracer uptake which may be infectious,
inflammatory or neoplastic in nature.
4. There is mild tracer uptake in both adrenal glands, left
slightly greater than right, which may be physiologic but should
be re-evaluated on follow-up imaging.
[**2123-3-5**] Pathology Tissue: FNA, 4R (Cell Block) [**2123-3-8**]
[**Last Name (LF) **],[**First Name3 (LF) **] Final
FNA, 4R lymph node, cell block:
Positive for metastatic carcinoma, most consistent with
metastatic small cell carcinoma of the lung. Note: Immunostains
show the tumor cells are positive for keratin cocktail
(AE1/AE3/CAM5.2), CK7, TTF-1 and synaptophysin; they are weakly
positive for p63, but negative for CK20, chromogranin and LCA.
The findings are most consistent with a metastatic small cell
carcinoma of the lung.
[**2123-3-4**] Cardiology ECHO [**2123-3-4**] [**Last Name (LF) **],[**First Name3 (LF) **] F.
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Transmitral Doppler and tissue
velocity imaging are consistent with normal LV diastolic
function. 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 structurally normal.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is a
small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade. IMPRESSION: Normal biventricular regional and global
function. Very small pericardial effusion.
[**2123-3-3**] Radiology CT CHEST W/CONTRAST [**Last Name (LF) **],[**First Name3 (LF) 10348**] Approved
1. Widespread malignancy in the thorax, most consistent with
advanced lung cancer (likely small cell ca and less likely
agressive nonsmall cell), with associated mediastinal and
pericardial invasion, high- grade narrowing of the superior vena
cava, bronchial obstruction, diffuse lymphadenopathy, and
malignant pleural disease.
2. Indeterminate fullness of left adrenal gland. If a PET CT is
obtained as part of overall staging process, this could be
further assessed at that time.
[**2123-3-3**] Cardiology ECG [**2123-3-5**] [**Last Name (LF) **],[**First Name3 (LF) **]
Sinus rhythm Indeterminate axis Q-Tc interval appears prolonged
but is difficult to measure Low lateral T wave amplitude
Findings are nonspecific and may be within normal limits, but
clinical correlation is suggested
[**2123-3-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2123-3-7**] URINE URINE CULTURE-FINAL INPATIENT
[**2123-3-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2123-3-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2123-3-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2123-3-5**] BRONCHOALVEOLAR LAVAGE ACID FAST SMEAR-FINAL; ACID
FAST CULTURE-PRELIMINARY [**Last Name (LF) **],[**First Name3 (LF) **]
[**2123-3-5**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2123-3-5**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2123-3-5**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2123-3-4**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2123-3-4**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Brief Hospital Course:
61 year old man remote smoking history presents 10 days cough,
hemoptysis and DOE, with likely malignant right sided lung mass.
.
MICU course:
Following admission, patient had a CT scan showing right-sided
invasive mass with associated large pleural effusion.
Interventional pulmonology team placed chest tube into right
pleural space with greater than two liters of serosanguinous
drainage. Pleural fluid was sent for gram stain, culture, AFB
stain and culture, chems, cell count, and cytology.
Echocardiogram was performed due to invasive vascular appearance
of lung mass and noted "Normal biventricular regional and global
function. Very small pericardial effusion." Given patient's
elevated LFTs at presentation, concerning for metastatic
disease; however, hepatitis serologies pending. Patient was
hemodynamically stable with no respiratory distress throughout
his stay. Was maintained on 2L NC with sats 99%.
.
RIGHT-SIDED LUNG MASS: Patient presented with cough, hemoptysis,
pain, and dyspnea. CT appearence was consistant with small cell
ca vs. agressive nonsmall cell lung cancer of right middle lobe.
He had a thoracentesis during which 2L of serosanguinous fluid
were drained, and a chest tube was placed. Repeat CT showed
extensive thoracic malignancy including evidence of pleural
metastatic disease. This process involved the pulmonary artery,
pulmonary veins, pericardium, and possibly the myocardium.
However, no abnormalities were seen on cardiac echo. Patient was
oxygenating well and hemodynamically stable. Patient had
EBUS/biopsy for tissue diagnosis on [**3-5**], and pathology was found
to be consistent with SCLC. Chest tube was removed on [**3-8**].
These findings were discussed and reviewed with the patient and
his family with the help of heme-onc consultants and social
work.
.
PNEUMONIA: Patient had progressive fever, spiking to 101.5 on
[**3-5**]. Repeat CT could not exclude infection. Given his high
risk for post-obstructive pneumonia and chest tube in place, he
was treated with a 7 day course fo levofloxacin for presumed
post-obstructive pneumonia. Cultures were negative. His fevers
may have also have been secondary to malignancy.
.
ANEMIA: Stable. Likely related to inflammatory process given
likely malignancy. Normocytic to microcytic. Elevated ferritin
c/w AICD. Could consider EPO if Hb < 10.
.
ELEVATED LFTs: Unclear etiology. Not previously documented.
Likely related to tumor extension across diaphragm. Hep B SAb
(+), core Ab borderline. Consistent with prior vaccination, but
could consider viral load to further eval.
Medications on Admission:
None
Discharge Medications:
1. Codeine Sulfate 30 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every
4 hours) as needed for cough, pain.
Disp:*45 Tablet(s)* Refills:*0*
2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. Wheelchair
5. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
6. Bedside commode
7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
8. Lactulose 10 gram/15 mL Solution Sig: One (1) 15 mL dose PO
twice a day.
Disp:*QS 1 mo* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
small cell lung cancer
malignant pleural effusion
post-obstructive pneumonia
anemia of chronic disease
Discharge Condition:
Stable, normal ambulatory oxygen saturation
Discharge Instructions:
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted with shortness of breath, bloody cough, and back pain.
You had imaging studies done that showed a lung mass and fluid.
This fluid was removed with a chest tube. You also had a biopsy
done on this tissue that showed Small Cell Lung Cancer. You had
a PET-CT scan done to determine the extent of this cancer and
what types of treatments would be available. You should follow
up with your oncologist to discuss these results and possible
treatment options.
You were started on antibiotics to treat a pneumonia that may be
associated with this mass. You completed 7 days of levofloxacin
while hospitalized.
Please take all your medications as prescribed. The following
changes were made to your medications:
1. Codeine-Sulfate 30 mg: 1 tablet by mouth every 4 hours as
needed for cough and pain.
2. Ferrous sulfate 325 mg: 1 tablet by mouth daily for iron
deficiency anemia.
3. Benzonatate 100 mg: 1 capsule by mouth three times a day as
needed for cough.
4. Colace 100 mg: 1 capsule by mouth twice daily for
constipation while taking iron.
Please keep all your medical appointments. The
Hematology-Oncology team will also see you as an outpatient in
their clinic.
If you have any of the following symptoms, please call your
doctor or go to the nearest ED: fever, chest pain, shortness of
breath, coughing up blood, constant nausea/vomiting/diarrhea,
abdominal pain, bright red blood in the toilet bowel, or any
other concerning symptoms.
Followup Instructions:
MD: [**Doctor First Name **] [**Doctor Last Name **]
Specialty: Primary Care Physician
Date and time: [**2123-3-17**] at 1pm
Location: [**Hospital1 392**]
Phone number: [**Telephone/Fax (1) 51633**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD; [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Specialty: Oncology
Date/Time:[**2123-3-16**] 10:30 AM
Phone:[**0-0-**]
Location: [**Hospital Ward Name 23**] 9
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2123-4-1**]
|
[
"511.81",
"285.29",
"724.5",
"459.2",
"531.90",
"486",
"V12.01",
"790.4",
"162.5",
"V15.82",
"196.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
12284, 12341
|
8871, 11448
|
342, 400
|
12506, 12552
|
3718, 8848
|
14127, 14732
|
2990, 3103
|
11503, 12261
|
12362, 12362
|
11474, 11480
|
12576, 14104
|
3118, 3699
|
273, 304
|
428, 2491
|
12381, 12485
|
2513, 2585
|
2601, 2974
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
914
| 124,723
|
21160
|
Discharge summary
|
report
|
Admission Date: [**2178-2-26**] Discharge Date: [**2178-3-13**]
Date of Birth: [**2128-6-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
R pleuritic chest pain and shortness of breath x1 day
Major Surgical or Invasive Procedure:
s/p liver transplant
IVC filter [**2178-2-27**]
Cholangiogram [**3-11**]
liver biopsy3/31
cardiac cath [**3-4**]
History of Present Illness:
p/w right chest pain and shortness of breath since previous
evening. Had liver biopsy and complained about chest pain and
sob.
Past Medical History:
OLT [**2177-12-23**], rejection rx'd with solumedrol
hep c
varices
h/o encephalitis
myoclonus/seizures s/p tx
Social History:
Lives with roommate on [**Location (un) **]. Has supportive family although
they live near [**Last Name (un) 17679**]
Physical Exam:
vs 100.3-116-116/64-22, O2 88% on 100% NRB
Mod distress, alert
neck: soft, supple, no jvd no bruits
Chest; RR, ST, no murmurs
Lungs: decreased BS at bases bilat
ABD: soft NT, ND
Ext no edema
Pertinent Results:
[**2178-2-26**] 09:43PM GLUCOSE-115* UREA N-8 CREAT-0.6 SODIUM-136
POTASSIUM-3.3 CHLORIDE-95* TOTAL CO2-32* ANION GAP-12
[**2178-2-26**] 09:43PM ALT(SGPT)-235* AST(SGOT)-298* LD(LDH)-487*
ALK PHOS-309* AMYLASE-33 TOT BILI-0.7
[**2178-2-26**] 09:43PM LIPASE-15
[**2178-2-26**] 09:43PM ALBUMIN-3.1* CALCIUM-8.5 PHOSPHATE-3.3
MAGNESIUM-1.6 URIC ACID-2.7*
[**2178-2-26**] 09:43PM TSH-1.8
[**2178-2-26**] 07:39PM PT-15.4* PTT-84.5* INR(PT)-1.5
[**2178-2-26**] 03:34PM HCT-33.4*
[**2178-2-26**] 03:34PM PT-15.2* PTT-68.4* INR(PT)-1.5
[**2178-2-26**] 02:10PM GLUCOSE-177* UREA N-8 CREAT-0.5 SODIUM-136
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
[**2178-2-26**] 02:10PM CK(CPK)-29*
[**2178-2-26**] 02:10PM CK-MB-NotDone cTropnT-0.01
[**2178-2-26**] 02:10PM CALCIUM-8.0* PHOSPHATE-2.8 MAGNESIUM-1.6
[**2178-2-26**] 02:10PM WBC-6.5 RBC-3.60* HGB-10.9* HCT-31.5* MCV-88
MCH-30.2 MCHC-34.5 RDW-18.0*
[**2178-2-26**] 02:10PM PLT COUNT-331
[**2178-2-26**] 02:10PM PT-15.5* PTT-105.5* INR(PT)-1.5
[**2178-2-26**] 11:55AM TYPE-ART PO2-70* PCO2-35 PH-7.53* TOTAL
CO2-30 BASE XS-6
[**2178-2-26**] 11:45AM WBC-7.3# RBC-3.93* HGB-11.8* HCT-34.9* MCV-89
MCH-29.9 MCHC-33.7 RDW-17.7*
[**2178-2-26**] 11:45AM PLT COUNT-368
[**2178-2-26**] 08:25AM GLUCOSE-165* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-29 ANION GAP-17
[**2178-2-26**] 08:25AM ALT(SGPT)-216* AST(SGOT)-281* CK(CPK)-26* ALK
PHOS-338* TOT BILI-0.6
[**2178-2-26**] 08:25AM CK-MB-NotDone cTropnT-0.02*
[**2178-2-26**] 08:25AM ALBUMIN-3.6
Brief Hospital Course:
Admitted on [**2178-2-26**] s/p liver biopsy for follow up of rejection
that was treated with solumedrol. Complained of right pleuritic
chest pain since the day before. He had some shortness of breath
as well. He was admitted to the MICU and had a chest CT that
revealed a right pulmonary artery saddle embolus. Results
revealed the following: CT CHEST WITH IV CONTRAST: There are
tubular shaped filling defects extending across the bifurcation
of the main pulmonary arteries. In addition, filling defects are
seen at the branch points of the right main pulmonary artery and
left main pulmonary artery with extension into the segmental
pulmonary arteries. There is flow in the subsegmental pulmonary
arteries but a paucity of opacification of the right lower lobe
vessels. Lung windows demonstrate a patchy area of consolidation
in the posterior right lower lobe. There are no pleural or
pericardial effusions. No axillary, mediastinal, or hilar
lymphadenopathy. The heart and pericardium are within normal
limits.
Visualized portions of the upper abdomen are remarkable for two
rounded low attenuation areas in the right hepatic lobe of fluid
density.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
CT RECONSTRUCTIONS: Coronal and sagittal reformatted images
confirm the above axial findings. Value grade I.
IMPRESSION:
1) Extensive bilateral pulmonary embolism involving major, lobar
and segmental divisions.
2) Patchy right lower lobe consolidation.
3) Two rounded low attenuation hepatic foci of fluid density.
Given this report, he was initiated on IV heparin. O2 sat was in
80s. He was placed on a non-rebreather 50%. He was
hemodynamically stable. CT surgery was consulted to evaluate for
embolectomy. Evaluation revealed that he was not a candidate for
surgical intervention at this stage. Dr. [**Last Name (STitle) 911**] (vascular
medicine/cardiology attending) was consulted to evaluate for
thrombolysis. After consultation with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **], a
IVC filter was placed on [**2178-2-27**] via left brachial site without
complication. Please see procedure note for further details.
On HD 1 he was transferred to the SICU where he spiked a
temperature of 103.5. He was pancultured for fever. He was
hydrated with IV D5W with bicarbonate and heparin was adjusted
by q2 hour coags. His ABG was improved. Bilateral leg duplex
ultrasound was done revealing old small clot in L SFV.
On HD 3 he was experiencing increaed chest pain on the left
side. This was concerning for reinfarction of lung. A cardiac
echo revealed the following: The left atrium was normal in
size. Overall left ventricular systolic function
appeared normal. Due to suboptimal technical quality, a focal
wall motion
abnormality could not be fully excluded. Right ventricular
systolic function
appeared normal. The aortic valve leaflets (3) appearred
structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appeared
structurally normal with trivial mitral regurgitation. Moderate
[2+] tricuspid
regurgitation was seen. There was moderate pulmonary artery
systolic
hypertension. There was no pericardial effusion.Compared with
the findings of the prior study (tape reviewed) of [**2177-12-28**],
there was no diagnostic change. An ekg was done that suggested
signs of strain with rate of 110 in NSR. Twave was down in
Va5-V6, Inferior and lateral leads. Cardiology was asked to
evaluate. Findings were reviewed with Dr. [**Last Name (STitle) 911**] and a repeat CTA
was suggested to assess stability of the thrombus. A cxr
revealed no acute changes.
Zosyn and vancomycin were started for fever and IV fluid changed
to D51/2NS at 75. Urine output was good, pain was controlled
with prn iv dilaudid and nebs were given. O2 sat was 99% on 50%
face mask. He received a unit of PRBC on [**2-28**] for a hematocrit of
26.
Neurology was consulted on HD 4 for medication review for
history of seizures and myoclonus. He was noted to be quite
ataxic on exam. Continuation of clonazepam and keppra were
recommended as well as corrected dilantin level of 15-20.
Recommended eventual taper of dilantin with Keppra as
monotherapy, but not in the acute care setting due to high risk
of seizure. Dilantin was increased to 100mg tid with an extra
dose given for corrected level of 10.9.
On [**3-2**] he was noted to be breathing better. Cultures were
normal. A CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST was
done for persistent elevated LFTs. This revealed: The lung base
images reveal the known PE demonstrated as big filling defects
within the lower lobe arteries blaterally. There is a large
consolidation within the right lower lobe, demonstrating either
pneumonia or unusual infarct.
The transplanted liver demonstrates numerous low-attenuation
lesions throughout both lobes of the liver, all of them small,
up to 3 cm except for one in segment V of the liver, which
measures 6 x 4 cm. There is no enhancement within or around any
of these lesions and there is no free air within them. They all
demonstrate fluid attenuation, around 10 Hounsfield units.
Periportal edema is demonstrated. There is no intra- or
extrahepatic biliary dilatation. No arterial supply is
demonstrated within the liver and a hepatic artery is
demonstrated only proximally outside the liver. The portal vein,
hepatic veins and IVC are patent. There are no enhancing lesions
within the liver. There is a trace amount of fluid around the
liver.
The spleen is homogeneous and enlarged. The kidneys, adrenal
glands, pancreas, and unopacified loops of small and large bowel
are unremarkable. There is a filter in the IVC. There are
multiple small lymph nodes, but no significant lymphadenopathy.
Given the liver findings, drainage was planned after hct of 24.7
was treated with 2 units of PRBC. Ast was108, alt 97, alk phos
436, t.bili 0.8 and Hep C viral load was 13.1M. On [**3-6**] he had
drainage of a right lobe bilioma and a drain was placed. bilioma
felt to be secondary to bile duct ischemia do to known hepatic
artery thrombosis. He was relisted for liver transplant.
Neuorology reassessed h/o nonconvulsive seizures and myoclonus.
Dilantin taper was initiated. No seizures were noted during this
hospital stay.
A cardiac cath was performed on [**3-4**] for evaluation of arterial
hypertension and PE.PA mean was 22.
He remained in ICU on IV vancomycin, zosyn, bactrim, gancyclovir
and fluconazole. Cultures were negative. He was transfered to
the transplant unit on HD 8. Vital signs were stable. Blood
glucose increased to 400 which required IV insulin therapy.
Glucoses trended down and [**Last Name (un) **] was consulted. Insulin sliding
scale with glargine was initiated.IV hydration was continued for
decreased po intake and hyperglycemia. A foley was left in
place do to difficulty with incontinence. Urine cx negative.
Lung sounds remained diminished with O2 sat of 95%. Coumadin 5mg
was initiated on HD 15. INR increased to 3.5 after a second dose
of 5mg of coumadin. Heparin IV was stopped. INR decreased to 3.0
on HD 16. Coumadin was resumed at 2mg.
An cholangiogram was done on [**3-11**] revealing small amount of
contrast passing into a small normal size bile duct.
Extravasation was noted under capsule. Study was stopped and
normal size bile ducts were noted. A triphasic liver CT was
performed.IMPRESSION:
1) No hepatic arterial flow visible within the liver, as
documented on prior imaging studies. Patent portal vein.
2) Multiple low-density areas within the liver consistent with
infarct/biloma. A drain is located within one of these
collections and contains some residual contrast material, which
does not appear to connect to the biliary tree.
3) Bilateral pulmonary emboli. Right internal iliac vein
thrombus visible, but IVC filter is also noted to be in place.
4) Increased consolidation at the right lung base with increase
in size of right partially loculated pleural effusion. Pneumonia
should be considered.
On HD 16 ([**2178-3-13**]) patient was insistent upon discharge to home
against medical advise. He had been advised to stay another day
to repeat coags. He refused and signed AMA form. He will follow
up in am for labs at [**Hospital3 **] Hospital. The transplant
coordinator will obtain results and adjust. He was given
medication schedule with script for percocet# 20 and coumadin
2mg po qd. Labs will be drawn twice weekly with results fax'd to
transplant center. Follow up appointments were reviewed. PT
evaluated him and felt he was stable for discharge with home PT
and a cane. VNA will follow him at home. He was afebrile and
vital signs were stable. He was tolerating his diet and was
ambulating independently.
Labs on [**2178-3-13**]: wbc 3.4, hct 28.6, potassium 3.5, creatinine
1.0, bun 10, ast 23, alt 16, alk phos 310, t.bili 0.4, PT 21.8,
INR 3.0. [**Last Name (un) 1380**] level [**3-12**] 15.3.
Medications on Admission:
klonopin 0.25mg tid, fluconazole 400qd, lasix 20mg qd, MMF 1gram
[**Hospital1 **], protonix 40mg qd, dilantin 260mg qd, rapamune 6mg qd,
lipiotr 10mg qd, methadone 100mg qd, valcyte qd, bactrim ss 1
qd, keppra
Discharge Medications:
1. Valganciclovir HCl 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. Methadone HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Methadone HCl 40 mg Tablet, Soluble Sig: Two (2) Tablet,
Soluble PO DAILY (Daily).
9. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
10. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO prn q 4-6: for
pain.
Disp:*20 Tablet(s)* Refills:*0*
12. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day: PCP
to monitor labs. Have INR/PT/PTT drawn with MON & Thurs labs.
Disp:*60 Tablet(s)* Refills:*1*
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day.
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **]
Discharge Diagnosis:
s/p R saddle pulmonary embolus, L pulmonary embolus
s/p liver transplant
Hepatic artery thrombosis
Hep C
Seizures
Myoclonus
Type 2 DM, Steroid induced
Discharge Condition:
stable.
Discharge Instructions:
call if any fevers, chills, shortness of breath, chest pain,
nausea, vomiting, inability to take medications, bleeding,
increased jaundice or lack of bile drainage from bile drain.
Labs every Monday & Thursday for cbc, chem 10,ast, alk phos,
alt, t.bili, albumin, PT, PTT, INR and trough rapamune level.
Fax results immediately to Transplant office [**Telephone/Fax (1) 697**] and
Dr. [**Last Name (STitle) **] (PCP) [**Telephone/Fax (1) 56107**]
Coumadin (blood thinner)dose will be managed by Dr. [**Last Name (STitle) **]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-3-26**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-4-2**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-4-9**] 11:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 673**] Call to schedule
appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2178-3-13**]
|
[
"305.90",
"780.6",
"415.19",
"333.2",
"416.0",
"285.9",
"996.82",
"780.39",
"250.00",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"87.54",
"50.11",
"38.7",
"50.91"
] |
icd9pcs
|
[
[
[]
]
] |
13077, 13132
|
2711, 11633
|
367, 482
|
13327, 13336
|
1133, 2688
|
13910, 14776
|
11893, 13054
|
13153, 13306
|
11659, 11870
|
13360, 13887
|
922, 1114
|
274, 329
|
510, 638
|
660, 772
|
788, 907
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,653
| 116,354
|
42565
|
Discharge summary
|
report
|
Admission Date: [**2126-10-28**] Discharge Date: [**2126-11-20**]
Date of Birth: [**2077-5-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
epigastric pain x 16 hrs
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
Pt is a 49M with sharp, continuous epigastric pain for the 16hrs
prior to presenting to [**Hospital1 18**] ED. No prior episodes. Vomitted
once without relief 12hrs PTP. Last BM/flatus 8hrs PTP. Pain
does not radiate. Also reports chills (did not check
temperature), but denies urinary s/s. + chest pain night PTP.
No SOB. Last meal chinese food/chicken fingers.
Past Medical History:
HTN
CRI
Social History:
no EtOH. No tobacco. Married with 4 children
Physical Exam:
Afebrile 92 175/112 19 98% 2L
AOx3, + distress from pain
anicteric
RRR
CTA b/l
Abd: decreased BS, distended, diffuse tenderness. + [**Doctor Last Name **],
-gret-[**Doctor Last Name 4862**]
guiac neg. - CVA tenderness
Ext: WWP, no CCE
Pertinent Results:
[**2126-10-28**] 10:05AM BLOOD WBC-12.2*# RBC-5.54 Hgb-16.1 Hct-44.7
MCV-81* MCH-29.1 MCHC-36.1* RDW-13.7 Plt Ct-226
[**2126-10-28**] 10:05AM BLOOD Neuts-90* Bands-5 Lymphs-2* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2126-10-28**] 10:05AM BLOOD PT-12.8 PTT-19.0* INR(PT)-1.1
[**2126-10-28**] 10:05AM BLOOD Plt Ct-226
[**2126-10-28**] 10:05AM BLOOD Glucose-195* UreaN-29* Creat-1.7* Na-144
K-4.2 Cl-103 HCO3-25 AnGap-20
[**2126-10-28**] 10:05AM BLOOD ALT-168* AST-269* LD(LDH)-489*
CK(CPK)-620* AlkPhos-106 Amylase-2452* TotBili-1.9* DirBili-0.9*
IndBili-1.0
[**2126-10-28**] 10:05AM BLOOD Lipase-3380*
[**2126-10-28**] 10:05AM BLOOD CK-MB-5
[**2126-10-28**] 10:05AM BLOOD cTropnT-<0.01
[**2126-10-28**] 10:05AM BLOOD Calcium-10.0 Phos-3.4 Mg-1.7
RADIOLOGY Final Report
ABDOMEN U.S. (COMPLETE STUDY) [**2126-10-28**] 12:45 PM
IMPRESSION:
1. Gallbladder wall thickening with no evidence of distention or
pericholecystic fluid. These findings are not typical of acute
cholecystitis and likely represent an etiology outside of the
gallbladder, such as the pancreas.
2. Nonobstructing gallstones.
3. Diffuse fatty liver-see above for.
Brief Hospital Course:
# Gallstone Pancreatitis: The patient was admitted to the SICU
for agressive IV hydration, pain control, serial exams, and
close monitoring. The patient continued to be stable with normal
vital signs and good urine output. Liver/pancreatic enzymes
steadily improved; On HD3 the patient was transfered to the
floor. Pain and liver/pancreatic enzymes continued to improve.
Vital signs/UO were normal. A CT scan was obtained on [**2126-11-2**]
when the abdominal pain had not improved and there was increased
abdominal distension. Imipenem was started [**11-6**] and a repeat
CT was obtained when the patient was persistently febrile
without postive cultures. It was negative for pseudocysts,
phlegmon, or reasons for fever. Imipenem was discontinued after
a 7-day course. On [**2126-11-18**] the patient underwent a
laparoscopic cholecystectomy. Post-op Amylase/Lipase were much
improved and he was advanced to full liquids on POD1. On POD2
the patient was tolerating a low fat diet. He was discharged
home after nutrition teaching for a low fat diet.
.
# Nutrition: A PICC line was placed on [**10-30**]; TPN was started
and continued throughout his hospital course. Of note Mr. [**Known lastname **]
showed signifcant insulin resistance while on TPN requring
approximately 150 units of insulin per bag of TPN to keep his
blood surgars less than 120. Sips were started on [**11-1**]. Clear
liquids as tolerated was started on [**2126-11-15**] when there was
resolution of his abdominal pain.
.
# Chronic renal insuffiency: slight increase from baseline
creatinine despite agressive hydration upon presentation.
BUN/Cr/UO monitored and Cr slowly returned to baseline.
.
# Enterococcus UTI: treated with a 5-day course of IV
Ciprofloxacin. [**2052-11-1**]
Medications on Admission:
tylenol prn, lasix 20 mg daily
Discharge Medications:
1. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
good
Discharge Instructions:
Restart you home medications as usual. Low Fat diet. You may
resume activity as tolerated.
You may shower, then pat-dry incision. Do not rub incision. No
tub baths or swimming for 3-4 weeks.
You may leave the incision uncovered or use a light dressing for
comfort. Keep the white strips until they fall off.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Pain/redness/drainage from wound
* Other symptoms concerning to you
Followup Instructions:
1. Call Dr.[**Name (NI) 1863**] office for a follow-up appointment
[**Telephone/Fax (1) 1864**]
2. Call Dr. [**Last Name (STitle) 18991**] office for follow-up appointment regarding
your chronic renal insufficiency ([**Telephone/Fax (1) 817**]
|
[
"401.9",
"585.9",
"575.11",
"780.57",
"560.1",
"577.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23",
"99.15",
"38.93",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
4515, 4521
|
2301, 4065
|
339, 370
|
4588, 4595
|
1132, 2278
|
5104, 5351
|
4146, 4492
|
4542, 4567
|
4091, 4123
|
4619, 5081
|
877, 1113
|
275, 301
|
398, 767
|
789, 799
|
815, 862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,745
| 117,259
|
38393
|
Discharge summary
|
report
|
Admission Date: [**2183-6-22**] Discharge Date: [**2183-7-4**]
Date of Birth: [**2149-12-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
?intracranial bleed
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Placement of a Peripherally Inserted Central Catheter
History of Present Illness:
Mr. [**Known lastname 85507**] is a 33 year old man with hepatitis C and bipolar
disorder who presented to an OSH with symptoms of meningismus,
and was transferred to [**Hospital1 18**] for evaluation of possible
intracranial hemorrhage.
Patient was admitted to [**Hospital1 18**] [**Location (un) 620**] on [**6-17**] with fever to 103,
photophobia for 2 days. He reported fatigue and a diffuse
headache. He was initially covered emperically with CFTX and
Vancomycin. His LP was negative for acute bacterial meningitis.
His blood cultures grew MSSA, and his antibiotics were switched
to Oxacillin. He underwent a thorough endcarditis work-up: TTE
and TEE were negative for endocarditis; CT torso showed
inflammation of the R lower quadrant mesentary and trace free
fluid without free air, cannot rule out acute appendicitis,
acute aortic coarctation, and a 1.8 cm indeterminant lesion in
the spleen. Head CT with possible parietal hyperdensities. The
patient today c/o of the worst headache of his life, then was
noted to become decorticate and have a blown L pupil. He was
emergently intubated and transferred without head imaging to
[**Hospital1 18**] for further work-up.
On arrival tothe ICU, patient was intubated, sedated, and unable
to answer questions regarding review of systems. Emergent Head
CT non-contrast was obtained which showed a L subdural hematoma
and 2 areas of ICH ?occipital lobe.
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:
Bipolar Disorder
Hepatitis C
?Co-arctation of aorta
Social History:
- Tobacco: none
- Alcohol:unknown
- Illicits: unknown
Family History:
unknown
Physical Exam:
General: intubated, sedation
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils pinpoint
and symmetric.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Neuro: purposeful movements R>L. obeys commands such as blinking
or squeezing hands. toes upgoing on R, mute on L.
Pertinent Results:
ADMISSION LABS:
[**2183-6-22**] 07:08AM WBC-11.3* RBC-4.59* Hgb-13.2* Hct-38.4* MCV-84
Plt Ct-409
[**2183-6-22**] 07:08AM Neuts-89* Bands-0 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2183-6-22**] 07:08AM PT-13.7* PTT-25.1 INR(PT)-1.2*
[**2183-6-22**] 07:08AM Glucose-181 UreaN-7 Creat-0.8 Na-141 K-3.3
Cl-103 HCO3-25
[**2183-6-22**] 07:08AM ALT-142* AST-89* LD(LDH)-398* CK(CPK)-404*
AlkPhos-70 Amylase-55 TotBili-0.6
[**2183-6-22**] 07:08AM Lipase-47
[**2183-6-22**] 07:08AM CK-MB-9 cTropnT-0.06*
[**2183-6-22**] 07:08AM Albumin-3.7 Calcium-8.6 Phos-3.1 Mg-2.1
Cholest-174
[**2183-6-22**] 07:08AM BLOOD Triglyc-212* HDL-12 CHOL/HD-14.5
LDLcalc-120
[**2183-6-22**] 07:08AM ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2183-6-22**] 07:28AM Lactate-1.5 Na-139 K-2.8* Cl-102
OTHER PERTINENT LABS:
[**2183-6-22**] 12:00PM Cryoglb-NEGATIVE
[**2183-6-22**] 03:55PM [**Doctor First Name **]-NEGATIVE
[**2183-6-22**] 03:55PM ANCA-NEGATIVE B
[**2183-6-22**] 12:00PM ESR-58*
[**2183-6-22**] 03:55PM CRP-103.3*
[**2183-6-22**] 07:08AM CK-MB-9 cTropnT-0.06*
[**2183-6-22**] 03:55PM CK-MB-5 cTropnT-0.04*
[**2183-6-23**] 03:19AM CK-MB-3 cTropnT-0.02*
URINE:
[**2183-6-25**] 02:41AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2183-6-25**] 02:41AM Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2183-6-25**] 02:41AM RBC-[**4-4**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2
[**2183-6-22**] 07:08AM bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
MICRO:
[**6-22**], [**6-25**] UCx: negative
[**6-22**], [**6-23**], [**6-24**], [**6-25**] BCx: NGTD
[**6-22**] RPR: non-reactive
[**6-24**], [**6-26**] Cdiff: negative
STUDIES:
[**6-22**] CT head:
New bilateral frontal intraparenchymal hemorrhage as well as
left subdural hemorrhage with 1.1 cm of midline shift.
Increased subdural hemorrhage extends along the tentorium
cerebelli and the posterior falx. Effacement of the basal
cisterns. There is no definite tonsillar herniation.
[**6-22**] MRA/MRV Head/Neck:
1. Bilateral intraparenchymal hematomas. Left frontoparietal,
temporal
subdural collection extending along the tentorium, likely
consistent with a hematoma, however, moderate restricted
diffusion is demonstrated along the subdural collection,
therefore a subdural empyema cannot be completely ruled out.
2. Questionable narrowing of the proximal segment of the
superior longitudinal sinus, also demonstrated in the maximal
intensity projections, however, the T2 axial images demonstrate
normal flow void signal, however, a possible partial thrombosis
vs flow related artifact cannot be completely ruled out,
correlation with CTV is recommended if clinically warranted.
3. The aortic arch is partially visualized, and is tortuous,
buckled, and is located high in the mediastinum, with a possible
coarctation or aortic pseudo-coarctation (110b:9) , correlation
with aortic MRA or CTA are recpmmended to determineate this
finding and possible collateral flow. Normal vascular flow is
demonstrated in the circle of [**Location (un) 431**].
4. Significant midline shifting towards the right, approximately
9 mm of
midline shifting deviation is demonstrated, causing narrowing of
the
perimesencephalic cisterns.
5. Small punctate focus of high DWI signal is visualized on the
right frontal region (5:20), septic or ischemic thromboembolic
event in this area are considerations.
CT Abdoman/ pelvis: [**6-22**]
CHEST: At the level of the pulmonary artery, the descending
aorta measures 45 x 48 mm (2; 11). The descending aorta at the
level of pulmonary vein measures 33 x 33 mm (2; 17). The aortic
arch has not been included on this study. The heart appears
unremarkable. Small bilateral pleural effusions with associated
bibasilar atelectasis are noted. The lungs are otherwise clear.
No hilar or mediastinal lymphadenopathy is noted. An endogastric
tube courses down the esophagus into the stomach.
ABDOMEN: The liver demonstrates a small area of hypodensity near
the
falciform ligament that is a common area for focal fatty
infiltration of the liver. Otherwise, there is no focal lesion
or biliary dilatation. The
gallbladder is normal appearing without evidence of stones or
wall thickening.
Spleen is normal in size and appearance. The pancreas shows no
masses, cysts, or calcifications. The adrenal glands are normal
appearing bilaterally. The kidneys enhance with and excrete
contrast symmetrically. In the interpolar right kidney, there is
a subcentimeter hypodensity that is too small to characterize,
but likely represents a cyst. A similar-appearing lesion is seen
in the mid-to-lower pole of the left kidney. Within the stomach,
the tip and side port of the endogastric tube are noted to
reside. The small and large intestine show no evidence of
obstruction or wall thickening. No lymphadenopathy is seen. No
free air or fluid is noted. The IVC and portal vein and their
major branches, in this limited assessment during arterial
phase, appear patent. The visualized portion of the bladder and
rectum appear unremarkable.
CTA: The celiac, SMA and [**Female First Name (un) 899**] branches of the aorta are all
patent.
Incidental note of duplicated renal arteries is seen on the
left. The right renal artery is patent. The aorta is of normal
caliber and tapers normally down to the iliac branches. There is
no evidence of stenosis or intimal flap.
BONES: There are no lytic or sclerotic lesions.
IMPRESSION: Incomplete assessment of the aortic arch in a
patient with a
history of coarctation of the aorta; recommend re-performing the
study as a CTA from the neck down through the mid chest;
otherwise, mildly prominent ascending aorta and small bilateral
pleural effusions.
CTA chest: [**6-22**]
Incomplete assessment of the aortic arch in a patient with a
history of coarctation of the aorta; recommend re-performing the
study as a CTA from the neck down through the mid chest;
otherwise, mildly prominent ascending aorta and small bilateral
pleural effusions.
MR head w/ and w/o contrast: [**6-23**]
1. No significant short-interval change in the bilateral
parietooccipital
parenchymal hematomas with surrounding vasogenic edema, or the
subdural fluid collection layering over the left cerebral
convexity with stable degree of mass effect and shift of midline
structures.
2. Allowing for the susceptibility artifact related to the
evolving blood
products, there is no specific abnormality of diffusion or
enhancement, and no finding on multi-voxel MR spectroscopy to
specifically suggest bacterial or other pyogenic abscess, or
empyema (though MRS [**Last Name (STitle) **] not specifically performed on the
left-sided extra-axial fluid collection).
Carotid U/S: [**6-23**]
Limited carotid duplex with no evidence of left carotid stenosis
or left vertebral artery stenosis.
[**2183-7-3**]
Preliminary Report !! PFI !!
Likely no significant interval change compared to [**2183-7-1**].
Bilateral
parieto-occipital intraparenchymal hematomas and associated
edema are stable, and a thin left convexity subdural hematoma is
less conspicuous, certainly not enlarged. The degree of mass
effect with rightward midline shift and equivocal left uncal
herniation, is also unchanged.
Brief Hospital Course:
1. MSSA bacteremia: On initial presentation to OSH, patient was
found to have MSSA bacteremia with positive blood cultures on
[**6-17**]. Multiple lesions in brain, with questionale spleen and
kidney lesions were suggestive of systemic septic emboli from an
unknown source. Prior to transfer, patient had a negative
cardiac workup for vegetation including TTE and TEE. On
admission to [**Hospital1 18**], severe sepsis with fevers to 103, intubated
for protection of airway, and hypotension requiring aggressive
fluid resuscitation via CVL. Antibiotic coverage was expanded to
nafcillin, vancomycin and zosyn given severity of illness.
Blood cultures, urine cultures, and stool studies were negative.
Repeat TTE and TEE done at [**Hospital1 18**] were negative (see below
regarding aortic regurgitation and bicuspid aortic valve). With
repeat negative infectious evaluation, de-escalation of
antibiotic regimen to nafcillin and levofloxacin alone. On
[**6-25**], levofloxacin was discontinued and monotherapy with
nafcillin alone. Nafcillin should continue for 6 week course to
be completed [**2183-8-3**] through PICC. Patient continued to
have low grade temperatures with rising leukocytosis prompting
another infectious evaluation.
Current plan: 6 weeks IV antibiotic therapy with nafcillin
alone, checking weekly chem 7, CBC, LFTs, ESR and CRP. Please
fax to [**Hospital **] Clinic at [**Telephone/Fax (1) 1419**] attn: [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1352**]. See
attached prescription.
2. Acute intracranial bleed: Prior to transfer, patient
complained of "worst headache in life" and was noted to have
acute neurologic deterioration with left blown pupil. CT scan
showed acute left sided SDH and bilateral occipital hemorrhages
with midline shift. Stat MRI/ MRA head showed no evidence of
venous thrombosis or empyema, and stable midline shift. Full
stroke evaluation continuing EKG, U/A, cardiac enzymes returned
negative. Neurologic findings were thought to be secondary to
septic emboli. Patient was initially started on dilantin for
seizure prophylaxis and then transitioned to keppra 750mg [**Hospital1 **].
All anticoagulation, including heparin for DVT prophylaxis was
held. Neurologic deficits improved although patient was noted
to have persistent left sided ptosis and Balints syndrome
(oculomotor apraxia, optic ataxia and simultanangnosia) likely
from bilateral parietal lesions.
3. Ascending aortic aneurysm: Patient with history of congenital
coarctation of aorta s/p repair at 3 weeks. Found to have
aortic aneurysm of 4.7 cm by CT scan/ TEE. Initially there was
concern for connective tissue disorder such as Marfans
especially with intracranial hemorrhages, but MRA head showed no
evidence [**Doctor Last Name **] aneurysm. Other etiologies for aortitis
including RPR, [**Doctor First Name **], and ANCA were also negative. Patient was
evaluated by cardiothoracic surgery who recommended semiurgent
repair as an outpatient.
4. Aortic regurgitation/ bicuspid valve: History of congenital
bicuspid valve and coarctation of aorta. Found to have 3+
aortic regurgitation on TEE to evaluate for endocarditis.
Cardiothoracic surgery evaluated patient while in hospital and
recommended close follow up as outpatient for surgical
replacement.
5. Erythematous rash: On [**6-26**] patient was noted to have an
erythematous, nonpainful blanching rash with superimposed
vesicles on dependent areas of body. Dermatology was consulted
and felt that rash represented milliaria [**Last Name (LF) 85508**], [**First Name3 (LF) **]
occlusion of the eccrine ducts that can occur in patients after
prolonged periods of bed rest.
6. Bipolar Disorder: He was continued on his home regimen of
lithium.
7. Mental status changes: On the morning of [**6-30**] Mr. [**Known lastname 85507**]
was noted to have increasing somnolence and worsening strength
on the left side. He was transferreed to the MICU. His labs
were notable for a sodium of 124 and a WBC of 19. He was
pan-cultured. He was fluid restricted and given salt tabs.
Hyponatremia thought to be secondary to combined DI picture from
long term lithium as well as SIADH from acute intracranial
process. A repeat CT scan of the head was without acute
changes. Patient initially placed on mannitol diuresis
empirically which is being weaned over the next 48 hours.
Neurology service consulted and reported that mental status was
at his new hospital baseline. Nsurg recommended no acute
intervention. Patient remained on IV nafcillin. At the time of
transfer, sodium had improved to 136.
======
REHAB TO DO:
[ ] weekly labs as noted above and faxed to [**Hospital **] clinic
[ ] aggressive PT
[ ] aggressive OT
[ ] avoid Heparin SQ and other blood thinners due to bleeding in
brain
DISCHARGE MENTAL STATUS: Mental status and neuro exam are
complex but patient is A+Ox2, doesnt know where he is, has left
sided ptosis, left sided weakness, left pupil smaller than
right. Somonlent, only opens eyes to command, but will converse
with them closed. Able to walk with physical therapy while in
the hospital
Medications on Admission:
Medications:
Lithium 30 mg PO BID
Paxil 30 mg PO daily
Medicatons on Tranfer:
IV Oxacillin
Lithium 30 mg PO BID
Paxil 30 mg PO daily
Discharge Medications:
1. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
2. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
4. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
6. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours): Last dose is [**2183-8-3**].
7. Outpatient Lab Work
Please send weekly labs including chem 7, CBC, Liver function
tests, ESR and CRP starting on [**Last Name (LF) 766**], [**2183-7-7**]. Fax to
[**Hospital1 18**] Infectious disease service, attn: [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1352**] at
[**Telephone/Fax (1) 1419**]
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
MSSA Bacteremia
Subdural Hematoma
CVA
Altered mental status
Diarrhea
Hyponatremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with an infection in your blood. This
was complicated by bleeding into your brain as well as a stroke
that left you weak. You were seen by specialists from
Neurology, Neurosurgery, and infectious disease.
We made the following changes to your medications:
We STARTED levetiracetam.
We STARTED nafcillin. Last day is [**2183-8-3**]
Please take all medications as prescribed.
Please keep all your medical appointments.
Followup Instructions:
Department: NEUROLOGY
When: FRIDAY [**2183-8-1**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SURGERY
When: WEDNESDAY [**2183-7-16**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: [**Hospital Ward Name **] [**2183-7-14**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Phone: [**Telephone/Fax (1) 85509**]
You also need to follow up with your primary care provider.
Also, please call ([**Telephone/Fax (1) 2726**] to schedule a follow- up
appointment with NEUROSURGERY in 6 weeks (mid [**Month (only) 205**]), with a
Non-contrast
CT scan of the head at that appointment. The office is located
in the [**Hospital **] Medical Building, [**Hospital Unit Name 12193**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2183-7-6**]
|
[
"348.4",
"276.8",
"449",
"348.5",
"705.1",
"441.2",
"285.9",
"424.1",
"995.92",
"342.90",
"518.81",
"296.80",
"276.1",
"431",
"787.91",
"746.4",
"785.52",
"348.31",
"276.3",
"070.54",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"38.93",
"96.71",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
16678, 16748
|
10345, 15160
|
334, 414
|
16893, 16893
|
3052, 3052
|
17613, 19086
|
2478, 2487
|
15657, 16655
|
16769, 16769
|
15498, 15634
|
17080, 17397
|
2502, 3033
|
17426, 17590
|
1868, 2316
|
275, 296
|
442, 1849
|
4817, 10322
|
3068, 3867
|
16788, 16872
|
3889, 4808
|
16908, 17056
|
2338, 2391
|
2407, 2462
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,809
| 135,126
|
18564
|
Discharge summary
|
report
|
Admission Date: [**2173-12-4**] Discharge Date: [**2173-12-7**]
Date of Birth: [**2110-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
63 year-old man with a history significant for stage IIIA NSCLC
(dx [**11-24**]) s/p right pneumonectomy ([**6-25**]), presented to the ED
with increasing productive cough and dyspnea over several days.
The morning of admission he had been doing errands and found
himself getting increasingly SOB (specifically that he could not
catch his breath). He got home at which time EMS was called, and
he was transported to the ED. He has DOE at baseline, but noted
worsening DOE over the past several days. He also has a chronic
cough with productive sputum, but noted this being worse
recently as well, and noted a yellow discoloration. On admission
he also c/o chest heaviness and diaphoresis. Denies
palpitations, chest pain, nausea, and vomiting.
Additional ROS: He reports decreased appetite (despite using
Megace) and weight loss. His baseline weight is approx 180 lbs
before his dx of lung CA. After his pneumonectomy he was as low
as 140 lbs, and has fluctuated between 140-150 lbs for the last
several weeks. Over the past weeks he has reported some night
sweats, but no rigors or fevers. He denies orthopnea or PND at
home prior to admission, although he coughs a lot during the
night. He has a chronic cough and has difficulty clearing sputum
(which is occasionally green in color). No blood in sputum. He
was given a 2-week course of Levaquin (started [**11-9**]) due to
concern for superimposed bronchitis. Cough improved with abx
treatment. No pneumonia seen on recent CXR prior to admission.
In addition, the patient has a history of respiratory tract
infections during hospitalizations within the past year. During
his [**4-25**] hospitalization, sputum cultures grew GNR and MSSA.
During his [**6-25**] hospitalization, sputum cultures grew MRSA and
he was treated with Vancomycin and later transitioned to
Linezolid on discharge for a total of a 10-day course.
The patient additionally reports right-sided chest pain and pain
with swallowing. Dr. [**Last Name (STitle) **] is aware of this and has been
working up this issue. In prior exams he has had no evidence of
thrush or mouth ulcers. It has been suggested that mediastinal
lymphadenopathy is a possible cause of his dysphagia. The
patient may have had a barium swallow last Tuesday?. Of concern
is that this pain with swallowing is contributing to his poor
intake. He was taking OxyContin 10mg [**Hospital1 **] and an occasional
oxycodone with decent relief of his right-sided chest pain/pain
with swallowing.
He reports a long-standing hx of diarrhea, although none since
his SBO/LOA in [**4-25**]. He does report occasional constipation for
which he takes Ex-Lax. He has blood on the toilet paper when he
is constipated, which is attributes to his hemorrhoids. Denies
melena or recent changes in his bowels. He also reports pain in
his left knee and loss of hearing in his right ear.
Past Medical History:
1) Non-small-cell lung cancer dx [**11-24**]. RLL, stage IIIA,
squamous type. He had two cycles of induction chemotherapy w/
Carboplatin and Taxol (initiated [**2172-12-22**]) followed by concurrent
XRT with Taxotere chemotherapy (initiated [**2173-2-2**]). He was
scheduled to undergo surgical resection on [**4-25**], but it was
deferred secondary to SBO/LOA. Pneumonectomy performed on [**6-25**]
w/ radical mediastinal lymph node dissection and a muscle flap.
He was found to have recurrent lung cancer in the mediastinal
area on [**10-25**] PET scan. Now taking Taxotere and has had 3 doses
(once per week for 3 weeks -[**11-9**], [**11-15**], [**11-23**]). He is followed
by Dr. [**Last Name (STitle) **].
2) SBO s/p emergent exploratory laparotomy ([**4-25**]). LOA
performed. Two small perforations were found in the small bowel;
these were repaired. Concern for sepsis post-op.
3) HTN. At 10/25 visit BP was low at 86/56 so the patient was
told to take only half of his Toprol XL pill.
4) Depressed Cardiac Function. Echo [**6-25**]: Estimated EF 35%. Mild
symmetric left ventricular hypertrophy. Global hypokinesis. RV
systolic function depressed. 1+ AR, 1+ MR.
5) Hemorrhoids and anal fissure s/p lateral sphincterotomy
([**11-24**]).
6) GERD.
7) Laparotomy s/p gunshot wound to the abdomen when he was in
high school.
Social History:
Married w/ 1 son (age 35). He works as a custodian for [**University/College **]
[**Location (un) **]. He has a significant (40 pack-year) smoking history.
Also has a history of alcohol use. He quit both cigarettes and
alcohol 6 months ago. No recreational drug use. Has difficulty
with a low Na diet.
Family History:
Mother had an MI at age 70. Health of father unknown. Diabetes,
HTN, and heart disease runs in his family.
Physical Exam:
--VS: Tc 97.1, HR 126, BP 130/76, RR 24, 99% 2L
--General: Slim man sitting up in bed. He appears comfortable.
Breathing without difficulty and able to speak in complete
sentences.
--Skin: Warm and dry. No rashes or bruises noted.
--Head: Sclera anicteric. PEERL, EOMI. Oropharynx clear.
--Neck: No LAD appreciated. No thyromegaly. JVP to level of
mandible bilaterally, with positive hepatojugular reflex.
Carotids w/out bruits.
--CV: Tachycardia. Regular rhythm. Normal S1 and S2. No murmurs,
rubs, or heaves appreciated.
--Pulm: Pneumonectomy scar on right thorax. Not not using
accessory muscles. Pt audibly clearing upper airways. Coughing
productive of white/yellow sputum. Dullness to percussion on the
right side. Diminished breath sounds on the right, although
air-movement and occassional rhonchi appreciated medially. Left
lung field has good air-movement with minimal rales at base.
--Abd: Midline scar from exploratory laparotomy. Soft, NT/ND.
Hepatosplenomegaly not appreciated.
--GU: Foley in place. Urine clear and yellow-pink.
--Extrem: Warm and well-perfused. No LE edema. PT pulse intact
bilaterally; DP pulse only appreciated on the right.
--Neuro: Alert and Oriented x3.
Pertinent Results:
[**2173-12-4**] WBC-20.0*# Hct-31.5* MCV-93 MCH-31.3 MCHC-33.8
RDW-15.7* Plt Ct-362
[**2173-12-5**] WBC-16.2* Hct-30.4* MCV-93 MCH-30.5 MCHC-32.9 RDW-15.8*
Plt Ct-296
[**2173-12-7**] WBC-7.1 Hct-29.4* MCV-91 MCH-31.5 MCHC-34.5 RDW-15.5
Plt Ct-280
[**2173-12-4**] Neuts-83* Bands-5 Lymphs-5* Monos-6 Eos-0 Baso-0
Atyps-1* Metas-0 Myelos-0
[**2173-12-7**] Neuts-83.6* Lymphs-11.0* Monos-5.1 Eos-0.2 Baso-0.2
[**2173-12-4**] PT-13.3 PTT-26.2 INR(PT)-1.1
[**2173-12-4**] Glucose-264* UreaN-5* Creat-0.6 Na-139 K-3.6 Cl-105
HCO3-23
[**2173-12-7**] Glucose-133* UreaN-6 Creat-0.6 Na-140 K-4.1 Cl-103
HCO3-30*
[**2173-12-4**] CK(CPK)-33*
[**2173-12-4**] CK(CPK)-33*
[**2173-12-5**] CK(CPK)-29*
[**2173-12-4**] CK-MB-NotDone cTropnT-0.01
[**2173-12-4**] CK-MB-NotDone cTropnT-0.05*
[**2173-12-5**] CK-MB-NotDone cTropnT-0.02*
[**2173-12-6**] Calcium-9.2 Phos-3.6 Mg-1.8
[**2173-12-6**] Iron-46 calTIBC-202* VitB12-230* Folate-7.3
Ferritn-966* TRF-155*
[**2173-12-6**] Cholest-144 Triglyc-83 HDL-38 CHOL/HD-3.8 LDLcalc-89
[**2173-12-4**] 04:49PM BLOOD O2 Sat-98
[**2173-12-4**] 03:09PM BLOOD Lactate-1.4
[**2173-12-4**] 04:49PM BLOOD Lactate-1.8
[**2173-12-4**] 03:09PM BLOOD pO2-469* pCO2-55* pH-7.28* calHCO3-27
Base XS--1
[**2173-12-4**] 04:49PM BLOOD Type-ART Temp-36.2 Rates-/33 PEEP-5
O2-100 pO2-520* pCO2-42 pH-7.40 calHCO3-27 Base XS-1 AADO2-178
REQ O2-38 Intubat-NOT INTUBA Comment-BIPAP
CXR [**12-4**] (AP): There is again evidence of prior pneumonectomy
with white-out of the right lung and surgical clips seen in the
superior right hilum. The left lung is clear without
pneumothorax, effusion, or focal consolidation. There is
expected shift to the right of the mediastinum. Degenerative
changes are noted in the lumbar spine. IMPRESSION: Expected
post-surgical changes with unremarkable left lung.
Sputum Sample [**12-4**]:
- GRAM STAIN (Final [**2173-12-4**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN
PAIRS AND CHAINS.
- CULTURE (Final [**2173-12-6**]):
MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S).
SPARSE GROWTH OF THREE COLONIAL MORPHOLOGIES.
Urine culture [**12-4**]: No growth
Blood culture [**12-5**]: Pending
CXR [**12-5**] (AP): No change from previous CXR.
CXR [**12-6**] (PA and lat): Status post right pneumonectomy. No
acute cardiopulmonary
abnormality is identified. The left lung is well inflated.
Echo [**12-7**]: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with hypokinesis
of the inferior wall, basal inferolateral wall, distal septum
and distal lateral walls, and apex. The remaining segments
contract well. Right ventricular chamber size is normal with
mild free wall hypokinesis. The aortic root is mildly dilated.
The aortic valve leaflets appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
leaflets appear structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a small circumferential pericardial
effusion without echo evidence for tamponade physiology.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction (EF 35%) c/w multivessel CAD or other diffuse
process. Pulmonary artery systolic hypertension. Small
circumferential pericardial effusion. Compared with the prior
study (tape reviewed) of [**6-25**], a small circumferential
pericardial effusion is now present. Right ventricular free wall
motion is improved, aortic regurgitation is no longer seen, and
the left ventricular function is better defined.
Brief Hospital Course:
63 year-old man with a history significant for stage IIIA NSCLC
(dx [**11-24**]) s/p right pneumonectomy ([**6-25**]), presented to the ED
with increasing productive cough and dyspnea over several days.
Admitted to the MICU for respiratory distress. Transferred to
the floor on [**12-5**].
In the ED/MICU ([**Date range (1) 50997**]): Upon arrival to the ED he was
found to have a temp of 100.6, RR to 50s, HR to 150s, BP
170/108, and O2sats 82-85% on RA. He was noted to have an
inspiratory wheeze, accessory muscle use, and orthopnea. He was
put on 100%NRB and O2sats improved to 100%. An ABG after NRB
placed was 7.28/55/469, w/ lactate 1.4. ECG showed sinus
tachycardia, LBBB, and no ST changes (ischemic changes difficult
to interpret in the settng of BBB). He had a WBC of 20 with
bandemia. CXR showed complete opacity of the right lung field
s/p pneumonectomy, and an unremarkable left lung field. He was
placed on CPAP. Cetriaxone and Azithromycin were started for
presumed acute-on-chronic bronchitis and/or CAP. Predisone was
started for bronchitis/COPD exacerbation. An esmolol drip was
started to decrease BP and HR. He was placed on a Nitro gtt for
concern for acute ischemia causing CHF. He also received 20mg
Lasix for a possible element of CHF. ROMI with 3 sets of cardiac
enzymes and telemetry were ordered. While in the MICU, his HR
and BP decreased (although he remained tachycardic) and he was
hemodynamically stable. His O2sats improved and he was
transfered to the floors on nasal cannula. Symptomatically he
was no longer SOB, but continued to cough and produce thick
white/yellow sputum.
On the floor ([**Date range (1) 31208**]):
--Respiratory Distress: Several etiologies were considered,
including acute-on-chronic bronchitis, CAP vs. aspiration PNA,
COPD exacerbation, and CHF. An infectious etiology was suggested
by the patient's presentation with a WBC of 20 (with a bandemia)
and a slight fever of 100.6. The patient had a chronic cough
that was productive of sputum, which had worsened prior to
admission. Acute-on-chronic bronchitis was believed to be the
most likely etiology. CAP and aspiration pneumonia were also of
consideration (especially given the patient's recent history of
pain and coughing with swallowing). However, they were believed
to be less likely since an infiltrate was not seen on CXR. The
physical exam was also more suggestive of an upper airway
process than a pneumonia. The sputum sample gram stain showed
gram-positive cocci in pairs and chains, suggestive of a Strep
species. The culture grew oropharyngeal flora. Ceftriaxone was
discontinued, and Azithromycin continued to complete a 3 day
course for acute bronchitis. During this hospitalization his
WBC has decreased from 20 to 7 and he was afebrile. He was also
started on Prednisone 60mg as well as nebulizers for this acute
on chronic bronchitis flare. The steriods were subsequently
tapered as the patient improved.
The patient's symptoms and exam improved during the
hospitalization. By [**12-6**] he no longer required supplemental
oxygen. He continued to cough and produce white/yellow sputum,
which he and his wife said was his baseline.
--Cardiovascular: CHF, possibly caused by acute ischemia or
infection in the setting of already depressed cardiac function
([**6-25**] estimated EF 35%), was also a consideration for the
patient's shortness of breath. There was no CHF evident on CXR,
but it was recognized that mild CHF might have been obscured by
COPD, therefore a repeat echo was obtained during this
hospitalization to evaluate his function and wall motion. The
echo during this hospitalization showed moderate regional left
ventricular systolic dysfunction (unchanged at EF 35%) with
hypokinesis of the inferior wall, basal inferolateral wall,
distal septum and distal lateral walls, and apex unchanged from
previous echo (better defined), consistent with multivessel CAD
or another diffuse process. The remaining segments contract
well. Right ventricular chamber size is normal with mild free
wall
hypokinesis, improved from previous echo.
His cardiac enzymes were flat. The patient was in sinus
tachycardia (HR 150s) on admission. During the hospitalization
is tachycardia was resolving (HR 100s), but should be followed
as an outpatient. His blood pressure was controlled with
Metoprolol 25mg [**Hospital1 **] while in the hospital. He was discharged on
his home dose of Toprol XL 100mg daily. Lisinopril 2.5mg daily
was added during this hospitalization due to his systolic
dysfunction (he was discharged on this medication after his
previous hospitalization in [**6-25**], but according to the patient
was not taking it on admission). He was discharged on Lisinopril
2.5mg daily. A lipid panel was performed that showed LDL 89, HDl
38, and TG 83. Will ask the primary medical providers about the
utlitiy of starting a statin or Aspirin in this patient.
--NSCLC: Dr. [**Last Name (STitle) **] (oncology) followed the patient while he
was in the hospital. His last Taxotere treatment on [**11-23**]. He
was not neutropenic. His appointment with Dr. [**Last Name (STitle) **] was
re-scheduled for next week.
--Right-Sided Chest Pain/Pain with Swallowing: The patient has
had this pain since his pneumonectomy. It is sometimes
associated with pain with swallowing. This issue is being worked
up as an outpatient. Outside studies prior to admission showed
that he has a new esophageal stricture, but no evidence of
dysphagia. He has decent relief with his home regimen of pain
medications (Oxycontin and Oxycodone) which were continued while
he was in the hospital.
--Anemia: The patient has been anemic for some time. His Hct has
been stable in low 30s during this hospitalization. Anemia
likely caused by his chemotherapy treatment. In addition, iron
studies suggested an anemia of chronic disease. The patient has
poor appetite and recent weight loss, so folate and vitamin B12
level were checked. His vitamin B12 was slightly low, so he was
given parenteral B12 while in house, and discharged on B12
supplementation 1000 mcg daily. The patient is on Epogen as an
outpatient and will resume treatments when discharged.
--Elevated Serum Glucose: His serum glucose levels were in the
100-150s during this admission. These values were interpreted
with caution in the setting of steroid usage. He was on an
Insulin sliding scale in the hospital and will suggest
outpatient follow-up of his glucose levels.
Medications on Admission:
Toprol XL 100 daily
Mucinex
Advair 250/50
Spiriva
Oxycontin 10mg [**Hospital1 **]
Oxycodone 5mg Q6H:PRN
Endocet
Discharge Medications:
1. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
2. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
3. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
4 days: Take one tablet a day for two days, then half a tablet
per day for two days.
Disp:*3 Tablet(s)* Refills:*0*
6. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute exacerbation of chronic bronchitis.
Left and right ventricular systolic dysfunction, depressed
ejection fraction 35%.
Discharge Condition:
Good, stable.
Discharge Instructions:
Resume all of your previous medications. We have started you on
two new medications: lisinopril 2.5 mg daily, and vitamin B12
1000 micrograms daily. The lisinopril is for your heart, and
the vitamin B12 is for your anemia.
You will also need to finish your taper of steroids (Prednisone)
by taking 20 mg daily for the next two days (1 tablet), then 10
mg daily for two more days ([**1-22**] tablet).
Continue your home inhalers. You can use mucinex/robitussin
over the counter as necessary.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2173-12-14**] 10:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] Date/Time:[**2173-12-14**] 11:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2173-12-14**] 11:00
Please make an appointment with your primary care doctor, Dr.
[**Last Name (STitle) **], in the next week [**Telephone/Fax (1) 50998**].
|
[
"401.9",
"491.22",
"398.91",
"197.1",
"E933.1",
"396.3",
"285.9",
"530.81",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17286, 17292
|
9963, 16410
|
323, 330
|
17460, 17475
|
6246, 9940
|
18020, 18666
|
4911, 5019
|
16573, 17263
|
17313, 17439
|
16436, 16550
|
17499, 17997
|
5034, 6227
|
276, 285
|
358, 3217
|
3239, 4576
|
4592, 4895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,985
| 138,520
|
7610
|
Discharge summary
|
report
|
Admission Date: [**2101-5-7**] Discharge Date: [**2101-5-14**]
Date of Birth: [**2026-5-18**] Sex: F
Service: CT [**Last Name (un) **]
CHIEF COMPLAINT: Transfer from [**Hospital6 27369**] with
chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
woman with known CAD status post MI and cath in [**2100-2-5**]
with LAD stent placed at that time. She presented to the
outside hospital with chest pain. She complained of three
days of chest pain upon awakening across her shoulder blades
and down her arms, lasting one to 1 1/2 hours, worse at night
when she lays down. She presented to the outside hospital
emergency room one day prior to admission to [**Hospital1 346**]. Given the history of CAD and
strong suspicion for acute coronary syndrome with troponin
that was mildly positive at 0.12 as well as break through
pain on heparin and nitroglycerin drip, the patient was
transferred to [**Hospital1 69**] for
management and evaluation of chest pain.
PAST MEDICAL HISTORY: Significant for CAD status post silent
MI in the [**2088**]. Cath in [**2090**] showed mid-LAD lesion 95%
which was treated with medicine. Cath in [**2100-2-5**]
showed RCA 50%, LAD 95%. The LAD was stented at that time.
Patient had complete heart block while the balloon was
wedged. Following the procedure she had left bundle branch
block. Status post right CEA in [**2099-1-5**]. COPD.
Hypertension. Hyperlipidemia. Osteoporosis. C-section.
ALLERGIES: No known allergies.
OUTPATIENT MEDICATIONS: Vasotec 5 mg b.i.d., betaxolol 10 mg
q.d., enteric coated aspirin 325 q.d., folate, Fosamax,
nitroglycerin patch, Pravachol 40 q.d., Serevent p.r.n.,
albuterol p.r.n.
MEDICATIONS ON TRANSFER: Pravachol 40 q.d., Vasotec 5
b.i.d., vitamin E 400 q.d., enteric coated aspirin 325 q.d.,
Lopressor 50 b.i.d., Fosamax 70 q.Saturday, folic acid one
q.d., nitroglycerin drip, heparin drip, Aggrastat drip.
SOCIAL HISTORY: Lives alone. Remote tobacco history, quit
over one year ago. No alcohol use.
PHYSICAL EXAMINATION: On admission vital signs temperature
98.2, heart rate 85, blood pressure 142/72, respiratory rate
20, O2 sat 96% on 2 liters. In general, in no acute
distress. HEENT pupils equally round and reactive to light.
OP clear. Mucous membranes moist. Neck no JVD. Chest clear
to auscultation bilaterally, no crackles. Heart sounds
regular rate and rhythm, sounds distant, no murmurs, gallops
or rubs. Abdomen soft, nondistended, nontender, normoactive
bowel sounds. Extremities with 1+ edema on the dorsal aspect
of the left foot. No ankle edema. Dorsalis pedis and
posterior tibial 2+ pulses.
LABORATORY DATA: White count 8.3, hematocrit 31.2, platelets
241. PT 12.5, PTT 37.7, INR 1. Sodium 142, potassium 4.7,
chloride 107, CO2 27, BUN 18, creatinine 0.7, glucose 99. CK
44, troponin 0.03.
HOSPITAL COURSE: The patient was followed by the medicine
service upon admission to [**Hospital1 188**]. On [**5-9**] she was brought to the cath lab. Please
see the cath report for full details. In summary, the cath
showed left main 40% to 50%, LAD 95% at proximal edge of
patent LAD stent, left circumflex 95% lesion, RCA with
diffuse luminal irregularities. At that time CT surgery was
consulted and patient was consented for coronary artery
bypass grafting. Prior to going to the operating room,
patient underwent carotid Doppler exams which showed no
significant lesions in either the right or the left carotid
arteries.
On [**5-11**] the patient was brought to the operating room.
Please see the operative report for full details. In
summary, patient had coronary artery bypass grafting times
four with LIMA to LAD, saphenous vein graft to OM2, saphenous
vein graft to diag sequentially to OM1. She tolerated the
operation well and was transferred from the operating room to
the cardiothoracic intensive care unit. At the time of
transfer patient's mean arterial pressure was 72, CVP 15.
She was AV paced at 80 beats per minute. She had epinephrine
0.03 mcg per kg per minute and propofol 10 mcg per kg per
minute. Additionally, patient was on milrinone 0.25 mcg per
kg per minute. In the immediate postoperative period patient
was kept sedated and ventilated as she was hemodynamically
unstable with labile blood pressure and cardiac index which
resolved with the initiation of milrinone and additional
volume in the immediate postoperative period. Additionally,
patient had mild respiratory acidosis.
On the morning of postoperative day one the patient was
hemodynamically stable. She was weaned from milrinone.
Sedation was discontinued. She was weaned from the
ventilator and successfully extubated. Later in the day of
postoperative day one patient was begun on small doses of
Lopressor secondary to tachycardia. However, with the
initiation of Lopressor, she displayed complete heart block
which required temporary pacing. Several hours later patient
recovered her sinus rhythm and remained hemodynamically
stable throughout this period. On the morning of
postoperative day three patient's PA catheter, chest tubes
and Foley catheter were discontinued and she was transferred
from the cardiothoracic intensive care unit to [**Hospital Ward Name 121**] 2 for
continuing postoperative care and cardiac rehabilitation.
Once the floor, with the assistance of the nursing staff and
physical therapist, patient activity level was increased.
Over the next several days her Lopressor dose was gradually
increased until on postoperative day five it was decided that
patient was stable and ready to be transferred to
rehabilitation for continuing postoperative care and
rehabilitation.
At the time of transfer, the patient's physical exam was as
follows. Vital signs temperature 98.4, heart rate 110 sinus
tach, blood pressure 142/80, respiratory rate 20, O2 sat 92%
in room air. Weight preoperatively 69.9 kg, at discharge
76.4 kg. Lab data white count 10.5, hematocrit 35.7,
platelets 214. Sodium 139, potassium 3.4, chloride 97, CO2
34, BUN 27, creatinine 0.9, glucose 121. Alert and oriented
times three. Moved all extremities. Followed commands.
Respiratory clear to auscultation bilaterally. Heart sounds
regular rate and rhythm, S1, S2 with no murmurs. Sternum was
stable. Incision with staples open to air clean and dry.
Abdomen soft, nondistended, nontender with positive bowel
sounds. Extremities were warm and well perfused with 1+
edema bilaterally. Left leg incision with staples. Small
amount of serosanguineous fluid draining from the upper pole
of that incision.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg b.i.d.
2. Potassium chloride 20 mEq b.i.d.
3. Enteric coated aspirin 325 q.d.
4. Plavix 75 mg q.d.
5. Pravastatin 40 mg q.d.
6. Metoprolol 100 mg b.i.d.
7. Enalapril 5 mg q.d.
8. Percocet 5/325 one to two tabs q.four hours p.r.n.
9. Albuterol two puffs q.four hours p.r.n.
DISCHARGE DIAGNOSES:
1. CAD, status post coronary artery bypass grafting times
four with LIMA to LAD, saphenous vein graft to OM2, saphenous
vein graft to diag and OM1 sequentially.
2. Status post right carotid CEA.
3. COPD.
4. Hypertension.
5. Hypercholesterolemia.
6. Osteoporosis.
7. Left bundle branch block.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation.
FOLLOWUP: The patient is to have followup with primary care
provider two weeks from the time of discharge from
rehabilitation. Follow up with Dr. [**Last Name (STitle) **] four weeks from
the time of discharge from [**Hospital1 188**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2101-5-16**] 12:10
T: [**2101-5-16**] 12:21
JOB#: [**Job Number 27771**]
|
[
"412",
"426.0",
"276.2",
"401.9",
"V45.82",
"410.71",
"414.01",
"496",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"37.22",
"88.52",
"39.61",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
6914, 7790
|
6595, 6893
|
2872, 6572
|
1532, 1700
|
2052, 2854
|
174, 228
|
257, 997
|
1726, 1932
|
1020, 1507
|
1949, 2029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,314
| 128,659
|
46035
|
Discharge summary
|
report
|
Admission Date: [**2114-1-13**] Discharge Date: [**2114-1-17**]
Date of Birth: [**2045-12-15**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 68 year old generally healthy lady who
experienced shortness of breath since returning from [**State 108**] 6
days prior to admission. She felt feverish but never checked her
temperture. She has also experienced chills. She did not have
cough, headache, focal neuro symtoms, chest pain, palpiations,
abdominal pain, diarrhea, constipation, nausea, vomitting,
dysuria or rash. She has not noticed any bleeding including not
experiencing any blood in stool or urine.
.
In the ED her vitals were Tmax 101.4 BP 123/63 HR 100 RR 30 86%
in RA with 99% on 4LNC. According to the ED resident's verbal
signout her oxygen sats improved to 99% on RA and was placed on
6L NC for comfort. Her CXR was suspicous for pneumonia and she
was given levofloxacin 750 mg IV once and combivent nebs. Her
hematocrit was found to be 14 and she received 1uPRBC and 1LNS.
She was trace guaic positive.
.
On arrival to MICU her vitals were T 99.6 HR 117 BP 161/59 RR 35
100% on NRB 100%.
Past Medical History:
history of pericarditis 4 years ago
Social History:
Lives alone by herself in Collidge Corner in a condominium. No
known family members. [**Name (NI) **] lots of friends who live nearby. 1
pack cig per day active smoker for approx 50 years.
Family History:
Father passed away of PNA.
Physical Exam:
Admission:
Vitals: T 99.6 HR 117 BP 161/59 RR 35 100% on NRB 100%.
Gen: Alert and awake, tacypnic, ? anxious
HEENT: Pale, MMM, OP clear
Heart: S1S2 regular rhythm, tachycardia, no MRG
Lungs: Bilateral diffuse rhonchi
Abdomen: BS present, soft NTND, no appreciable
mass/organomegaly.
Ext: WWP, no edema
Neuro: Following commands, strength 5/5 b/l, CN III/XII grossly
intact
.
Discharge:
VS: Afebrile, HR 70s, RR 20, O2 sat 95% on RA at rest, 90-93% on
RA with ambulation
Gen: A&O, NAD
HEENT: MMM, OP clear
Heart: RRR, normal S1 and S2, no M,R,G
Lungs: Crackles at the bases bilaterally, no wheezes
Abd: soft, NT, ND, normoactive BS
EXT: no edema
Neuro: walks without difficulty
Pertinent Results:
Admission Labs:
WBC-4.7# RBC-1.19*# Hgb-4.9*# Hct-14.2*# MCV-120*# MCH-41.4*#
MCHC-34.6 RDW-23.4* Plt Ct-269
Neuts-70 Bands-4 Lymphs-14* Monos-9 Eos-0 Baso-1 Atyps-1*
Metas-1* Myelos-0
BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-2+
Polychr-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]2+
PT-17.8* PTT-43.1* INR(PT)-1.6*
BLOOD Glucose-130* UreaN-16 Creat-1.0 Na-135 K-3.8 Cl-102
HCO3-21*
ALT-36 AST-33 CK(CPK)-65 AlkPhos-66 TotBili-1.4 Lipase-13
cTropnT-<0.01 proBNP-2858*
Calcium-7.8* Phos-2.9 Mg-1.7 Iron-19*
calTIBC-159* VitB12-679 Hapto-90 Ferritn-936* TRF-122* Ret
Aut-3.4*
Type-ART Temp-37.1 Rates-/30 pO2-36* pCO2-34* pH-7.40 calTCO2-22
Base XS--2 Intubat-NOT INTUBA Comment-O2 DELIVER
BLOOD Lactate-3.1*
Other Labs:
TSH-4.1
IgA-76, tTG-IgA-2
Discharge Labs:
WBC-5.3 Hgb-9.2* Hct-26.0* MCV-96 Plt-186
Glucose-92 UreaN-16 Creat-0.7 Na-142 K-3.8 Cl-112* HCO3-24
[**2114-1-14**] 12:32 am URINE Site: NOT SPECIFIED
**FINAL REPORT [**2114-1-15**]**
URINE CULTURE (Final [**2114-1-15**]): NO GROWTH.
[**2114-1-14**] 5:38 pm URINE Source: Catheter.
**FINAL REPORT [**2114-1-15**]**
Legionella Urinary Antigen (Final [**2114-1-15**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Studies:
[**2114-1-13**] Chest x-ray - Retrocardiac opacity obscuring the left
hemidiaphragm is most likely atelectasis, however early
developing pneumonia not entirely excluded. Correlate
clinically.
[**2114-1-13**] EKG: NSR, vent rate 100s, nl axis, nl intervals, no
significant ST-T changes compared 11/[**2108**].
[**2114-1-13**] CTA Chest - IMPRESSION:
1. Bilateral dense lower lobe pneumonias with small reactive
pleural effusions (consolidation is denser on the left, however
effusion is slightly larger on the right).
Additional scattered more ground-glass opacities as noted above,
which may
also be infectious or represent regions of alveolar edema in
this patient with mild interstitial septal thickening suggestive
of mild pulmonary edema.
2. Scattered small right middle lobe nodular densities measuring
up to 5 mm. In a patient at low risk for intrathoracic
malignancy, a dedicated followup CT should be obtained in one
year; if high risk, a dedicated followup can be obtained in 6 to
12 months.
3. No evidence of aortic dissection or pulmonary embolism.
4. Cardiomegaly with prominent right atrium.
[**2114-1-15**] EKG - Technically difficult study. Sinus rhythm Late R
wave progression - probable normal variant. T wave
abnormalities. Since previous tracing of [**2114-1-13**], heart rate
slower, and T wave abnormalities
less.
[**2114-1-15**] TTECHO - The left atrium is mildly dilated. The right
atrial pressure is indeterminate. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Moderate
pulmonary artery systolic hypertension. Mild mitral
regurgitation.
This constellation of findings suggests a primary pulmonary
process (e.g.., COPD, bronchospasm, pulmonary embolism, etc.)
[**2114-1-15**] Chest x-ray - IMPRESSION: Increasing right pleural
effusion. Essentially unchanged left lower lobe consolidation
and associated effusion. Empyema cannot be excluded on this
examination and if there is continued clinical concern for
empyema a dedicated chest CT with IV contrast is recommended.
[**2114-1-16**] Chest x-ray, lateral decubitus - IMPRESSION: Bilateral
small pleural effusions. Left side estimated to 1-200 mL. The
right-sided effusion is less than that matches the small amount
of pleural effusion demonstrated on chest CT performed on
[**2114-1-13**].
Brief Hospital Course:
Mrs. [**Known lastname **] is a 68 year old female who was admitted with
shortness of breath and fatigue and found to have pneumonia and
anemia.
# Pneumonia - In the ED the patient was ruled out for a PE with
a CTA given her Aa gradient. CTA showed an impressive bilateral
pneumonia. The patient was initially admitted to the MICU as
she was on a non-rebreather, but was weaned down to 3L NC
overnight. She was transfered to the general medical floor the
following day. She was continued on levofloxacin 750 mg for
community acquired pneumonia and continued to improve
clinically. Urine Legionella antigen was negative. She was
given nebulized albuterol and an ipratropium MDI for wheezing.
She also had an ECHO to evaluate for CHF given an elevated BNP
on admission. Her ECHO was largely unremarkable except for an
elevated pulmonary artery systolic pressure, likely secondary to
pneumonia. The patient had an episode of acute chest pain
during/immediately after the ECHO. EKG was unremarkable. Her
chest pain was most likely a result of movement and pleural
irritation from her pneumonia. She was given morphine IV,
tylenol, and ibuprofen with resolution of her chest pain and no
further episodes. As a result of this episode, consideration
was given to tapping her pleural effusions to rule out empyema
and AP and decubitus chest x-rays were performed, however, it
was felt that there was too little fluid to tap, the patient's
chest pain resolved, and she continued to improve clinically.
The patient was evaluated by physical therapy. On the morning
of discharge the patient's room air O2 sat at rest was 95%.
With ambulation it was mostly 92-93%, but did briefly dip to
90%.
Given the severity of the patient's pneumonia, it is recommended
that she have a follow-up chest x-ray in two months to evaluate
for resolution. In addition, given her smoking history and the
pulmonary nodules that were noted on CTA, the patient should
have a repeat CT scan in [**7-13**] months.
# Anemia - On arrival to the MICU, the patient received 2
additional units of blood and her hematocrit increased
appropriately to 20 and she remained hemodynamically stable.
The anemia was also evaluated with haptoglobin (nl), nl folate,
nl B12 and reticulocyte count which was appropriately elevated.
Iron studies demonstrated iron deficiency anemia but with an
elevated ferritin. It should be noted, however, that these
studies were performed after the patient had already received
some blood and therefore, may not be entirely accurate. The
patient was transfused an additional 2 units of PRBCs on the
medicine floor with an appropriate hematocrit increase to 26
that remained stable. Gastroenterology was consulted. The
patient has never had a colonoscopy previously and they
recommended a colonoscopy as an outpatient given trace guaiac
positive stools in the ED and the uncertainty around the acuity
of the patient's anemia, though she denied melena or BRBPR. Per
GI recs TSH was checked and was normal. Serum IgA and tTG-IgA
were also checked and did not indicate celiac sprue. The
patient was instructed to call the [**Hospital **] clinic to schedule a
colonoscopy sometime during [**Month (only) 404**]. The patient was also
advised to have her primary care physician check her hematocrit
to ensure that it remains stable.
Medications on Admission:
ASA 81 mg daily
No OTC/herbal medications
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed: Do not drive if you are taking this medication.
Disp:*30 Tablet(s)* Refills:*2*
3. Combivent 18-103 mcg/Actuation Aerosol Sig: [**2-1**] Inhalation
four times a day as needed for shortness of breath or wheezing
for 4 weeks.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Pneumonia
2. Anemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital with pneumonia and anemia.
You were given an antibiotic for the pneumonia and five red
blood cell transfusions because of the anemia. You will also
need further evaluation of your anemia as an outpatient.
Please take the antibiotic levofloxacin for the next 6 days. It
is important that you take all of it, even if you are feeling
better, to get over your pneumonia.
You were also given a prescription for an inhaler to help with
shortness of breath and wheezing.
You were also given a prescription for Zolpidem to help you
sleep at night. Please do not drive if you take this
medication.
Please follow-up with the providers outlined below.
Please call your physician or return to the hospital if you
develop fevers, worsening shortness of breath, worsening cough,
chest pain, or orther concerning symptoms.
Followup Instructions:
Please follow-up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] on
tuesday, [**2114-1-23**] at 9:00 am. His office phone number is
[**Telephone/Fax (1) 2205**].
Please follow-up with the gastroenterologists within the next
month for a colonoscopy. Please call [**Telephone/Fax (1) 463**] and ask for a
fellow booked procedure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"786.59",
"799.02",
"518.89",
"276.8",
"486",
"285.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10714, 10720
|
6825, 10162
|
288, 295
|
10806, 10816
|
2338, 2338
|
11714, 12222
|
1598, 1626
|
10254, 10691
|
10741, 10785
|
10188, 10231
|
10840, 11691
|
3139, 6802
|
1641, 2319
|
229, 250
|
323, 1317
|
2354, 3084
|
1339, 1376
|
1392, 1582
|
3096, 3123
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,573
| 187,291
|
1120
|
Discharge summary
|
report
|
Admission Date: [**2129-5-30**] Discharge Date: [**2129-5-31**]
Date of Birth: [**2070-7-15**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58M PMH CAD--s/p CABG [**2-27**], most recent cath [**2129-2-17**] with
diffuse 3VD, patent grafts, and no intervention; ESRD on HD; s/p
recent admission 1 month ago for hyperkalemia, bradycardia,
fluid overload, and chest pain in the setting of renal failure
from only 2 HD sessions in 10 days, who now returns with chest
pain, hyperkalemia, and bradycardia, in the setting of renal
failure.
Past Medical History:
1. CAD
- s/p CABG [**2-27**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1
- [**2127-6-20**] cardiac cath: LMCA 40%, LAD mid 70%, LCx 60%, RCA
previously known proximal 99% occlusion; Patent grafts.
- Stress [**2127-10-10**]: unchanged from [**2127-6-18**]; moderately
reversible inferolateral to inferior walls perfusion defects
with EF 44%; repeat ETT [**2-2**] (6 min Modified [**Doctor First Name **], stopped
fatigue and chest pain, blunted HR response) with inferior wall
defect now fixed--not reversible--on MIBI
- Cath [**2129-2-17**], 3VD with patent grafts. Pressure wire of 60% LCX
ostial lesion: FFR 0.97 to 0.91 with adenosine indicating
non-flow limiting
2. Diabetes mellitus: diet controlled
3. Dyslipidemia
4. Hypertension
5. Congestive heart failure: Echo [**2129-4-7**] revealed biatrial
enlargement; LVEF 60%, 1+ MR (eccentric), [**12-28**]+ TR, Mod PA HTN
6. Peripheral [**Month/Day (2) 1106**] disease: s/p stent to bilateral CIAs
(Genesis) and steft to [**Female First Name (un) 7195**]
- s/p POBA and atherectomy of L SFA [**2126-7-17**]
7. End-stage renal disease: [**1-28**] Diabetic Nephropathy - on HD
T/Th/Sat
- currently undergoing evaluation for renal transplant although
considered high risk
8. ? COPD - no PFTs available
9. Tracheomalacia
10. h/o c.diff colitis
11. h/o UGI bleed : EGD ([**2-2**]) showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
tear, gastropathy, and gastritis
12. Pulmonary Fibrosis: PET scan [**2129-4-27**], no areas of abnormal
FDG uptake. Cannot rule out broncheoalveolar carcinoma.
Social History:
Patient is originally from [**Country 7192**]. His wife and family are
still there. Patient currently lives alone, but his brother is
nearby. He is on disability. His sister-in law works @ [**Hospital1 18**] in
housekeeping.
Family History:
Father died of CAD
Mother and brother with [**Name (NI) 7199**]
Physical Exam:
per Dr. [**Last Name (STitle) **]
VS: T:97 BP:134/49 HR:51 RR: O2:100
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 up to ear lobes.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Loud systolic and dialstolic murmur heard. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
labs:
129 100 60
---------------< 392
7.4 19 9.2
CK: 67 to 49
MB: Notdone to notdone
Trop-T: 0.16 to 0.18
Ca: 8.3 Mg: 3.1 P: 4.8
.
14.1
9.0 >====< 241
43
N:80.8 L:10.6 M:3.8 E:4.4 Bas:0.4
.
PT: 11.8 PTT: 29.2 INR: 1.0
lactate 1.6
Hct to 37.1 at discharge
Potassium to 4.1 morning of discharge.
.
admission CXR: There is evidence of prior coronary artery bypass
grafting. The cardiomediastinal silhouette is stable. The lung
volumes are low. Moderate cardiomegaly and pulmonary [**Last Name (STitle) 1106**]
engorgements are longstanding. Right pleural thickening vs
loculated fluid and rounded atelectasis in the right lower lobe
is stable. There is new blunting of the left costophrenic angle,
which may be consistent with atelectasis versus effusion.
unchanged from previous
.
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 low
normal (LVEF 50%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Transmitral
Doppler and tissue velocity imaging are consistent with Grade II
(moderate) LV [**Last Name (STitle) 7216**] dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2129-4-7**], the left ventricular ejection fraction is
somewhat reduced; other findings are similar.
.
EKG on admission: demonstrated sinus bradycardia with PR
prolongation, long QT interval, inverted T-waves in leads I,
aVL, V5-V6, and peaked T-waves in the precordial leads V1, V2.
Incomplete right bundle branch block. no significant change
compared with prior dated
.
EKG the following day: sinus brady resolved. NSR with
resolution of long QT. Inverted T waves persist, peaked T waves
have resolved.
.
Brief Hospital Course:
58M PMH CAD-s/p CABG, DM, ESRD on HD, presented with
hyperkalemia, fluid overload, and chest pain in the setting of
acute renal failure. Hospital course by problem:
.
# Hyperkalemia - Likely [**1-28**] ESRD. Unclear precipitant. Patient
has been compliant with meds. He reports diarrhea so if
anything it would likely have decreased his potassium. Patient
does report some dietary indiscretion though which may account
for hyperkalemia. EKG as above. patient received urgent HD on
evening of admission. The following morning, his potassium was
4.3. He received scheduled HD. We discontinued his lisinopril
thinking that if anything it may lead to increased potassium.
Patient will otherwise resume normal HD schedule. Followup EKG
showed resolution of hyperkalemic changes.
.
# Cards ischemic: hx of known CAD. He came in with atypical
chest pain. It resolved rather promptly although we initially
treated with a heparin gtt while checking serial enzymes given
his risk for disease. He received two sets of negative enzymes
and our suspicion for ischemia was low. We stopped heparin gtt
prior to d/c.
.
# Cards rhythm: Sinus brady in the ED. This can be [**1-28**]
hyperkalemia. It resolved after HD and likely improvement of K.
.
# HTN: We held his ACEi as mentioned above. We discharged
patient on Toprol XL 50 and added amlodipine 5 in setting of
holding the ACEi. We discussed this with his PCP and further
adjustments will be made on an outpatient basis
.
# Cards Pump: A repeat echo suggested slightly worsened EF from
previous but otherwise no change. We seemed well volume
regulated with HD.
.
# Hyperlipidemia: continue statin
.
# Code: FULL
Medications on Admission:
ALLERGIES: Cefepime
.
CURRENT MEDICATIONS:
1. Aspirin 81 mg PO DAILY
2. Sevelamer 800 mg PO TID
3. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
4. Isosorbide Mononitrate 30 mg 24 hr PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO TID
8. Pregabalin 25 mg PO Daily
9. Pantoprazole 40 mg Q12H
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO once a day.
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Hyperkalemia
Bradycardia
Chest pain, nonischemic
Secondary Diagnoses:
Coronary Artery Disease
Diabetes
ESRD on HD
Discharge Condition:
Good. Patient with normal hemodynamics, no pain, ambulating.
Discharge Instructions:
You came in with high potassium and slow heart rate. We treated
you with dialysis and adjusted your medications slightly.
.
Weigh yourself every morning, call your doctor if your weight
gain is greater than 3 pounds.
.
Adhere to 2 gm sodium diet
.
Please take all medications as directed. Medication changes
include:
-Discontinue taking your lisinopril
-Addition of new medication: amlodipine 5mg daily (prescription
provided)
-Continue your Toprol XL at 50 daily
Please follow up with your appointments as directed
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 6301**] and set up a follow up appointment in the next [**12-28**]
weeks.
Please follow up with the previously scheduled appointments:
1.) Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2129-6-1**] 9:30
2.) Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-6-6**]
8:45
3.) Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2129-6-14**] 1:00
|
[
"427.89",
"403.91",
"250.40",
"428.0",
"272.0",
"276.7",
"414.01",
"787.91",
"585.6",
"V45.81",
"786.59",
"428.30",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8567, 8573
|
5692, 5830
|
281, 288
|
8751, 8815
|
3463, 5265
|
9381, 10109
|
2563, 2628
|
7759, 8544
|
8594, 8663
|
7391, 7413
|
8839, 9358
|
2643, 3444
|
8684, 8730
|
231, 243
|
5858, 7365
|
7434, 7736
|
317, 711
|
5279, 5669
|
733, 2304
|
2320, 2547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,678
| 146,493
|
9190
|
Discharge summary
|
report
|
Admission Date: [**2143-11-15**] Discharge Date: [**2143-11-22**]
Date of Birth: [**2072-3-4**] Sex: F
Service: SURGERY
Allergies:
Benadryl / Vancomycin Hcl
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Infected left femoral popliteal bypass graft.
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Removal of infected aortofemoral limb and the left fem-
[**Doctor Last Name **] bypass grafts.
2. Left common femoral artery endarterectomy and patch
angioplasty with arm vein.
3. Left the popliteal patch angioplasty with arm vein.
4. Left common iliac artery and external iliac artery
recanalization with balloon angioplasty and stenting.
Completion arteriograms.
History of Present Illness:
71F with PVD and multiple revascularization procedures due to
infected bypass grafts who presented with recurrent infected L.
fem-BK-[**Doctor Last Name **] bypass graft with bacteremia due to pseudomonas,
proteus and MRSA.
Past Medical History:
CAD s/p PTCA/drug eluting stent of RCA ([**2-18**]), CHF, EF 60%
([**2143-10-19**]), HTN, ^chol, GIB [**1-17**] ASA, DM2, MRSA, VRE, carotid
stenoses (R 40-59%, L 60-69%)
PSH: Ao-bifem ([**2128**]), B fem-[**Doctor Last Name **] ([**2127**]), fem-fem w/ R SFA endart
([**2127**]), removal fem-fem ([**2128**]), re-do left CFA-bk [**Doctor Last Name **] w/PTFE and
thrombectomy of L CFA ([**11-16**]), L temporal artery Bx ([**3-19**]), R
jumpgraft f/ R fem-ak [**Doctor Last Name **] w/ PTFE to BK [**Doctor Last Name **], [**Doctor Last Name **] a. endart [**2-17**],
exc. R fem [**Doctor Last Name **]-and jump graft ([**12-21**]), right BKA ([**1-21**]), L
fem-[**Doctor Last Name **] graft replacement [**1-17**] MRSA infection [**7-21**]
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem / BKA
lle - palp fem, [**Doctor Last Name **], pt, dp
Surgical inc c/d/i
Pertinent Results:
[**2143-11-22**] 03:49AM BLOOD
WBC-11.5* RBC-2.96* Hgb-9.4* Hct-26.5* MCV-90 MCH-31.7
MCHC-35.5* RDW-15.2 Plt Ct-330
[**2143-11-21**] 05:01AM BLOOD
PT-13.8* PTT-28.4 INR(PT)-1.2*
[**2143-11-22**] 03:49AM BLOOD
Glucose-94 UreaN-18 Creat-1.0 Na-139 K-3.9 Cl-100 HCO3-32
AnGap-11
[**2143-11-20**] 01:24PM BLOOD
ALT-6 AST-10 LD(LDH)-181 AlkPhos-113 TotBili-0.5
[**2143-11-22**] 03:49AM BLOOD
Calcium-8.0* Phos-3.2 Mg-2.2
RADIOLOGY Final Report
[**2143-11-19**] 10:02 AM
CT ABD W&W/O C; CT PELVIS W&W/O C
TECHNIQUE: MDCT acquired axial images were obtained through the
abdomen and pelvis with and without intravenous contrast.
Coronal and sagittal reformations were displayed with 5-mm
slice-thickness and used for better anatomical localization.
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: A small
hyperdense fluid collection is identified starting just inferior
to the left renal lower pole in the retroperitoneum and
extending down to the pelvic brim just superior to where the
iliacus muscle begins. This likely represents a small hematoma,
likely related to recent left retroperitoneal surgical
dissection. The liver displays no focal masses. The patient is
status post cholecystectomy. There is a grossly unchanged
appearance to a slightly prominent common bile duct and very
minimal intrahepatic biliary dilatation. No ductal stones are
identified and the pancreatic duct is also mildly prominent. The
spleen, stomach, intraabdominal bowel, and kidneys appear
grossly normal. Again identified is prominence of the adrenal
glands bilaterally, the left adrenal gland lesion appears to be
a benign adenoma and the right adrenal lesion is indeterminate,
but likely benign. The patient is status post removal of
previous left aortofemoral bypass graft and left femoral
popliteal bypass graft. Since prior examination, there has been
interval placement of a left common iliac and external iliac
artery stent. The right aortofemoral bypass graft appears patent
and again displays areas of focal thickening as noted on prior
CT examination. There is no free air or pathologically enlarged
abdominal lymphadenopathy identified. There are diffuse coronary
and aortic calcifications.
CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: There is marked
stranding of the subcutaneous tissues, likely from prior surgery
as well as multiple hyperattenuating soft tissue lesions, likely
related to subcutaneous injections. Superior to the left
external iliac artery prior to its formation of the left common
femoral artery, there is an ill-defined 2.3 x 2.5 cm pocket of
fluid collection with multiple pockets of air bubbles. This was
not noted on prior examination and may represent a normal
post-surgical fluid collection, surgi-seal, or an early abscess.
Other small pockets of fluid collection are noted more distally
within the left thigh. Multiple surgical drains are identified.
The distal arteries are difficult to evaluate in terms of
patency due to the limits of this study, however, the left
common femoral and profunda branches appear patent and the left
SFA appears diffusely diseased with no gross contrast noted
within the vessel. A Foley is present in the bladder along with
a small pocket of air. The uterus, adnexa, rectum, and sigmoid
colon appear otherwise unremarkable. Note is made of a slightly
enlarged left inguinal lymph node measuring approximately 1.8 x
1.4 cm, likely reactive. No pathologically enlarged pelvic lymph
nodes are identified. There is trace free fluid noted within the
pelvic cavity.
BONE WINDOWS: No suspicious blastic or lytic lesions are
identified. Again identified are changes likely related to a
prior right inferior pubic ramus fracture. There are
degenerative changes of the spine.
IMPRESSION:
1. Small left-sided retroperitoneal hyperdense fluid
collection/hematoma. Likely related to recent surgical
dissection within this area.
2. Bilateral pleural effusions and compression atelectasis.
3. Unchanged prominence to common bile duct after
cholecystectomy.
4. Small focal fluid collection anterior to the left external
iliac artery with air bubbles. [**Month (only) 116**] represent area of recent
surgicel use an infected collection cannot be excluded.
5. Left adrenal adenoma with indeterminant right adrenal lesion.
6. Status post removal of left aortofemoral bypass graft and
left femoral popliteal bypass graft with interval placement of
left common and external iliac stents, unable to definitively
assess patency of distal vessels on this non- angiographic CT.
Brief Hospital Course:
Mrs. [**Known lastname **] presented to us complaining of fevers from
recurrent infected L. fem-BK-[**Doctor Last Name **] bypass graft with bacteremia
due to pseudomonas, proteus and MRSA.
She was evaluated by the Vascular surgery department and found
to have infected L aorto femoral limb and left fem-bk [**Doctor Last Name **] bypass
grafts.
Pan cx'd / ID consulted / IV antibiotics
Followed by [**Hospital **] Clinic
She was admitted and consented for surgery. On [**2143-11-15**], she was
prepped and brought down to the operating room for surgery.
PROCEDURE:
1. Removal of infected aortofemoral limb and the left fem-
[**Doctor Last Name **] bypass grafts.
2. Left common femoral artery endarterectomy and patch
angioplasty with arm vein.
3. Left the popliteal patch angioplasty with arm vein.
4. Left common iliac artery and external iliac artery
recanalization with balloon angioplasty and stenting.
Completion arteriograms.
Intra-operatively, she was closely monitored and remained
hemodynamically stable. She tolerated the procedure well without
any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She was then transferred to the floor for further recovery.
On the floor, she remained hemodynamically stable with her pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents.
She was discharged home with services in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]: norvasc 10', isordil 10'', lisinopril 20', metroprolol
25'', lasix 80', NPH insulin (25qAM, 13qPM, SSI), plavix,
heparin, protonix 40mg', liptor 80mg',neurontin 300'', Celexa
40'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Medications
norvasc 10', isordil 10'', lisinopril 20', metroprolol 25'',
lasix 80', NPH insulin (25qAM, 13qPM, SSI), plavix, heparin,
protonix 40mg', liptor 80mg',neurontin 300'', Celexa 40'
3. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Isordil Titradose 10 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
7. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Celexa 20 mg Tablet Sig: Two (2) Tablet PO once a day.
9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 weeks.
Disp:*60 Tablet(s)* Refills:*0*
13. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4
weeks.
Disp:*56 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
CBC weekly / please fax results to @ [**Telephone/Fax (1) 31582**]
15. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
16. Insulin
Take as directed [**First Name8 (NamePattern2) **] [**Hospital **] clinic
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Infected left femoral popliteal bypass graft.
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING LEG BYPASS SURGERY
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 no specific restrictions on activity. You should be as
active as is comfortable. Some fatigue is expected for the first
several weeks. Leg swelling is typical following this type of
surgery and can be controlled by elevating your leg above the
level of your heart when you are not walking. Resume driving
when you are comfortable without the need for pain medication.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
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 4 weeks.
No heavy lifting greater than 20 pounds for the next 7 days.
BATHING/SHOWERING:
You shower immediately upon coming home. No bathing. A clear
dressing may cover your leg incision 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. Dissolving sutures,
which do not have to be removed, were probably used.
If you have staples these will be removed on your follow-up
appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for removal.
When the sutures / staples 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
two 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 bending for 4-6 weeks.
No strenuous activity for 4-6 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:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-12-17**]
10:30
Please call Dr [**Last Name (STitle) 23782**] office and schedule an appoinment
after the new year. He can be reached at [**Telephone/Fax (1) 2625**].
Completed by:[**2143-11-22**]
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21,202
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30385
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Discharge summary
|
report
|
Admission Date: [**2146-2-14**] Discharge Date: [**2146-2-24**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Cipro
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Hypoxic Respiratory Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year h/o AML, s/p BMT w/ chronic GVHD of the liver, skin, and
eye, reporting 3 days of productive cough, malaise, nausea,
non-bilious, non-bloody vomiting x1 and weakness who was seen in
[**Hospital 3242**] clinic today with fever to 101, hypotension 90's/50's, tachy
120's, hypoxia 91% on RA, 93-94% on 2 L via NC. An EKG was
obtained with showed V4-V6 Twave inversions prompting further
evaluation in the ED. Prior to leaving the clinic he received 1
Liter NS, 60 mg Solumedrol (stress dose as pt on chronic
steroids), vancomycin 1gm IV with blood cultures sent from
clinic.
.
In the ED, initial vs were: T 101.9 HR 117 BP 107/73 RR 24 POX
89% on RA. Improved to 95% on a NRB, then on ventimask 50%.
Repeat blood cultures and urine culture were sent. Patient was
given dilaudid, aztreonam 2gm IV, benadryl and prochloperazine
for headache/belly ache. IV access 2 18g PIVs. CTA negative for
PE, but did show scatteredtree in [**Male First Name (un) 239**] opacities. EKG was not far
from baseline and plan established to trend CEs per BMT team, no
aspirin given [**1-18**] low platelets. VS 90 126/78 16 97% on 50%
ventimask prior to transfer.
.
On the floor, patient denied shortness of breath but did report
vague diffuse chest discomfort, headache, and nausea. Wife
reported recent course of azithromycin.
.
Review of sytems:
(+) Per HPI, has baseline rhinorrhea that is unchanged,
(-) Denies chills, night sweats, recent weight loss or gain.
Denies sinus tenderness or congestion. Denied palpitations.
Denied diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
- Type 2 DM, steroid induced
- Hyperlipidemia
- H/o AVN bilateral hips
- HTN
- H/o nephrolithiasis, lithotripsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
- h/o left interpolar renal lesion, followed with MRs
- h/o BCC s/p excision
- h/o SCC left cheek, s/p Mohs' [**5-/2144**]
- h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware)
- h/o anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**]
- Chronic numbness, neuropathic pain in left upper extremity.
- Multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4.
- h/o pulmonary embolism [**11-23**] on anticoagulated from
[**Date range (1) 72256**]
- h/o RSV [**11/2144**] requiring ICU admission
- h/o OSA, on BIPAP followed by [**Location (un) 4507**]
Social History:
Lives with his wife, and one of children, worked as a [**Company 22957**]
technician now retired.
Tob: previously smoked 1ppd for many years but quit 3 years ago
EtOH: h/o social use; none recently
Family History:
Mother died suddenly in her 70s. Father died of unknown cancer
with tumors visible across body. One sister has thyroid cancer.
One brother has diabetes and kidney stones. One sister has
[**Name (NI) 5895**].
Physical Exam:
General: Sleepy but easily arousable, oriented x3, no acute
distress, speaking in full sentences w/out accessory muscle use
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Scatter crackles, rhonchi at left base, no wheezes, good
air movement, no stridor
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, distended, soft, non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU:no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, strength intact throughout
Pertinent Results:
[**2146-2-14**] 10:00AM WBC-6.5 RBC-4.46*# HGB-16.3# HCT-48.7
MCV-109* MCH-36.5* MCHC-33.4 RDW-13.6
[**2146-2-14**] 10:00AM NEUTS-86* BANDS-3 LYMPHS-5* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2146-2-14**] 10:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2146-2-14**] 10:00AM UREA N-17 CREAT-1.5* SODIUM-133 POTASSIUM-3.8
CHLORIDE-93* TOTAL CO2-25 ANION GAP-19
[**2146-2-14**] 10:00AM CALCIUM-9.0 PHOSPHATE-1.6* MAGNESIUM-1.8
[**2146-2-14**] 10:00AM ALT(SGPT)-52* AST(SGOT)-46* LD(LDH)-227
CK(CPK)-43* ALK PHOS-125 TOT BILI-0.3
[**2146-2-14**] 10:00AM cTropnT-0.02* proBNP-364*
[**2146-2-14**] 01:48PM LACTATE-1.7
[**2146-2-14**] 03:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2146-2-14**] 03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2146-2-14**] 03:10PM URINE RBC-[**2-18**]* WBC-[**5-26**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2146-2-14**] 03:10PM URINE GRANULAR-0-2 HYALINE-[**11-5**]*
[**2146-2-14**] 05:10PM CK(CPK)-51
[**2146-2-14**] 05:10PM CK-MB-NotDone cTropnT-<0.01
[**2146-2-14**] 08:26PM PT-11.7 PTT-31.7 INR(PT)-1.0
Brief Hospital Course:
55 year h/o AML, s/p BMT w/ chronic GVHD to skin and liver, on
steroids, presenting with hypoxic respiratory failure secondary
to parainfluenza infection.
# Hypoxic Respiratory Failure - Pt admitted to the ICU with
fever, SOB, productive cough, and O2 sat of 86% on RA, improving
to 94% on non-rebreather. CTA negative for PE, hypoxia out of
proportion to imaging findings of scattered tree-in-[**Male First Name (un) 239**]
opacities. Rapid viral screen returned positive for
parainfluenza. Sputum gram stain demonstrated GPCs and GNRs.
Sputum culture (prelim) demonstrated commensal flora, yeast,
negative PCP. [**Name10 (NameIs) 72257**] only mildly elevated. No evidence of
meningismus. Started on vancomycin/aztreonam empirically for
pneumonia as allergic to cipro and cefepime. Doxycycline also
added for mycoplasma coverage but this was D/Ced after
parainfluenza diagnosis. Patient was gradually weaned from a non
rebreather to NC supp O2. He was able to ambulate and maintain
O2 sat >90% on RA though still required 2-3L NC O2 to maintain
sat >90% while seated in bed. Baseline O2 sat is around 94% RA.
He was transferred to the floor for furhter management. Oxygen
was continued on a prn basis. Scheduled nebulizers were
continued. Mr. [**Known lastname 47367**] developed a rash and vancomycin and
aztreonam were discontinued. Oxygen requirement was
intermittant. Due to continued malaise and oxygen requirement,
Ig levels were drawn and Mr. [**Known lastname 47367**] was determined to be IgG
deficient. He recieved IVIG and prednisone was increased to 15
mg daily. His oxygen status improved within 48 hours of these
changes. On day of discharge, ambulatory oxygen saturation was
90% and oxygen saturation at rest was 94-96%. He was discharged
home to follow-up with Dr. [**Last Name (STitle) **] on Monday, [**2-28**].
# Abnormal EKG/Lateral ST-depressions and T-wave inversions -
Has had similar EKG changes in setting of physiologic stress.
ECHO [**8-25**] showed EF >55%, borderline pulm HTN, could not rule
out WMA due to poor quality of study. Patient was ruled out for
MI with negative cardiac enzymes, no further symptoms or EKG
changes.
.
# Hypotension - Responded to IVF and has since remained
normotensive. Received stress dose steroids in clinic and on ICU
Day 1, given diagnosis of steroid-induced adrenal insufficieny
on last hospital admission, but decreased to his home dose the
following morning.
# Acute Renal Failure - Baseline 0.9-1, 1.5 on presentation.
Likely prerenal in etiology given poor po, nausea/vomiting, and
hypotension. Rapidly resolved with IV hydration.
# Steroid-induced DMII: Covered with 12 units NPH in AM (per
home regimen) and SS. Daytime fingerstick BS were 200-300, down
to 100s at bedtime and in AM. Erratic BS expected, given
administration of stress-dose steroids and resumption of full
diet following reduced PO intake prior to admission. Blood
sugars were well controlled prior to discharge.
# AML s/p BMT w/ GVHD. Patient continued on home doses of
prednisone 10mg daily and acyclovir/bactrim prophylaxis, also
folic acid and vitamin D. Prednisone increased to 15mg prior to
discharge and should be re-evaluated at follow-up appointment
with Dr. [**Last Name (STitle) **].
# Thrombocytopenia - Baseline 160-220, down to 140s on
admission, likely [**1-18**] hemoconcentration. Platelets were trended
and noted to be stable.
Medications on Admission:
Acyclovir 400 mg PO Q8H
Folic Acid 1 mg PO DAILY
Prednisone 10 mg PO DAILY
Pantoprazole 40 mg Tablet PO Q12H
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
Oxycodone SR (60 mg)QAM , (20 mg) Q2PM, and 60mg QPM
Ranitidine HCl 150 mg PO HS
Budesonide 3 mg SR PO three times a day.
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Humulin N Twelve (12) units Subcutaneous twice a day.
Insulin Lispro QACHS Per sliding scale.
Discharge Medications:
1. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO BID (2 times a day).
8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q2PM ().
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
10. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: [**5-28**]
units Subcutaneous twice a day: Take as previously prescribed.
13. Humalog 100 unit/mL Solution Sig: 1-12 units Subcutaneous
before meals and at bedtime: Take as previously prescribed.
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Parainfluenza infection
- Acute Renal Failure
- Hypotension, responsive to fluids
Secondary:
- Diabetes, type II
- Chronic GVHD
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted for shortness of breath. You initially went
to the ICU for monitoring because you required oxygen and you
had low blood pressure. Your low blood pressure improved with
fluids. You were transferred to the BMT unit once you were
stable. You tested positive for parainfluenza, which causes
symptoms similar to a common cold. You were treated with
antibiotics to help avoid getting another infection. You were
given antibodies and your prednisone was increased to help you
breathe easier. You are being discharged home to follow up with
Dr. [**Last Name (STitle) **].
Changes in Medication:
Increase Prednisone to 15 mg by mouth daily
Please take all other medications as previously prescribed
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] after discharge. An
appointment has been made for you and is listed below. Please
call and reschedule if you are unable to make this appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2146-2-28**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2146-2-28**] 3:00
|
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"E930.8",
"249.00",
"V12.51",
"V58.65",
"327.23",
"272.4",
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"794.31",
"996.85",
"205.00",
"518.81",
"401.9",
"487.0",
"255.41",
"E932.0",
"584.9",
"693.0",
"E878.0",
"279.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
10585, 10591
|
5336, 8740
|
305, 312
|
10775, 10775
|
4091, 5313
|
11664, 12187
|
3248, 3458
|
9212, 10562
|
10612, 10754
|
8766, 9189
|
10923, 11641
|
3473, 4072
|
238, 267
|
1673, 1990
|
340, 1655
|
10790, 10899
|
2012, 3015
|
3031, 3232
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,802
| 146,395
|
38691
|
Discharge summary
|
report
|
Admission Date: [**2102-11-13**] Discharge Date: [**2102-11-24**]
Date of Birth: [**2026-7-18**] Sex: F
Service: SURGERY
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Descending thoracic aneurysm, 5.8cm
Major Surgical or Invasive Procedure:
[**2102-11-13**]: Thoracic aortic endograft repair of descending
thoracic
aortic aneurysm using a 40-mm x 15-cm [**Doctor Last Name 4726**] Tag
endograft. [**Doctor Last Name **] TAG Catalog #[**Serial Number 85942**].
Batch code #[**Numeric Identifier 85943**].
2. Thoracic, abdominal and pelvic angiography.
3. Endovascular repair of ruptured right common and
external iliac artery with two Viabahn endografts, as
well as two Excluder AAA limbs.
The graft data is the following:
[**Doctor Last Name 4726**] Excluder limb: Catalog #[**Serial Number 85944**]. Lot #[**Serial Number 85945**].
[**Doctor Last Name 4726**] Viabahn: Catalog # [**Serial Number 85946**]. Lot #[**Serial Number 85947**].
[**Doctor Last Name 4726**] Excluder limb: Catalog #[**Serial Number 85948**]. Lot #[**Serial Number 85949**].
[**Doctor Last Name 4726**] Viabahn: Catalog #[**Serial Number 85946**]. Lot #[**Serial Number 85950**].
8. Open Left femoral artery to femoral artery bypass
using a 10-mm Dacron interposition tube graft.
Abdominal Closure
Flex sigmoidoscopy
History of Present Illness:
Ms. [**Known lastname 18231**] is a 76-year-old female who was discovered in fall
of [**2100**] to have a descending thoracic aneurysm. This was
incidentally seen on a CAT scan performed to evaluate vague
abdominal complaints, which has since resolved.
She has no symptoms referable to her aneurysm. Specifically,
she denies any back, chest, or abdominal discomfort. She
reports that her sister had a history of abdominal aortic
aneurysm. Otherwise, there is no known family history. She is a
former smoker, having quit three years ago. She has since
undergone surveillance CT scans, and most recently was found to
have an interval increase to 5.8cm. She presents today for
elective repair.
Past Medical History:
PMH: thoracic aortic aneurysm 5.8cm in [**10/2102**], infrarenal
abdominal aortic aneurysm (3.2 x 3.0 cm)with focal ulceration,
hyperlipidemia, hypothyroidism, history heart murmur,
uncharacterized, ? bicuspid aortic valve, severe AS on ECHO
[**10/2102**]
PSH: total abdominal hysterectomy with appendectomy,
laparoscopic cholecystectomy, tonsillectomy
Social History:
Retired, lives with husband. Used to smoke, quit 3 years ago
after <[**1-15**] pack per day for 60 years. Denied alcohol or illicit
drug use.
Family History:
Denies premature coronary artery disease, history of aneurysm
Physical Exam:
Upon discharge:
Tmax 98.8, HR 66, BP 122/60, HR 18, O2 sat 97%RA
General: Elderly female in NAD
Neuro: A&Ox4, CNII-XII grossly intact
Cardiac: RRR
Lungs: CTA bilat, no resp distress
Abd, nl bs, soft, nt, nd
Wound: scant amount of serous drainage from abd wound with
slight staple erythema. Does not appear infected
Extremities: B LE edema
Pulse exam: LLE fem palp/DP palp/PT dopp
RLE fem palp/DP palp/PT dopp
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT TEE [**2102-11-13**]
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 85951**] (Complete)
Done [**2102-11-13**] at 2:59:41 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2026-7-18**]
Age (years): 76 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for endovascular repair of
descending thoracic aortic aneurysm
ICD-9 Codes: 441.2, 424.1, 424.0
Test Information
Date/Time: [**2102-11-13**] at 14:59 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine: U/S 6
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: *4.4 cm <= 3.4 cm
Aorta - Descending Thoracic: *5.1 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *64 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 36 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness, cavity size,
and global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Simple atheroma in ascending aorta. Focal calcifications in
ascending aorta. Simple atheroma in aortic arch. Markedly
dilated descending aorta Complex (mobile) atheroma in the
descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Severe AS (area 0.8-1.0cm2). Moderate
(2+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No MS.
Mild to moderate ([**1-15**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Very small pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. A TEE was performed in the location listed above. I
certify I was present in compliance with HCFA regulations. The
patient was under general anesthesia throughout the procedure.
No TEE related complications. The patient appears to be in sinus
the patient.
Conclusions
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is a saccular, aneurysmal area in the proximal ascending aorta
that measures 4.4 cm at its greatest size. The sections of
ascending aorta both proximal and distal to this segment appear
normal. There are simple atheroma in the aortic arch. The
descending thoracic aorta is very ectatic and has an area of
marked dilation. Spontaneous echo contrast and intramural
hematoma is seen in this segment. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve is
bicuspid. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**1-15**]+) mitral regurgitation is seen. There is a very
small pericardial effusion.
After deployment of the endovascular graft, it was very
difficult to image the descending thoracic aorta. Small flow at
the edges of the graft could be seen but their significance can
not be determined. The ascending aorta and arch appeared
unchanged. No other changes were seen from the pre-stent period.
Drs. [**Last Name (STitle) 914**] and [**Name5 (PTitle) **] were notified in person of the results in
the operating room at the time of the study.
[**2102-11-13**] 12:00PM BLOOD WBC-7.2 RBC-3.57* Hgb-11.3* Hct-33.3*
MCV-93 MCH-31.6 MCHC-33.8 RDW-14.1 Plt Ct-120*
[**2102-11-14**] 03:00AM BLOOD WBC-14.4*# RBC-4.91 Hgb-15.2 Hct-42.9
MCV-87 MCH-31.0 MCHC-35.6* RDW-14.6 Plt Ct-124*
[**2102-11-15**] 04:28AM BLOOD WBC-13.5* RBC-3.18*# Hgb-9.8*# Hct-28.1*#
MCV-88 MCH-30.9 MCHC-35.0 RDW-14.9 Plt Ct-66*
[**2102-11-15**] 11:41AM BLOOD Hct-33.6*#
[**2102-11-16**] 02:34AM BLOOD WBC-13.1* RBC-3.87* Hgb-12.1 Hct-34.4*
MCV-89 MCH-31.2 MCHC-35.1* RDW-15.7* Plt Ct-68*
[**2102-11-17**] 02:51AM BLOOD WBC-14.2* RBC-3.90* Hgb-11.8* Hct-34.9*
MCV-90 MCH-30.2 MCHC-33.7 RDW-15.5 Plt Ct-94*
[**2102-11-18**] 01:55AM BLOOD WBC-13.6* RBC-3.49* Hgb-10.6* Hct-31.6*
MCV-91 MCH-30.5 MCHC-33.7 RDW-15.0 Plt Ct-120*
[**2102-11-19**] 06:19AM BLOOD WBC-12.3* RBC-3.60* Hgb-10.9* Hct-32.8*
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.0 Plt Ct-195#
[**2102-11-20**] 02:45AM BLOOD WBC-12.8* RBC-3.48* Hgb-10.5* Hct-31.8*
MCV-92 MCH-30.2 MCHC-33.0 RDW-14.8 Plt Ct-243
[**2102-11-21**] 06:55AM BLOOD WBC-17.4* RBC-3.53* Hgb-10.5* Hct-32.6*
MCV-92 MCH-29.9 MCHC-32.4 RDW-14.8 Plt Ct-317
[**2102-11-22**] 07:20AM BLOOD WBC-18.1* RBC-3.47* Hgb-10.4* Hct-31.8*
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.9 Plt Ct-364
[**2102-11-23**] 05:20AM BLOOD WBC-19.5* RBC-3.61* Hgb-10.6* Hct-32.7*
MCV-91 MCH-29.4 MCHC-32.5 RDW-14.9 Plt Ct-414
[**2102-11-24**] 07:30AM BLOOD WBC-14.6* RBC-3.57* Hgb-10.5* Hct-32.3*
MCV-91 MCH-29.5 MCHC-32.6 RDW-14.8 Plt Ct-448*
[**2102-11-13**] 05:33PM BLOOD Glucose-138* UreaN-13 Creat-1.0 Na-143
K-3.7 Cl-112* HCO3-20* AnGap-15
[**2102-11-14**] 03:00AM BLOOD Glucose-136* UreaN-16 Creat-1.3* Na-138
K-3.7 Cl-110* HCO3-23 AnGap-9
[**2102-11-15**] 04:28AM BLOOD Glucose-80 UreaN-19 Creat-1.2* Na-138
K-3.7 Cl-106 HCO3-27 AnGap-9
[**2102-11-16**] 02:34AM BLOOD Glucose-104* UreaN-19 Creat-1.1 Na-140
K-3.7 Cl-106 HCO3-28 AnGap-10
[**2102-11-17**] 02:51AM BLOOD Glucose-89 UreaN-26* Creat-1.2* Na-140
K-3.8 Cl-104 HCO3-29 AnGap-11
[**2102-11-18**] 01:55AM BLOOD Glucose-73 UreaN-28* Creat-1.0 Na-141
K-3.4 Cl-103 HCO3-30 AnGap-11
[**2102-11-19**] 06:19AM BLOOD Glucose-91 UreaN-23* Creat-0.9 Na-140
K-3.3 Cl-100 HCO3-33* AnGap-10
[**2102-11-20**] 02:45AM BLOOD Glucose-99 UreaN-22* Creat-0.8 Na-139
K-3.5 Cl-100 HCO3-30 AnGap-13
[**2102-11-21**] 06:55AM BLOOD Glucose-113* UreaN-22* Creat-1.0 Na-137
K-3.5 Cl-97 HCO3-33* AnGap-11
[**2102-11-22**] 07:20AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-137
K-3.7 Cl-97 HCO3-32 AnGap-12
[**2102-11-23**] 05:20AM BLOOD Glucose-89 UreaN-19 Creat-1.1 Na-137
K-4.2 Cl-98 HCO3-32 AnGap-11
[**2102-11-24**] 07:30AM BLOOD Glucose-91 UreaN-18 Creat-1.1 Na-136
K-4.0 Cl-99 HCO3-32 AnGap-9
[**2102-11-21**] 06:55AM BLOOD ALT-14 AST-30 AlkPhos-126* TotBili-1.3
[**2102-11-13**] 05:33PM BLOOD CK-MB-3 cTropnT-<0.01
[**2102-11-14**] 12:01AM BLOOD CK-MB-3 cTropnT-<0.01
[**2102-11-14**] 11:37AM BLOOD CK-MB-3 cTropnT-<0.01
[**2102-11-14**] 07:19PM BLOOD CK-MB-5 cTropnT-<0.01
[**2102-11-15**] 04:28AM BLOOD CK-MB-5 cTropnT-<0.01
[**2102-11-24**] 07:30AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.4
[**2102-11-14**] 8:26 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2102-11-22**]**
GRAM STAIN (Final [**2102-11-15**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2102-11-22**]):
SPARSE GROWTH Commensal Respiratory Flora.
CITROBACTER FREUNDII COMPLEX. RARE [**Last Name (STitle) 85952**], [**Doctor First Name **] ([**Numeric Identifier 85953**]) REQUESTED FOR WORK UP ON
[**2102-11-20**].
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days therefore be warranted if third generation
cephalosporins were used therefore be warranted if
third
generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2102-11-14**] 9:09 pm URINE Source: Catheter.
**FINAL REPORT [**2102-11-16**]**
URINE CULTURE (Final [**2102-11-16**]): NO GROWTH.
[**2102-11-22**] 5:03 pm URINE Site: NOT SPECIFIED OLD S#
1678N.
URINE CULTURE (Preliminary):
WORKUP REQUESTED [**Numeric Identifier 85954**].
YEAST. <10,000 organisms/ml.
Radiology Report CHEST (PA & LAT) Study Date of [**2102-11-22**] 3:26 PM
VSURG VICU [**2102-11-22**] 3:26 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 85955**]
Reason: 76 F sp TEVAR, persistent leukocytosis with recent
sputum +
[**Hospital 93**] MEDICAL CONDITION:
76 F sp TEVAR, persistent leukocytosis with recent sputum +
citrobacter
REASON FOR THIS EXAMINATION:
76 F sp TEVAR, persistent leukocytosis with recent sputum +
citrobacter, r/o
pneumonia
Final Report
HISTORY: Postoperative leukocytosis, to assess for pneumonia.
FINDINGS: In comparison with study of [**11-15**], all of the
monitoring and support
devices have been removed in this patient with an extensive
aortic graft. The
basilar regions have substantially cleared with some residual
pleural effusion
and compressive atelectasis bilaterally. No vascular congestion
or acute
focal pneumonia.
Brief Hospital Course:
Mrs. [**Known lastname 18231**] was admitted on [**2102-11-13**] for elective descending
thoracic aortic endovascular stent graft. She was consented and
brought to the operating room where she underwent thoracic
aortic endograft repair of descending thoracic aortic aneurysm
complicated by right CIA-EIA avulsion and underwent subsequent
endovascular repair of ruptured right common and external iliac
artery with two Viabahn endografts, and open left femoral artery
to femoral artery bypass using a 10-mm Dacron interposition tube
graft. Please see operative report for formal details. She was
transfused 14 units of PRBCs and other blood products in the
operating room for significant intraoperative blood loss.
Postoperatively she was transferred to the CVICU in stable
condition, sedated on the ventilator with a lumbar drain and
open abdomen. On POD 1, the patient was brought back to the
operating room for abdominal washout and closure. She was
intermittently awoken and found to be neurologically intact. On
POD3, she was diuresed, successfully extubated, and lumbar drain
was removed. Pain was well controlled. HIT was sent for
thrombocytopenia, which was negative, and subcutaneous heparin
was resumed for DVT prophylaxis. On POD 4, she was started on
sips of clears and transferred to the stepdown unit. Her diet
was slowly advanced and well tolerated. She was diuresed with
furosemide toward her preoperative weight. She was started on a
7 day course of oral levofloxacin for pan -sensitive citrobacter
in her sputum. Her WBC count continued to increase over the
course of her stay. CXR was negative for pneumonia. Urine
culture grew out 10,000 yeast. Foley was discontinued and wbc
trended down to 14 on the day of discharge. She was evaluated by
physical therapy, who recommended rehab to increase her strength
and mobility. On the day of discharge she was afebrile,
neurologically intact, tolerating a regular diet, voiding
adequate amounts with pain well controlled. On [**2102-11-24**] she was
discharged to rehab in stable condition.
Medications on Admission:
levothyroxine 100mcg po daily
pravastatin 20mg po daily
multivitamin 1 tab po daily
tylenol prn pain
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): Continue until ambulating
TID every day for DVT prophylaxis, then may stop.
6. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 10 days: hold for sedation, RR<12.
Disp:*30 Tablet(s)* Refills:*0*
11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days: Last dose 11/16.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
Descending Thoracic Aortic Aneurysm
Ruptured right common and external iliac artery
Aortic Stenosis
Hypertension
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Endovascular Descending Thoracic Aortic Aneurysm Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-16**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling
?????? gradually increase your activities and distance walked as you
can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-19**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2102-12-5**] 3:00 for staple removal
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15553**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2103-1-17**] 1:40
Completed by:[**2102-11-24**]
|
[
"530.81",
"V14.5",
"424.1",
"285.1",
"998.2",
"278.00",
"518.51",
"287.5",
"998.11",
"276.52",
"V14.2",
"E878.1",
"272.4",
"244.9",
"401.9",
"041.85",
"441.7",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.25",
"96.71",
"39.29",
"38.86",
"45.24",
"39.73"
] |
icd9pcs
|
[
[
[]
]
] |
17205, 17298
|
13873, 15926
|
339, 1447
|
17479, 17479
|
3244, 12840
|
20071, 20415
|
2723, 2787
|
16077, 17182
|
13245, 13317
|
17319, 17458
|
15952, 16054
|
17662, 19491
|
19517, 20048
|
2802, 2802
|
264, 301
|
13349, 13850
|
12875, 13205
|
2818, 3225
|
1475, 2171
|
17494, 17638
|
2193, 2548
|
2564, 2707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,444
| 129,984
|
47897
|
Discharge summary
|
report
|
Admission Date: [**2194-6-4**] Discharge Date: [**2194-6-13**]
Date of Birth: [**2113-3-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 21990**]
Chief Complaint:
Hypotension, R arm swelling, R supraclavicular mass
Major Surgical or Invasive Procedure:
FNA of right supraclavicular mass
History of Present Illness:
81 y/o F w/HTN, R-sided stroke (?hemorrhage) who was sent here
from [**Last Name (un) 1188**] house for w/u of large R sided neck mass and R
sided edema. Essentially noted by her sons on [**Name (NI) 1017**] night that
she had significant RUE edema compared to the left (left is her
hemiparetic side). Today, her NP[**MD Number(3) 100559**] a large R sided neck mass
that had not been noted in the past, and she had a low-grade
temp to 100 and was tachycardic in the 110s. She was sent here
for further w/u.
.
In the ED, she was initially normotensive but then dropped her
bp with a map in the 50s. Lactate was 4. She had a subclavian
line placed (currently undocumented) and was given 4L NS without
improvement in her bp or lactate, so was started on levophed.
Had chest CT showing large amorphous neck and supraclavicular
mass, differential hematoma vs malignancy. Admitted to ICU.
.
Upon further discussion with her sons, the pt had been doing
well until the past month, when she stopped eating and required
increasing tube feeds. She also has been talking less, and only
answers things with yes/no.
Past Medical History:
HTN
Stroke [**October 2193**] at [**Hospital1 2025**]
Spinal compression fx
Dementia
s/p G tube placement (after stroke)
Social History:
Lives in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] since 2 months ago. Has 2 sons.
Family History:
Unknown.
Physical Exam:
Gen: NAD
Skin: healed burn wound on anterior chest wall (from childhood)
Neck: prominent, firm, poorly circumscribed R neck mass
CV: RRR, nl s1+s2, no M/G/R
Pulm: CTA B
Abd: S/NT, mildly distended; +BS; G-tube site C/D/I
Ext: 3+ RUE, 2+ BLE, 1+ LUE edema; no clubbing, cyanosis; faint
PT/DP pulses b/l
Neuro: A+O->self only (says "[**Known lastname 101072**]"); only answers yes or no
to most questions.
Pertinent Results:
[**2194-6-12**] 05:15AM BLOOD WBC-9.8 RBC-2.99* Hgb-9.9* Hct-29.6*
MCV-99* MCH-33.0* MCHC-33.3 RDW-18.9* Plt Ct-184
[**2194-6-12**] 05:15AM BLOOD Glucose-94 UreaN-19 Creat-0.2* Na-134
K-4.0 Cl-99 HCO3-24 AnGap-15
[**2194-6-12**] 05:15AM BLOOD ALT-13 AST-25 LD(LDH)-488* AlkPhos-107
TotBili-0.3
[**2194-6-12**] 05:15AM BLOOD Albumin-1.8* Calcium-8.2* Phos-3.0 Mg-1.9
UricAcd-5.0
***********
MRI CHEST/MEDIASTINUM W/O & W/; MRI ABDOMEN W/O & W/CONTRAST
[**2194-6-7**]
1) Enhancing multilobulated/conglomerate right-sided mass
extending from the base of the neck through the supraclavicular
region and into the axillary/right chest wall region. Findings
are most suggestive of lymphoma.
2) Right adrenal nodule cannot be assessed on this examination
due to motion artifact which was likely due to patient fatigue
from this extended study.
**********
FNA Neck Mass
B-cells demonstrate a monoclonal kappa light chain restricted
population. They co=express pan-B-cell markers CD19 and CD20.
They do not express aberrant antigens CD5 or CD10.
Immunophenotypic findings are consistent with involvement by a
kappa-restricted B-cell lymphoproliferative disorder.
Correlation with morphology is needed for further
subclassification.
***********
Right Upper Extremity USG [**2194-6-5**]
Upper extremity DVT with thrombosed brachial veins and partially
thrombosed axillary vein. Markedly slow flow is present in the
right subclavian vein, which may be related to this large
right-sided mass.
***********
ECHO [**2194-6-6**]
The left atrium is moderately dilated. Overall left ventricular
systolic
function appears normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is mildly dilated. Right
ventricular systolic function is normal. The number of aortic
valve leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There is an
anterior space which most likely represents a fat pad. There are
no echocardiographic signs of tamponade.
************
Brief Hospital Course:
81F h/o CVA, who presented intially with hypotension, R arm
edema, and large R supraclavicular/chest wall mass.
.
# Lymphoma: Mass in the neck. Initially suspicious for hematoma
from Chest CT ([**2194-6-3**]). RUE U/S ([**2194-6-5**]) showed DVT with
thrombosed brachial and partially
thrombosed axillary veins, and slow flow in R subclavian vein,
which likely due to stasis due to this large R-sided mass. MRI
([**2194-6-7**]) showed the mass to be diffusely enhancing, suggestive
of malignancy. FNA ([**2194-6-6**]) with cytopathology c/w malignancy,
likely kappa restricted B-cell lymphoproliferative disorder.
Given the extent of the mass, other comorbidities and patient's
clinical status, it was decided to pursue comfort measures only.
There was discussion about using radiation to reduce tumor
burden for possible reduction in right arm edema. However it
would likely not help as edema is from hypoalbuminemia and DVT.
Decision about tube feeds would be made by the family in
discussion with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] once the patient is back to
[**Last Name (un) 2299**] house.
.
# Anasarca: Asymmetric swelling RUE>RLE,LLE>LUE appears
secondary large R sided mass, along with R brachial and axillary
vein thrombosis, and low albumin (1.8).
Medications on Admission:
lopressor 50 mg qam, miacalcin nasal spray, calcium, vitamin d,
duonebs prn, celexa, colace, metamucil, multivitamin, senna
prilosec, tylenol, tramadol, nortriptyline, trazodone, lidoderm
patch, dulcolax, ritalin
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed.
3. Morphine Sulfate 0.5-1 mg IV Q4H:PRN
hold for RR <12
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Lymphoma in R supraclavicular region
Discharge Condition:
Minimally responsive with stable vitals.
Discharge Instructions:
She has a lymphoma in her neck and after discussions with the
physicians and family, it has been decided not to pursue any
further workup or treatment of her lymphoma. It has been decided
to proceed with comfort measures.
Followup Instructions:
NONE
|
[
"202.81",
"401.9",
"995.92",
"427.31",
"V44.1",
"453.40",
"785.52",
"294.8",
"438.89",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
6402, 6475
|
4497, 5796
|
366, 401
|
6555, 6598
|
2272, 4474
|
6868, 6876
|
1823, 1833
|
6059, 6379
|
6496, 6534
|
5822, 6036
|
6622, 6845
|
1848, 2253
|
275, 328
|
429, 1534
|
1556, 1678
|
1694, 1807
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,987
| 185,180
|
44032
|
Discharge summary
|
report
|
Admission Date: [**2133-8-18**] Discharge Date: [**2133-8-25**]
Date of Birth: [**2075-5-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / adhesive / azithromycin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status
.
Reason for MICU transfer: Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 year old female with h/o chronic dyspnea with mild ILD and
reduced DLCO, orthostatic hypotension, and recent hip
replacement who presents with dypsnea, cough, and altered mental
status.
.
She had a hip replacement 3 months ago and was at rehab until 1
week ago. Per her mother, she had an episode of syncope at
home. She found her in the bathroom this morning and the
patient told her she had fallen a few times. Unclear if LOC
occurred. her mother helped her out of bathtub and she had an
episode of rigidity with her eyes rolling backward. She also
had productive cough since last night. She appeared dyspneic
over the last day, although denied obvious orthopnea as mother
offered her an extra pillow and she declined. Denies
complaining of CP. No history of blood clots. Denies fevers,
chills, nausea, vomiting. No leg swelling.
.
She was originally taken to [**Hospital1 **] [**Location (un) 620**]. She was started on
Bipap for desats and sats improved to mid-90's. Chest x-ray
showed significant opacification of the right hemithorax, read
as pulmonary edema. Bedside echo showed no pericardial effusion
and formal echo showed new wall motion abnormality with EF 45%.
Also was reportedly bradycardic in junctional rhythm. Labs were
significant for WBC 16, Hct 28, K 3.2, Mg 1.2, Trop neg, BNP
5532. She was given 1g vancomycin, 3.375g Zosyn, 2g magnesium,
20mEq of potassium, and lasix prior to transfer. CT head and CT
c-spine were negative.
.
In our ED, she initially triggered for hypoxia to high 80's with
RR40, HR 66, BP 100/79, improved to 94-95%NRB. Exam showed
diffuse crackles. Blood cultures sent. She was tried on BiPap,
but remained tachypneic and was intubated due to hypoxic
respiratory failure.
.
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:
Dyspnea with mild interstitial lung disease on recent PFTs and
reduced diffusing capacity
Orthostatic hypotension/autonomic dysfunction causing falls
(followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
Osteoporosis, remote T12 and L2 endplate deformities
Right femoral neck fracture s/p ORIF, non-weightbearing [**5-/2133**]
Right wrist fracture
Recurrent chest pains
Depression
Panic attacks
Asperger's syndrome
Migraines
Iron deficiency anemia (baseline hct 27-35 per [**Hospital1 **] [**Location (un) 620**])
Reflux
Mildly elevated CPK and aldolase, hyperreflexia, positive
babinski
Elevated LFTs
Social History:
The patient lives with her mother. She has a
daughter and two sisters. She is on disability. She does claim
cigarette and alcohol abuse. She walks with a walker for ADLs
at times but also requires a wheelchair.
Family History:
No family history of lung disease
Physical Exam:
On Admission:
Vitals: 101.0 80 141/88 27 99%AC
General: Intubated and sedated, roving eye movements, but pupils
brisk and reactive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP elevated to earlobe bilaterally, no LAD
Lungs: Clear to auscultation bilaterally with mild rales
CV: Regularly irregular without murmurs
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no apparent rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2133-8-24**] 01:18AM BLOOD WBC-13.8* RBC-3.68* Hgb-9.4* Hct-28.5*
MCV-78* MCH-25.6* MCHC-33.1 RDW-16.9* Plt Ct-431
[**2133-8-18**] 05:20PM BLOOD WBC-17.1*# RBC-3.73* Hgb-9.7* Hct-29.5*
MCV-79* MCH-26.0* MCHC-32.8 RDW-16.1* Plt Ct-338
[**2133-8-24**] 01:18AM BLOOD Neuts-83.7* Lymphs-9.3* Monos-2.1
Eos-4.9* Baso-0.1
[**2133-8-18**] 05:20PM BLOOD Neuts-89.1* Lymphs-8.9* Monos-1.7*
Eos-0.1 Baso-0.2
[**2133-8-24**] 01:18AM BLOOD PT-16.8* INR(PT)-1.5*
[**2133-8-23**] 12:57AM BLOOD PT-20.7* PTT-56.0* INR(PT)-1.9*
[**2133-8-22**] 06:55AM BLOOD PT-18.5* PTT-33.9 INR(PT)-1.7*
[**2133-8-19**] 05:40AM BLOOD PT-14.6* PTT-27.7 INR(PT)-1.3*
[**2133-8-18**] 05:20PM BLOOD PT-13.4 PTT-23.0 INR(PT)-1.1
[**2133-8-19**] 05:40AM BLOOD Ret Aut-3.0
[**2133-8-24**] 01:18AM BLOOD Glucose-94 UreaN-56* Creat-1.7* Na-150*
K-3.7 Cl-114* HCO3-23 AnGap-17
[**2133-8-23**] 02:07PM BLOOD Glucose-135* UreaN-45* Creat-1.5* Na-149*
K-4.3 Cl-113* HCO3-23 AnGap-17
[**2133-8-21**] 05:00AM BLOOD Glucose-73 UreaN-21* Creat-0.6 Na-137
K-4.6 Cl-105 HCO3-26 AnGap-11
[**2133-8-18**] 05:20PM BLOOD Glucose-132* UreaN-12 Creat-0.6 Na-134
K-5.0 Cl-103 HCO3-20* AnGap-16
[**2133-8-24**] 01:18AM BLOOD ALT-771* AST-[**2129**]* LD(LDH)-1626*
AlkPhos-252* TotBili-4.6*
[**2133-8-23**] 12:57AM BLOOD ALT-689* AST-2316* LD(LDH)-[**2069**]*
CK(CPK)-281* AlkPhos-241* TotBili-4.6*
[**2133-8-22**] 02:15PM BLOOD CK(CPK)-320*
[**2133-8-22**] 06:55AM BLOOD ALT-385* AST-895* LD(LDH)-968*
AlkPhos-198* TotBili-3.2*
[**2133-8-21**] 02:06PM BLOOD CK(CPK)-410*
[**2133-8-21**] 05:00AM BLOOD ALT-273* AST-549* LD(LDH)-802*
CK(CPK)-258* AlkPhos-154* TotBili-2.9* DirBili-2.0* IndBili-0.9
[**2133-8-21**] 12:59AM BLOOD CK(CPK)-270*
[**2133-8-20**] 02:40AM BLOOD ALT-152* AST-221* AlkPhos-128*
TotBili-2.2*
[**2133-8-18**] 05:20PM BLOOD ALT-137* AST-241* CK(CPK)-165
AlkPhos-181* TotBili-1.2
[**2133-8-24**] 01:18AM BLOOD Lipase-59
[**2133-8-21**] 05:00AM BLOOD Lipase-10
[**2133-8-22**] 02:15PM BLOOD CK-MB-5 cTropnT-0.03*
[**2133-8-22**] 06:55AM BLOOD proBNP-7962*
[**2133-8-21**] 02:06PM BLOOD CK-MB-8 cTropnT-0.06*
[**2133-8-19**] 05:40AM BLOOD CK-MB-5 cTropnT-<0.01
[**2133-8-18**] 10:20PM BLOOD CK-MB-5 cTropnT-<0.01
[**2133-8-18**] 05:20PM BLOOD CK-MB-4 cTropnT-<0.01
[**2133-8-24**] 01:18AM BLOOD Calcium-7.8* Phos-3.2 Mg-3.9*
[**2133-8-23**] 02:07PM BLOOD Calcium-7.5* Phos-4.7* Mg-4.2*
[**2133-8-23**] 12:57AM BLOOD Calcium-8.0* Phos-5.1* Mg-5.6*
[**2133-8-19**] 05:40AM BLOOD Calcium-8.4 Phos-2.1* Mg-3.4*
[**2133-8-24**] 01:18AM BLOOD Ferritn-722*
[**2133-8-21**] 05:00AM BLOOD Hapto-212*
[**2133-8-22**] 02:15PM BLOOD TSH-0.81
[**2133-8-22**] 02:15PM BLOOD IgM HAV-NEGATIVE
[**2133-8-19**] 02:08PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2133-8-21**] 08:59AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2133-8-21**] 09:38PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2133-8-20**] 06:21PM BLOOD Vanco-14.1
[**2133-8-22**] 02:15PM BLOOD tTG-IgA-5
[**2133-8-19**] 02:08PM BLOOD HCV Ab-NEGATIVE
[**2133-8-24**] 01:27AM BLOOD Type-[**Last Name (un) **] pO2-53* pCO2-37 pH-7.46*
calTCO2-27 Base XS-2
[**2133-8-21**] 01:01AM BLOOD Type-ART Rates-/18 Tidal V-510 FiO2-50
pO2-121* pCO2-39 pH-7.51* calTCO2-32* Base XS-7
Intubat-INTUBATED Vent-SPONTANEOU
[**2133-8-20**] 02:41AM BLOOD Type-CENTRAL VE Temp-38.9 Rates-/15 Tidal
V-500 PEEP-5 FiO2-50 pO2-87 pCO2-42 pH-7.42 calTCO2-28 Base XS-2
Intubat-INTUBATED Vent-SPONTANEOU Comment-100F AXILL
[**2133-8-19**] 05:28AM BLOOD Type-ART Temp-36.9 Tidal V-400 PEEP-10
pO2-129* pCO2-38 pH-7.45 calTCO2-27 Base XS-3 Intubat-INTUBATED
[**2133-8-18**] 11:31PM BLOOD Type-ART pO2-62* pCO2-38 pH-7.44
calTCO2-27 Base XS-1
[**2133-8-18**] 05:30PM BLOOD Comment-GREEN TOP
[**2133-8-24**] 01:27AM BLOOD Lactate-2.1*
[**2133-8-20**] 02:41AM BLOOD Lactate-1.4
[**2133-8-19**] 05:28AM BLOOD Lactate-1.6
[**2133-8-18**] 11:31PM BLOOD Lactate-1.7
[**2133-8-18**] 05:30PM BLOOD Lactate-2.9* K-5.2*
[**2133-8-21**] 01:01AM BLOOD freeCa-1.10*
[**2133-8-23**] 12:12PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-PND
[**2133-8-23**] 12:12PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-PND
[**2133-8-22**] 10:13PM BLOOD CERULOPLASMIN-PND
[**2133-8-22**] 10:13PM BLOOD ALPHA-1-ANTITRYPSIN-PND
Brief Hospital Course:
Primary Reason for Hospitalization: 58 year old female with h/o
chronic dyspnea with mild ILD and reduced DLCO, orthostatic
hypotension, and recent hip surgery who presented with dypsnea,
cough, and altered mental status and passed away from hypoxic
respiratory failure in the MICU.
.
#. Hypoxic Respiratory Failure: This was initially suspected to
be from CHF given that she had new wall motion abnormalities on
the echo at [**Location (un) **] and CXR consistent with pulmonary edema.
However the patient was still profoundly hypoxic despite
diuresis and improvement in exam and chest x-ray. The etiology
of the new wall motion abnormality was unclear given that she
had no history of MI symptoms and CE's were negative on
presentation. Non-ischemic cardiomyopathies were considered but
these would not typically produce such focal wall motion
abnormalities. Of note repeat TTE at [**Hospital1 18**] showed normalization
of LV function. The etiology of these findings was unclear.
[**Name2 (NI) 227**] the persistent hypoxemia after diuresis it could have been
that she had a worsening of her ILD. A CT scan was attempted
but the patient was not able to tolerate the study. Empiric
steroids were also considered but she and her family declined in
the setting of shifting goals of care. She was also treated with
broad empiric coverage for respiratory pathogens however this
did not seem to provide any benefit and she was persistently
febrile while on antibiotics. Drug fever was suspected given
that she was afebrile before starting antibiotics. All culture
data was repeatedly negative and therefore antibiotics were
stopped.
.
The patient was intubated in the emergent setting in the ED but
in the MICU family clarified that she would not want prolonged
intubation. After she was extubated she was made DNR/DNI by her
mother [**Name (NI) 382**] which multiple family members also agreed would be
the patient's wishes. When the patient awoke and was oriented
she confirmed that she wanted to be DNR/DNI.
.
After being extubated, the patient repeatedly insisted that she
did not want to wear the oxygen face mask and just wanted to be
comfortable with her family. The family including her HCP all
confirmed that this was congruent with her previously stated
wishes. A decision was made by the patient and family to make
the patient CMO. The family was repeatedly informed that
although her condition was not fully understood she did not
appear to have a condition that was imminently terminal. They
all voiced understanding of this but felt that the patient did
not wish to drag out her hospitalization any longer and was
tired of fighting. She received IV opioids and ativan to limit
pain and respiratory distress. She and family wanted to have all
supplemental oxygen removed. She progressively desaturated until
she passed away at 2:15AM on [**8-25**].
.
#. Transaminitis: Etiology uncertain. Doppler/RUQ negative.
Viral studies negative so far. Hepatitis workup was all negative
at the time of death although some studies were still pending.
[**Month (only) 116**] have been related to medications however LFTs continued to
trend upwards after all frequently hepatotoxic meds were
discontinued.
.
#. Leukocytosis/Fever: Initially treated as PNA but then thought
to be drug fever or hepatitis. Etiology still uncertain at the
time of death.
.
#. Torsades de Pointes/Long QT: Went into torsades on [**8-22**].
Given IV mag. Then was in ?AVNRT at rate of 140s. Spontaneously
converted back in sinus rhythm early morning [**8-23**]. The
etiology of the patient's long QT was not clear but may have
been related to high doses of prozac. Her QT decreased after
stopping prozac although did not totally normalize despite
stopping all offending meds. She did not have a previously
documented history of long QT.
.
#. Delirium: Patient had baseline of Asperger??????s and bipolar
disorder, and had intermittent delirium likely related to
underlying disease. She also had intervening periods of lucidity
in which she was fully oriented. The patient also likely had a
not fully worked up neurological illness. Her most recent
neurological consultations as an outpatient suggested
parkinson's plus syndromes including [**Last Name (un) **] body disease and
multi-systems atrophy given that she also had some autonomic
insufficiency. Her exam during this hospitalization was
consistent with prior showing increased tone and hyperreflexia.
Medications on Admission:
x Fludrocortisone 0.2mg [**Hospital1 **]
Reclast 5mg IV
Topamax 50 mg p.o. q.a.m. per PCP [**Last Name (NamePattern4) **] ?75 mg po daily? per [**Hospital1 **]
[**Location (un) 620**]
x Prozac 120 mg p.o. daily
x Wellbutrin 100 mg daily
Imitrex 50 mg daily prn migraines
x Clonazepam 2mg po qhs and 1mg prn anxiety/panic attack
x Omega-3 fish oil [**2121**] mg po daily
Melatonin 15mg po qhs
x Miralax 17 g po daily
Potassium chloride 10 mEq ER daily
- Tums 650 mg [**Hospital1 **]
- Vitamin D 1000 units daily
- Multivitamin
- [**Last Name (un) **]-zyr D (cetirizine-pseudoephedrine) 1 tab daily
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"584.9",
"733.00",
"780.61",
"426.82",
"299.80",
"296.80",
"V66.7",
"428.0",
"V49.86",
"E930.9",
"337.9",
"V43.64",
"780.60",
"280.9",
"427.1",
"293.0",
"333.0",
"428.31",
"790.4",
"331.82",
"518.81",
"294.10",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13396, 13405
|
8311, 12748
|
367, 373
|
13456, 13465
|
4127, 8288
|
13521, 13531
|
3512, 3547
|
13426, 13435
|
12774, 13373
|
13489, 13498
|
3562, 3562
|
2158, 2606
|
269, 329
|
401, 2139
|
3576, 4108
|
2628, 3262
|
3279, 3496
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,580
| 119,263
|
3103+55441
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-9-17**] Discharge Date: [**2182-9-27**]
Date of Birth: [**2103-5-13**] Sex: M
Service: TSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 4272**]
Chief Complaint:
Right lower lobe mass
Major Surgical or Invasive Procedure:
Mediastinoscopy
Right lower lobectomy and mediastinal lymph node dissection
Bronchoscopy
Foley catheter
Central Line placement
Epidural placement
Chest tube placement
History of Present Illness:
This is a 79-year-old man with a history of hemoptysis who had
subsequent work-up and was found to have a large right lower
lobe mass. PET scan demonstrated increased activity in the right
hilum.
Past Medical History:
Emphysema
Benign prostatic hypertrophy
Gastroesophageal reflux disease
Herniorrhaphy '[**43**]
Parotidectomy '[**44**]
Social History:
1 PPD for 60 years
Occasional EtOH
No IDU
Worked as Civil Engineer
Family History:
Laryngeal and lung cancer
Physical Exam:
On Admission, patient's physical exam is as follows:
Vitals: T=96.2, BP=162/64, P=89, R=12, SpO2=98%RA
Gen: NAD, AAOx3
HEENT: PERRL, EOMI, no LAD, MMM, sclera anicteric
CVS: RRR, no murmurs
Pulm: CTA bilaterally
Abd: soft, NT/ND, +BS
Ext: trace clubbing, no cyanosis or edema
Neuro: no focal deficits, CN2-12 grossly intact
Pertinent Results:
Pathology Examination [**2182-9-17**]
A. 4R paratracheal lymph node: No evidence of malignancy.
B. 2R upper paratracheal lymph node: No evidence of malignancy.
C. 7 subcarinal lymph node: No evidence of malignancy.
D. Right lower lobe: Carcinoma, see synoptic report.
E. 8R paraesophageal node: No evidence of malignancy.
F. Level 7 subcarinal node: No evidence of malignancy.
G. Mediastinal nodes near thymus: 7 lymph nodes with no evidence
of malignancy.
CHEST (PORTABLE AP) [**2182-9-17**] 7:13 PM
IMPRESSION: Small right pneumothorax
CHEST (PORTABLE AP) [**2182-9-19**] 11:37 AM
1) Interval placement of a right subclavian venous catheter in
good position.
2) Stable size of the right apical pneumothorax.
3) Stable atelectasis at the left base.
CHEST (PORTABLE AP) [**2182-9-21**] 10:20 AM
Comparison is made to prior study 2 days ago. Right apical
pneumothorax looks slightly smaller. Basilar density is
essentially unchanged. This may represent consolidation,
atelectasis and/or effusion.
Brief Hospital Course:
Mr. [**Known lastname 14731**] was admitted to the Thoracic Surgery service at
[**Hospital1 18**] under Dr.[**Name (NI) 14732**] care on [**2182-9-17**]. On that day he
underwent a cervical mediastinoscopy with biopsies, fiberoptic
bronchoscopy and right lower lobectomy with mediastinal lymph
node dissection. For details of the operation, see procedure
note. Preoperatively, the patient had an epidural line placed
and a foley catheter and 2 chest tubes placed intraoperatively.
His primary issue in the immediate post-op period was pressure
support for which he was placed on a neosynephrine drip-stopped
prior to going to the floor. Due to his BP issues, his epidural
was removed on POD#1 and a PCA was installed for pain control.
On POD#2, the patient went into atrial fibrillation and was
treated with 2g of IV magnesium sulfate, fluid boluses, 150cc
amiodarone bolus x2, calcium chloride, diltiazem and was then
moved to the critical care unit for BP monitoring. At that time
he was started on a diltiazem drip.
On POD#3, patient's hematocrit was noted to be 26.8; however, a
repeat hematocrit was 29.3 and it was decided not to transfuse
the patient with blood products. Also, the patient was moved to
the floor after being deemed stable enough on the diltiazem drip
that same day.
On POD#4, the chest tubes and foley catheter were removed.
Also, the patient was started on a Heparin drip and coumadin 5mg
QHS for anticoagulation secondary to the atrial fibrillation.
EPS was consulted at that time and recommended maintaining
amiodarone at 800mg/day for 1 week, 400 mg/day 2 weeks
thereafter and finally 200mg/day to finish. Also, the diltiazem
drip was subsequently discontinued that day. They also
requested the patient follow-up with Dr. [**Last Name (STitle) 73**] in
Cardiology/[**Hospital **] Clinic in 6 weeks and to continue on coumadin
until then.
On POD#7, patient became therapeutic on his coumadin with an INR
of 2.3. He was seen by physical therapy who had recommended he
be placed in a rehabilitation facility for further conditioning
the previous day. He was finally discharged on POD#8, [**2182-9-25**],
in good condition, tolerating a house diet and ambulating with
assistance. He is asked to follow-up with Dr. [**Last Name (STitle) 175**] in [**12-7**]
weeks and to call for an appointment. He must also continue
having his PTT/INR checked on a daily basis for conitnued
coumadin dosing.
Medications on Admission:
Hytrin 10mg PO QHS
Prilosec 40mg PO QD
Discharge Medications:
1. Terazosin HCl 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*15 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Squamous Cell Carcinoma
Atrial fibrillation
Hypovolemia
Discharge Condition:
Good
Discharge Instructions:
You may restart any medications you were on prior to your
admission.
You may shower.
You may have a regular diet.
You may ambulate with assistance as tolerated.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 175**] in [**12-7**] weeks. Please call
[**Telephone/Fax (1) 2348**].
Please follow-up with Dr. [**Last Name (STitle) 73**] in Cardiology/[**Hospital **] clinic in 6
weeks. Call [**Telephone/Fax (1) 902**] for an appointment.
Completed by:[**2182-9-25**] Name: [**Known lastname 2329**],[**Known firstname 33**] N Unit No: [**Numeric Identifier 2330**]
Admission Date: [**2182-9-17**] Discharge Date: [**2182-9-27**]
Date of Birth: [**2103-5-13**] Sex: M
Service: TSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 2331**]
Chief Complaint:
Right lower lobe mass
Major Surgical or Invasive Procedure:
Mediastinoscopy
Right lower lobectomy and mediastinal lymph node dissection
Bronchoscopy
Foley catheter
Central Line placement
Epidural placement
Chest tube placement
Brief Hospital Course:
Mr. [**Known lastname **] was finally discharged to [**Location (un) 2332**] House Nursing
& Rehabilitation Center - [**Location (un) 2333**] on [**2182-9-27**]. He stayed due to
feelings of nausea and dizziness when ambulating on [**2182-9-25**]-his
originally scheduled discharge date. At discharge, Mr.
[**Known lastname **] was ambulating without issue around the hospital floor
with assistance.
Furthermore, he had continued episodes of intermittent atrial
fibrillation. For continued therapy, his amiodarone was
increased to 400mg PO TID from [**Hospital1 **]. He will then stay on this
for one week and then slowly be weaned the following week to
400mg PO BID, then 400mg PO QD then 200mg PO QD as tolerated.
In that time, he is to continue having his beta-blocker titrated
up for control. He is to follow up with Dr. [**Last Name (STitle) **] in 6
weeks.
Also, on [**2182-9-26**], patient's INR was 5.2 and he was kept
in-house on fall precautions. On the day of discharge, it had
trended down to 4.6 and he was deemed able to go to rehab. He
is asked to have daily INR checks at his rehab facility and to
have his coumadin dosed daily to maintain a therapeutic INR
level between 2 and 3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]
Discharge Diagnosis:
Squamous cell carcinoma of the lung
Atrial fibrillation
Hypovolemia
Discharge Condition:
Good
[**Known firstname 33**] [**Last Name (NamePattern4) 2334**] MD [**MD Number(1) 2335**]
Completed by:[**2182-9-27**]
|
[
"V16.2",
"530.81",
"162.5",
"997.1",
"492.8",
"600.00",
"E870.0",
"E878.8",
"276.5",
"305.1",
"427.31",
"V16.1",
"518.0",
"427.32",
"458.0",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"89.61",
"40.11",
"33.22",
"39.31",
"32.4",
"40.3",
"34.22"
] |
icd9pcs
|
[
[
[]
]
] |
8652, 8747
|
7422, 8629
|
7230, 7399
|
8859, 9011
|
1355, 2358
|
6473, 7152
|
968, 995
|
4902, 6021
|
8768, 8838
|
4839, 4879
|
6288, 6450
|
1010, 1336
|
7169, 7192
|
529, 726
|
748, 868
|
884, 952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,838
| 176,677
|
2760
|
Discharge summary
|
report
|
Admission Date: [**2135-7-19**] Discharge Date: [**2135-7-29**]
Date of Birth: [**2072-11-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Anemia, Gastrointestinal bleed
Major Surgical or Invasive Procedure:
EGD, colonoscopy
History of Present Illness:
62 year-old male w/ HIV (last CD4 175), HTN, CAD s/p MI and 5
vessel CABG w/ MVR [**2131**], here presents with dizziness, black
stools, and Hct 20. Pt reports intermittent black stools over
the last month. He was in [**Country 13622**] Republic until [**2135-7-16**] and
was hospitalized briefly there w/ these complaints. He was told
his INR was high and he was given 3 units of PRBC's. He was not
scoped and has never been scoped. He returned to the U.S. on
[**7-16**] and received his lab results from the D.R. w/ hct 20 and
INR 9.4. He went to see his PCP and was referred to ED from
there. He has been off coumadin since [**7-16**] and noted black
colored stool on his toilet paper but brown stool in toilet over
last few days. He denies hematochezia, diarrhea, weight loss but
does have mild SOB and dizziness. He takes NSAIDs regularly for
aches/pains ([**2-6**] pills per day). In ED, VSS, Hct 19, INR 1.3.
Given 2 units of blood (to HCT 23), 2 peripheral IV's, and NG
lavage was immediately clear with no blood. He was guaiac
positive. He was transferred to MICU because of complicated GIB
and need for anticoagulation [**3-9**] mvr.
Past Medical History:
1. HIV (VL 175 on [**2135-6-21**])- on HAART
2. HTN
3. CAD s/p MI x 2 and 5V CABG [**2131**]
4. MVR [**2131**] w/ cabg
5. left thoracotomy [**8-6**] for pleural effusion
6. cord compression/spinal stenosis w/ c4-c6 laminectomy and
decompression [**10-8**]
7. H pylori positive [**9-6**] - unclear whether he got treated
8. EF 40% [**2132**]
9. anemia - fe deficiency (baseline hct 30), had been worked up
for pancytopenia in the past and this was when his HIV dx was
discovered. per pt, his only risk factor was transfusions during
CABG. Family all aware.
10. Type II DM
Social History:
+smoker, 1pack/day for 42 years, occasional EtOH, lives in
[**Hospital1 1474**] with wife and 2 sons. [**Name (NI) **] used to work in business
importing merchandise. Born in [**Country 13622**] Republic.
Family History:
Non-contributory
Physical Exam:
T 98.2 BP 171/ 78 (151-199/50-98) HR 75 RR 20-25 O2sat 99% RA
I's/O's: 3900/1500 (24 HR). Total +5.6 L in the MICU
Gen: NAD, pleasant, sitting up in chair
HEENT: NC/AT, PERRL, anicteric sclera, MMM, no plaque or oral
lesion
CV: regular, mechanical S1, nl S2, II/VI holosystolic murmur at
LLSB.
Lungs: decreased BS at left base.
Abd: soft, NTND, +BS
Ext: no edema
Neuro: AOx3, CN III-XII intact, moving all 4 extremities well.
Brief Hospital Course:
1)GI bleed: Pt presented with Hct of 19 in a setting of
supratherapeutic INR and weeks of melena. As his vital signs
were stable, it was likely a slow bleed. He was initially in
the MICU and received a total of 7 units of PRBC, and his Hct
has been stable at 30 since. He underwent EGD and colonoscopy
by GI which were essentially negative except fro grade I
hemorroids. He also underwent small bowel follow through which
was also negative. Plan is to do an outpatient capsule
endoscopy since Hct stable. However since he does not have
insurance, this procedure could not be done. He is in a process
of applying for FreeCare. Once he is approved, he will need to
have his PCP arrange for outpatient capsule study. He will be
continued on Protonix [**Hospital1 **]. Hct on discharge was 34.1.
2)MVR: In a setting of GI bleed, he was maintained on Heparin
drip with low PTT goal (50-60). Once Hct was stable, he was
restarted on coumadin with a goal INR of 2.5-3.5 for the
mechanical valve. INR on discharge was 2.3, receiving coumadin
10mg po qd
3)HIV: He was started on Bactrim for prophylaxis (VL
undetectable and CD4 175). He was continued on his HAART
regimen.
4)HTN: His valsartan and metoprolol were titrated up till
SBP<140. Currently, he is taking Valsartan Valsartan 320 mg qd
and Metoprolol 37.5 mg [**Hospital1 **].
Medications on Admission:
robitussin
stavudine 40 mg [**Hospital1 **]
valsartan 160 mg qd
tenofovir 300 qd
lamivudine 150 [**Hospital1 **]
coumadin 5 mg qd
lasix 40 qd
glucamide ?glyburide 5 mg qd
atenolol 25 mg qd
?sulfametazone - unsure if he is taking this
Discharge Medications:
1. Stavudine 40 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*30 Capsule(s)* Refills:*2*
2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday) as needed for PCP
[**Name Initial (PRE) 1102**].
Disp:*30 Tablet(s)* Refills:*2*
5. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal Bleed
Discharge Condition:
excellent
Discharge Instructions:
Patient should follow up with PCP for coumadin level check on
Tuesday next week.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 8499**] on [**2135-8-2**] 10:30am
[**Hospital1 7975**] INTERNAL MEDICINE Where: [**Hospital1 7975**] INTERNAL MEDICINE
Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2135-8-2**] 10:30
Please follow up with Dr. [**Last Name (STitle) 6173**] in the [**Hospital **] clinic on Tuesday
[**8-9**], 11am. [**Last Name (NamePattern1) **] in the basement suit GProvider:
[**Last Name (LF) **],[**First Name3 (LF) **]
|
[
"V43.3",
"250.00",
"V08",
"V45.81",
"305.1",
"V58.61",
"280.0",
"401.9",
"578.1",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04",
"96.34",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5339, 5345
|
2862, 4205
|
347, 366
|
5412, 5423
|
5552, 6014
|
2377, 2395
|
4489, 5316
|
5366, 5391
|
4231, 4466
|
5447, 5529
|
2410, 2839
|
277, 309
|
394, 1541
|
1563, 2136
|
2152, 2361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,236
| 143,885
|
7097
|
Discharge summary
|
report
|
Admission Date: [**2123-4-5**] Discharge Date: [**2123-4-11**]
Date of Birth: [**2046-10-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Dyspnea, Tachycardia
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
The patient is a 76 year old female with medical history
pertinent for cholangiocarcinoma diagnosed in [**2112**], unresectable
at time of diagnosis, treated with 5-FU and radiation therapy as
well as bilateral metal biliary stents who now presents with
concerns for dyspnea, tachycardia and LE edema.
As above, the patient was diagnosed and treated with
chemo/XRT and biliary stenting. The patient's course has been
complicated by biliary obstruction from her stents with
recurrent cholangitis and hepatic abscesses. The patient has
undergone placement of a plastic stent in her metal stent with
decrease in episodes of cholangitis. The patient is followed by
Infectious Disease with note from
[**2123-2-24**] reflecting infectious course. The patient has had
hepatic collection cultures revealing for Klebsiella oxytoca and
Strep Milleri on [**7-31**] for which patient was on CTX and
levofloxacin. Repeat smapling in [**11-30**] revealed [**Female First Name (un) 564**] for
which patient was treated with fluconazole, IV CTX was changed
to Augmentin on [**2123-1-12**] and appeared to be doing well ultimately
on a regimen of Augmentin, Levofloxacin, and Fluconazole. The
patient seemed to tolerate transition from IV to PO meds
although ID note on [**2123-2-24**] noted rising trend in WBC concerning
for worsening of underlying infection.
In addition to above the patient has been noted to have an
additional issue of weight loss and abdominal distention. The
patient was seen by her gastroenterologist Dr. [**First Name (STitle) **] [**Name (STitle) **]
on [**2123-3-19**] with plan for interventional radiology consultation
for evaluation of percutaneous transhepatic cholangiography for
biliary drainage, impression that repeat ERCP would be of
limited utility given obstructing metal ducts. Plan was also
made for upper and lower endoscopy to rule out bowel
obstruction.
The patient now presents from her PCPs office who presents
with concern for ongoing loss of energy, weight loss, abdominal
distention, lower extremity edema and dyspnea on exertion. In
the office the patient was noted to have a heart rate of 120
with dyspnea on minimal exertion. The patient was referred to
the ED for evaluation with concern for PE or Tamponade.
ED Course: 97.5, 121/74, 123, 20, 98% RA. Labs were notable
for WBC 14.6, AP 386, Alb 2.9, lactate 1.6. The patient had a CT
C/A/P revealing no PE or pericardial effusion, did reveal
interval increase in size of multiple superinfected bilomas with
additional finding of marked distention of the stomach, filled
with debris as well as mild to moderate ascites, no obvious
obstruction to account for gastric dilation. The patient was
seen by surgery with recommendation for NGT decompression, not
performed in ED prior to floor transfer. The patient received 1L
NS, no medications, and was transferred to the medical service
for ongoing management.
Past Medical History:
Onc Hx: She was diagnosed with cholangiocarcinoma in [**2112**] after
presenting to [**Hospital6 1708**] with painless
jaundice. ERCP was unsuccessful in stenting the lesion and she
underwent bilateral percutaneous cholangiograms with external
drain placement and eventual internalization of the drains. As
the tumor seemed to grow up the hepatic artery, it was deemed
unresectable. She underwent cholecystectomy with pathology
confirming the presence of cholangiocarcinoma. She was treated
with 5-FU and radiation therapy. Over the past nine years, she
has had multiple admissions for cholangitis and obstruction of
the biliary drainage system by sludge and stones. In addition,
she has had soft tissue ingrowth into the lumen of the biliary
stents, first noted in 10/[**2119**]. This area was subsequently
stented and has been unchanged since that time.
.
PMH:
Osteoporosis
Glaucoma
Appendectomy
Tonsillectomy
Adenoidectomy
Social History:
The patient is married, she lives with her husband in [**Name (NI) **],
MA. She has 4 children. The patient's HCP is her husband
[**Name (NI) **]. The patient was previously a teacher
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-contributory
Physical Exam:
Vitals: 97.8, 114/74, 119, 18, 99% RA
Orthostatics: HR 140s when standing
General: Patient is a chronically ill appearing female, appears
tired but in no acute distress
HEENT: NCAT, EOMI, sclera anicteric, conjunctiva WNL
OP: MM dry appearing, black discoloration of tongue
Neck: JVP flat, appears at clavicle
Chest: Generally CTA anterior and posterior
Cor: Tachycardic, regular, no murmurs
Abdomen: Moderately distended, tympanitic. No obvious shifting
dullness. Soft, moderate tenderness to deep palpation in RUQ,
mild tenderness in LLQ
Rectal: Normal external exam, no fissue, skin tags or fistula.
Normal tone, moderate tenderness on deep exam, no palpable mass
or fluctuance. Soft brown stool in rectal vault, guaiac negative
Ext: 2+ pitting edema to mid shins, fine maculopapular rash over
feet appears secondary to edema
Skin/Nails: Rash as above
Neuro: Grossly intact
Pertinent Results:
[**2123-4-5**] 01:24PM WBC-14.6*# RBC-4.01* HGB-12.5 HCT-37.3 MCV-93
MCH-31.2 MCHC-33.5 RDW-18.2*
[**2123-4-5**] 01:24PM NEUTS-88.4* LYMPHS-6.0* MONOS-4.8 EOS-0.5
BASOS-0.3
[**2123-4-5**] 01:24PM PLT COUNT-380
[**2123-4-5**] 01:24PM GLUCOSE-94 UREA N-15 CREAT-0.6 SODIUM-137
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2123-4-5**] 01:24PM ALT(SGPT)-31 AST(SGOT)-68* LD(LDH)-292*
CK(CPK)-30 ALK PHOS-385* TOT BILI-1.4
[**2123-4-5**] 01:24PM cTropnT-<0.01
[**2123-4-5**] 01:24PM CK-MB-NotDone
[**2123-4-5**] 01:24PM ALBUMIN-2.9* CALCIUM-9.2 PHOSPHATE-2.6*
MAGNESIUM-1.7
[**2123-4-5**] 01:24PM TSH-2.6
[**2123-4-5**] 01:24PM LACTATE-1.7.
.
CTA CHEST W&W/O C&RECONS:CT ABDOMEN W/CONTRAST
IMPRESSION:
1. No pulmonary embolism.
2. Increase in size of multiple intrahepatic bilomas, several of
which appear to rim enhance consistent with superinfection.
Apparent occlusion of the indwelling biliary stents is again
associated. Moderate ascites.
3. Marked gastric distension warrants decompression.
4. A small amount of tree-in-[**Male First Name (un) 239**] opacity in the right lower lobe
may
represent small airways disease/infection.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN
IMPRESSION:
1. Normal flow in the main portal vein, right portal vein and
its branches.
The left portal vein is not visualized.
2. Multiple hepatic abscesses containing debris.
3. Small-to-moderate amount of ascites for which a spot could
not be marked
on the skin.
Brief Hospital Course:
Assessment/Plan: The patient is a 76 year old female with
history of cholangiocarcinoma s/p 5-FU and radiation, chronic
biliary obstruction with infected bilomas/hepatic abscess now
presents with abdominal distention, LE edema, dyspnea.
.
76 year old female with cholangiocarcinoma diagnosed in [**2112**],
s/p 5-FU and radiation, chronic biliary obstruction with
infected bilomas/hepatic abscess on augmentin/levo/fluconazole
suppression presented [**4-5**] from PCPs office with abdominal
distention, LE edema, dyspnea found to have duodenal obstructing
mass on ERCP [**4-9**] complicated by hypoxia and aspiration event.
.
# Acute Hypoxic Respiratory Failure: Patient s/p reintubation.
Patient was intubated after ERCP for hypoxia. After intubation,
patient's airway was suctioned and revealed aspiration contents
that are likely reason for patient's hypoxia. She self
extubated on [**4-10**] and then was reintubated. She is s/p
bronchoscopy and a small piece of food (likely meat) was
suctioned from her LUL which corresponded to her LUL collapse on
CXR. Patient is currently on Vanc/Zosyn, which has broad
coverage. Her sputum was sent for cx and is growing yeast with
pseudohyphae and gram + cocci in pairs. family decided on
extubation and [**Name (NI) 3225**], pt. died within several hours of extubation.
.
# hypotension: On the morning of [**4-11**] she dropped her BPs
requiring requiring starting levo and boluses of several liters
of fluids. She remained afebrile but had an increasing white
count. continued on vancomycin/zosyn/fluconazole until decision
for [**Date Range 3225**] confirmed and then Abx stopped.
.
#. Cholangitis/Superinfected bilomas: CT performed on admission
demonstrating increase in size of infected bilomas, rising WBC
despite PO Augmentin, Levofloxacin, Fluconazole at home. There
was concern for infection/abx failure/poor abx absorption in
setting of gastric outlet obstruciton. Her antibiotics were
changed to vancomycin/zosyn/fluconazole on admission. In light
of the duodenal obstruction found on ERCP her failure of her
home antibiotics were likely due to poor absorption
continued on vancomycin/zosyn/fluconazole until decision for [**Date Range 3225**]
confirmed
.
#. Duodenal Stricture: Pt had gastric distention secondary to
duodenal stricture. Patient's CT had massive gastric
distention. Patient had a stent placed in duodenum. It was
unclear what the etiology of the stricture is, whether related
to malignancy or benign process. Patient's CT torso is negative
for mass or mass effect. Prior EGDs have noted duodenal
stricture, so this was not a new process, but perhaps a
pre-existing lesion that became clinically significant. NGT
placed to suction and a lot of bilius fluid came back. She was
started on reglan and was started on TPN.
.
#. Cholangiocarcinoma: Patient with unresectable disease at time
of diagnosis, s/p 5-FU and radiation. Patient without known
recurrence of disease to date although constellation of symptoms
above concerning for potential disease recurrence (vs. all
attributable to infectious sequelae).
.
#. Communication - Husband/HCP [**Name (NI) **] [**Telephone/Fax (1) 26456**]
Medications on Admission:
Augmentin 875-125mg twice daily
Levofloxacin 750mg daily
Fluconazole 400mg daily
Brimonidine 0.15% OU twice daily
Hydrochlorothiazide 12.5mg daily
Megestrol 800mg daily
Metoclopramide 5-10mg before meals
Omeprazole 40mg before bedtime
Timolol 0.5% OU daily
Ursodiol 300mg daily
Zolipdem 10mg qhs
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2123-4-11**]
|
[
"536.3",
"996.59",
"572.0",
"038.9",
"576.1",
"995.92",
"V10.09",
"197.4",
"261",
"996.69",
"537.3",
"576.2",
"518.81",
"276.52",
"518.0",
"537.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.85",
"33.22",
"99.15",
"96.04",
"98.15",
"97.55",
"38.93",
"50.91",
"51.10",
"96.71",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10471, 10480
|
6908, 10092
|
335, 341
|
10532, 10542
|
5415, 6885
|
10599, 10638
|
4485, 4503
|
10438, 10448
|
10501, 10511
|
10118, 10415
|
10566, 10576
|
4518, 5396
|
275, 297
|
369, 3277
|
3299, 4227
|
4243, 4469
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,707
| 174,968
|
5397
|
Discharge summary
|
report
|
Admission Date: [**2157-8-19**] Discharge Date: [**2157-8-21**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol / Cardizem / Protonix / epinephrine / IV
Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
? Anaphylaxis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo woman with a questionable history of systemic mastocytosis
and CAD s/p CABG who presented from the radiology suite where a
code blue was called in the setting of iodine administration.
The patient had been in the radiology suite receiving IV
contrast for a CT pancreas when she developed acute chest pain,
shortness of breath and diffuse itching. Given her history of
anaphylaxis a CODE BLUE was called. Patient was alert and
responsive, was satting 100% on RA though in clear distress.
She was given IV benadryl 75 mg, IV solumedrol 50 mg,
epinephrine IM, racemic epinephrine nebulizer and IV famotidine.
Patient's respriatory status waxed and waned over the course of
the code, but no crowding of the oropharynx was observed and
patient was intermittently stridirous, but also noted to be
holding her breath for short periods of time followed by a
series of rapid deep breaths with good airation. VS during the
code were 158/72, 102 (sinus) sating 100% on face mask and room
air. She was admitted to the ICU for further monitoring.
On arrival to the MICU, patient's VS: 97.9, 137/65, 84, 25, 96%
RA. Patient was speaking in full sentances though clutching at
her chest saying that she could not breath.
Past Medical History:
-CABG [**12/2156**]
- Mast Cell Degranulation Syndrome (Not mastocytosis)
- Primary allergist: [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **]
([**Hospital1 112**]; [**Telephone/Fax (1) 21735**]; [**E-mail address 21761**])
- Also seen by Dr. [**First Name (STitle) **]
([**Location (un) 511**] Allergy Asthma and Immunology; [**Telephone/Fax (1) 21748**])
- Portacath [**3-8**] - removed for MRSA infection, re-placed [**2151-6-9**]
- syncope attributed to orthostatic hypotension with positive
tilt table testing [**6-11**]
- Hypothyroidism
- Histrionic personality disorder
- ADHD/depression/anxiety
- Erosive rheumatoid arthritis
- GERD, gastritis and esophagitis on EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction on fiberoptic laryngoscopy
- s/p hysterectomy and oophorectomy
- left wrist cellulitis concerning for necrotizing fasciitis s/p
fasciotomy
- s/p cholecystectomy
- s/p tonsillectomy
Social History:
Patient denies history of alcohol, tobacco, or drug use. She
used to work as an ED tech. Lives alone. Her PCP is her proxy.
Family History:
Mother died of MI at 76. Sister with breast cancer and bilateral
mastectomy and thyroid cancer. Brother with [**Name2 (NI) 21778**] and
hyperlipidemia.
Physical Exam:
Physical Exam:
Vitals: 97.9, 137/65, 84, 25, 96% RA
General: Alert, oriented, complainging of chest pain, violently
itching face and chest
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2157-8-19**] 04:49PM WBC-5.5 RBC-4.28 HGB-12.8 HCT-37.5 MCV-88
MCH-29.8 MCHC-34.0 RDW-14.9
[**2157-8-19**] 04:49PM PLT COUNT-223
[**2157-8-19**] 04:49PM GLUCOSE-133* UREA N-9 CREAT-0.8 SODIUM-142
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13
[**2157-8-19**] 04:49PM estGFR-Using this
[**2157-8-19**] 04:49PM CK(CPK)-63
[**2157-8-19**] 04:49PM CK-MB-2 cTropnT-<0.01
[**2157-8-19**] Radiology CHEST (PORTABLE AP)
Heart size and mediastinum are stable in this patient after
median sternotomy and CABG. Lungs are essentially clear except
for minimal atelectasis at the left lower lung, unchanged since
[**2157-8-3**]. No definitive evidence of aspiration
demonstrated. Calcified mediastinal lymph nodes are seen.
Port-A-Cath catheter tip is at the level of mid low SVC.
[**8-19**] CT Scan:
FINDINGS: A 2-mm left lower lobe pulmonary nodule (2:3) is
stable since
[**2154-10-27**] and is benign. Minimal scarring is seen in the
lingula. Mild
coronary arterial calcification is present.
No focal liver lesions are seen. Mild prominence of the
intrahepatic biliary
tree and CBD, relates to the post-cholecystectomy status. The
adrenal glands
are normal. Mild asymmetric urothelial enhancement is seen in
the right renal
pelvis/ureter, more pronounced in the proximal right ureter
where a focal area
of more marked mural enhancement is seen(3A:83). There is no
frank
hydronephrosis though prominence of the renal pelvis is noted.
The left
kidney is unremarkable.
A 6-mm hypodense lesion in the proximal pancreatic body (3A:67)
and a 6-mm
lesion in the distal pancreas (3A:66), correspond to two of the
cystic lesions
seen in the prior MRI. Additional smaller lesion seen on MRI
are not
visualized in the current study. There is no evidence of
abnormal
enhancement within or adjacent to these lesions, which are
compatible with
dilated side branches as in side branch IPMN. The main
pancreatic duct is
nondilated. Again seen are multiple non-enhancing hypodense
lesions in the
spleen, consistent with simple cysts. The spleen is normal in
size measuring
10.3 cm. The stomach and imaged portion of the small and large
bowel loops are
unremarkable. The abdominal aorta has moderate atherosclerotic
calcification
without aneurysmal dilation. No significant retroperitoneal or
mesenteric
lymphadenopathy is seen. No free fluid is seen.
IMPRESSION:
1. Two 6-mm cystic lesions in the body of the pancreas,
correspond to the
lesions seen on previous MRI study. Additional smaller lesions
are not
visualized. No areas of abnormal enhancement are identified.
These most likely
represent side branch IPMNs. Please note that noncontrast MRI
can be
performed for follow up of these lesions (suggest next follow up
noncontrast
MRCP in one year).
2. Splenic cysts.
3. Asymmetric urothelial enhancement in the right kidney, more
pronounced in
the proximal right ureter, may relate to mild inflammatory
change or pyelitis.
However, urothelial tumor can not be entirely excluded.
Recommended
urinalysis including urine cytology for further assessment.
4. Severe allergic reaction to iodinated contrast media
requiring code blue
and admission to ICU for further evaluation and management.
Brief Hospital Course:
TRANSITIONAL ISSUES FROM MICU:
- Patient was counseled to seek therapy re. panic attacks.
- Patient to follow up with outpatient urology and PCP [**Last Name (NamePattern4) **].
potential UTI
MICU COURSE
? Anaphylaxis: Patient was treated in a code blue setting for
acute airway compromise after receiving ionodated CT contrast.
Received antihistamines, solumedrol and epinephrine in that
setting. Was never hypoxic or hypotensive. Patient was
maintained on home regimen of antihistamines and telemetry/O2
monitoring. Troponins were negative. Patient had no further
acute events, although requested IV benadryl, which was provided
as a slow infusion prn.
Foul smelling urine with evidence of kidney inflammation on
imaging: Patient wanted to leave the hospital today because she
will be going to outpatient urology tomorrow. Patient was
provided with printed records of her imaging studies to take
with her. UA was also performed (which showed 23 WBCs, LG leuks,
but no nitrites).
Hypothyroidism: Continued home levothyroxine.
ADHD/depression/anxiety: Continued home antidepressents.
Erosive rheumatoid arthritis: Held Enbrel and MTX while in
hospital as is q weekly dosing.
GERD: Stable, continued home PPIs.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Aripiprazole 1 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 3.125 mg PO DAILY
hold for SBP <90 or HR <60
5. Clopidogrel 75 mg PO DAILY
6. cromolyn *NF* 100 mg/5 mL Oral QID
please give 30mL
7. Duloxetine 60 mg PO DAILY
8. Ferrous Sulfate 650 mg PO DAILY
9. Fexofenadine 180 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Gabapentin 600 mg PO TID
13. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
14. Levothyroxine Sodium 25 mcg PO DAILY
15. Lorazepam 1 mg PO DAILY PRN nausea
16. Methadone 5 mg PO TID
17. Methotrexate 22.5 mg PO 1X/WEEK (FR) [**Last Name (NamePattern4) 2974**]
18. Montelukast Sodium 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Omeprazole 40 mg PO DAILY
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. Promethazine 25 mg PO Q8H:PRN nausea
23. Ranitidine 300 mg PO HS
24. Rosuvastatin Calcium 40 mg PO DAILY
25. Vitamin D 1000 UNIT PO DAILY
26. Zolpidem Tartrate 10 mg PO HS
27. etanercept *NF* 50 mg/mL (0.98 mL) Subcutaneous qweek
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Aripiprazole 1 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 3.125 mg PO DAILY
hold for SBP <90 or HR <60
5. Clopidogrel 75 mg PO DAILY
6. Duloxetine 60 mg PO DAILY
7. Ferrous Sulfate 650 mg PO DAILY
8. Fexofenadine 180 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
13. Levothyroxine Sodium 25 mcg PO DAILY
14. Lorazepam 1 mg PO DAILY PRN nausea
15. Montelukast Sodium 10 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Promethazine 25 mg PO Q8H:PRN nausea
20. Ranitidine 300 mg PO HS
21. Rosuvastatin Calcium 40 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. Zolpidem Tartrate 10 mg PO HS
24. cromolyn *NF* 100 mg/5 mL Oral QID
please give 30mL
25. etanercept *NF* 50 mg/mL (0.98 mL) Subcutaneous qweek
26. Methadone 5 mg PO TID
27. Methotrexate 22.5 mg PO 1X/WEEK (FR) [**Last Name (NamePattern4) 2974**]
Discharge Disposition:
Home
Discharge Diagnosis:
Please keep your appointment with your urologist on [**2157-8-22**] and
inform him of your CT scan results.
Please see your PCP within [**Name Initial (PRE) **] week of discharge to follow-up the
results of your CT scan and urinalysis.
Discharge Condition:
Stable
Mental status wnl
Fully ambulatory
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] for a possible allergic raection to
iodine during your CT scan. Your respiratory status stabilized
and you were deemed appropriate for discharge on hospital day 2.
Please continue your home medications as prescribed.
Followup Instructions:
Department: RHEUMATOLOGY
When: THURSDAY [**2157-10-6**] at 2:30 PM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], 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
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2157-11-15**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2157-8-22**]
|
[
"478.5",
"757.33",
"995.0",
"V12.04",
"E947.8",
"577.9",
"V45.81",
"V45.82",
"244.9",
"314.01",
"289.50",
"714.0",
"301.50",
"518.82",
"311",
"300.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10364, 10370
|
6833, 8057
|
437, 444
|
10651, 10695
|
3579, 3579
|
11037, 11737
|
2807, 2960
|
9275, 10341
|
10391, 10630
|
8083, 9252
|
10719, 11014
|
2990, 3560
|
384, 399
|
472, 1693
|
3595, 6810
|
1715, 2649
|
2665, 2791
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,863
| 196,077
|
19272
|
Discharge summary
|
report
|
Admission Date: [**2100-9-14**] Discharge Date: [**2100-10-15**]
Date of Birth: [**2066-5-7**] Sex: M
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Motor cycle crash with traumatic left leg amputation
Major Surgical or Invasive Procedure:
1. Left hip disarticulation, operative debridement of Left leg
amputation [**2100-9-14**]
2. Exploratory laparotomy with mesenteric tear [**2100-9-15**]
3. G-tube placement [**2100-9-15**]
4. Left external fixation of forearm fracture [**2100-9-14**]
5. Revision External fixation of forearm fracture [**2100-9-22**]
6. External fixation Right foot fracture [**2100-9-22**]
7. External fixation of pelvic fractue [**2100-9-23**]
8. Split thickness skin graft to left leg amputation [**2100-10-7**]
History of Present Illness:
36 year old male status post motorcycle vs Motor vehicle at high
speed with traumatic amputation of Left leg. Patient was found
prone, unresponsive, diaphoretic, and pale with agonal
breathting. He was found apporxiamately 100 feet from the
motorchycle. He had a traumatic amputation of this left lower
extremity, with an estimated blood loss of 2 liters at the
scene. He was helmeted but his helmet was crushed. He had
decreased breath sounds and oxygen saturations 90%, had a GCS of
3 and the patient was intubated prior to presentation with out
medication. The patient was med flighted in.
Past Medical History:
asthma
Social History:
Tree surgeon, recently divorced, many relatives in [**Name (NI) 6171**]
Family History:
Non contributory
Physical Exam:
On arrival, the patient was awake moving both upper extremities,
but intubated and not following commands. His eyes were open.
pulse 117, blood pressure 60/palp, bagged with oxygen saturation
of 91%
Head and Neck: trachea midline, in c collar. no scalp abrasions
or obvious head trauma.
Cardiac: regular rate and rhythm
Lungs: decreased breath sounds on left, small rush of air when
chest tube was placed
Abdomen: soft, non distended
Rectal: No tone (on vecuronium), heme negative
Neuro: moving both upper extremities,
Extremities: Left upper extremity unstable, larg laceration
Left lower extremity: taumatic amputation, approximately 10 cm
from hip joint. Femur exposed, hamstring muscles, pulsitile
bleeding.
Right lower extremitiy, unstable forefoot
Spine: no stepoffs
Pertinent Results:
XRAY Left upper extremity [**2100-9-14**]:
IMPRESSION:
1. Probable fracture of the coronoid process of the left elbow.
Additonal elbow views or CT is recommended.
2. Comminuted nondisplaced fracture of the left radiostyloid.
3. Oblique fracture of the left third metacarpal base and fifth
metacarpal head.
AP pelvis and Right lower extremity [**2100-9-14**]:
IMPRESSION:
Limited evaluation of the pelvis. Within the limits, there
appears to be a widen left sacroiliac joint. Fractures of the
left superior inferior pubic ramus. CT of the pelvis is
recommended.
Comminuted fracture of the 2nd and 3rd metatarsals with
significant soft tissue swelling.
CT spine [**2100-9-15**]:
IMPRESSION: Unremarkable cervical spine CT scan. Tip of the
spinous process of C7 was not fully imaged; fracture cannot be
excluded in this locale. Otherwise unremarkable cervical spine
CT scan.
CT abdomen/pelvis [**2100-9-15**]:
IMPRESSION:
1) Sternal fracture with bilateral hemothoraces. Status post
left chest tube insertion.
2) Moderate hemoperitoneum. No solid abdominal organ laceration
or contusion identified.
3) Multiple pelvic fractures with diastatic bilateral sacroiliac
joints and amputated left lower extremity.
CT head [**2100-9-15**]:
IMPRESSION:
1) No evidence of intracranial hemorrhage.
2) No definite evidence of fracture, although the facial bones
are not fully imaged.
3) Bilateral air fluid levels in the maxillary sinuses and sinus
mucosal thickening as described.
Spine [**2100-9-15**]:
LUMBAR SPINE, TWO VIEWS:
No fracture. Alignment is normal.
Xray Right foot [**2100-9-20**]:
IMPRESSION: Comminuted fracture of first metatarsal with
displacement. Comminuted of second metatarsal without
displacement. Fracture of distal tibia which is not well
visualized.
XRay Right ankle [**2100-9-21**]:
IMPRESSION: Transverse fracture of medial malleolus.
Brief Hospital Course:
The patient arrived in the trauma bay with an initial Hematocrit
of 14, and a blood gas significant for a pH of 6.91 and a base
deficit of 23. The trauma panel demonstrated a pelvic fracture.
He was had pulsitile bleeding coming from his left lower
extremity, that was completely amputated, demonstrating
pulsitile bleeding, exposed femur (approximately 10cm) and
exposed muscles, with complete loss of skin. The patient was
given a Left chest tube that produced a rush of air. His
initial fast was negative. Clamps and packing were used to get
initial hemostasis, while the patient was actively resuscitated
with Lactated ringers and Blood products. He was rushed to the
operating room for control of the hemorrhage. After ligating
actively bleeding vessels, performing a hip disarticulation and
performing a debridement, the wound was packed and covered with
sterile materials, and the patient was transfered to the
intensive care unit. He by that time had recieved over 20 units
of packed red blood cells and greater than 15 units of Fresh
frozen plasma. Aggressive resucitation was continued, and a
sheet was used to stabilize his pelvis. He was monitored
closely with serial bladder pressures. His bladder pressures
were initially in in the 30s but trended down. Once stabilized
he was also brought to the CT Scan for films. On post op day 1,
the patient was taken back to the operative room for debridement
of the Left stump and for an exploratory laparatomy for fluid
demonstrated on his CT scan. A Vac drain was placed over the
stump. He was concurrently treated with antibiotics. Tube
feeds were started on hospital day 3(post operative days 2 and
1). He was started on a vent wean. On hospital day 6, the
patient was extubated after he bit a hole in the tube. He also
had some gram negative rods in his sputum that was treated with
antibiotics. His chest tubes were discontinued on Hosptial day
7. The patient was stable for transfer to the surgical floor.
His antibiotic regimen included cipro/ceftaz. He returned to
the operating room on hospital day 9 for revision of his Left
upper extremity fracture and for fixation of his right lower
extremity foot fracture. The following day he went to the
operating room for placement of an external fixation device on
his pelvis. He continued to have VAC dressing changes every [**3-9**]
days. When he was more awake, the patient started complaining
of some vivid "flashback" dreams and requested psyciatric help.
The patient was given a sitter for his saftey until he was
evaluated by psychiatry, who felt that he had an acute stress
reaction, but was not suicidal and did not require a sitter. he
was placed on zoloft and seroquel, and his work up also included
and EEG to rule out seizures (negative). His sleep was much
improved with the medication. He was seen daily by psyciatry.
He was continued on his tube feeds until he was tolerating a
regular diet, and he was doing so by hospital day 13. He was
also seen by physical therapy and they began working with him
and setting goals. The patient remained stable on the floor,
his antibiotics were discontinued, his white blood cell count
trended down, was being seen by physical therapy and psychiatry,
while his VAC dressing was changed every three days. It was
granulating nicely by Hospital day 15, and plastic surgery was
consulted to look at the wound the next vac change to assess the
possibility for a skin graft. The patient was taken to the OR
by plastic surgery on HD 23 for a split thickness skin graft to
the left leg amputation site. At discharge on HD 31 the patient
was doing well. He will be discharged to [**Hospital 1319**] rehab with
close follow up in the plastic, orthopedic, and trauma clinics.
Medications on Admission:
None
Discharge Medications:
1. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for breakthrough pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for anxiety/agitation.
6. Methadone HCl 10 mg Tablet Sig: One (1) Tablet PO Q 1800 AND
MIDNIGHT ().
7. Methadone HCl 5 mg Tablet Sig: Three (3) Tablet PO Q 0600 AND
1200 ().
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Nortriptyline HCl 50 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
11. Quetiapine Fumarate 25 mg Tablet Sig: seven Tablet PO at
bedtime: patient to take 175 mg po qHS .
12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed for insomnia .
13. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection
Q3-4H () as needed for breakthrough pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Traumatic left leg amputation
2. Mesenteric tear
3. right Medial maleolus fracture
4. bilateral hemothoraces
5. Sternal fracture
6. right Third metatarsal fracture
7. right second metatarsal fracture
8. right first metatarsal fracture
9. Multiple pelvic fractures
10. Left fifth metacarpal fracture
11. Left third metacarpal fracture
12. Left radiostyloid fracture
13. Acute stress reaction
14. status post chest tube placement
15. status post Left hip disarticulation, operative debridement
of Left leg amputation [**2100-9-14**]
16. status post Exploratory laparotomy with mesenteric tear
[**2100-9-15**]
17. status post G-tube placement [**2100-9-15**]
18. status post Left external fixation of forearm fracture
[**2100-9-14**]
19. status post Revision External fixation of left forearm
fracture [**2100-9-22**]
20. status post External fixation Right foot fracture [**2100-9-22**]
21. status post External fixation of pelvic fractue [**2100-9-23**]
22. Acute blood loss anemia requiring transfusion
23. Coagulopathy
24. Acute hypotension
Discharge Condition:
Good
Discharge Instructions:
Continue pin care, wound care, PT at rehabilitation center.
Continue taking meds as directed.
Followup Instructions:
1. F/U in plastic surgery clinic next Tuesday, [**10-19**]. Please
call for appt. [**Telephone/Fax (1) **]
2. F/U in orthopedic surgery clinic in 2 weeks. Please call for
appointment [**Telephone/Fax (1) 52501**].
3. F/U in trauma clinic in 2 weeks. Please call for appointment
[**Telephone/Fax (1) **].
|
[
"808.9",
"E812.2",
"285.1",
"958.4",
"863.89",
"486",
"897.2",
"459.0",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"39.98",
"96.72",
"86.72",
"84.18",
"79.62",
"83.45",
"79.27",
"96.6",
"34.04",
"54.11",
"96.04",
"79.09",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
9375, 9445
|
4366, 8123
|
381, 891
|
10557, 10563
|
2482, 4343
|
10705, 11014
|
1653, 1671
|
8178, 9352
|
9466, 10536
|
8149, 8155
|
10587, 10682
|
1686, 2463
|
289, 343
|
919, 1518
|
1540, 1548
|
1564, 1637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,470
| 161,564
|
52754
|
Discharge summary
|
report
|
Admission Date: [**2114-1-21**] Discharge Date: [**2114-1-28**]
Date of Birth: [**2035-6-5**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Demerol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
bilateral leg pain found to have hip abscess
Major Surgical or Invasive Procedure:
Washout of R hip prosthesis
Intubation
Central line placement
Arterial line placement
History of Present Illness:
78F w/PMHx polymyalgia rheumatica, bowel obstruction s/p hemi
colectomy with ileostomy, went to OSH ED ([**Hospital1 **]) with diffuse
bilateral lower extremity pain for 4 days, and has been unable
to ambulate at home due to the pain. She complained separately
of a right inner thigh abcess and a left lower extremity ulcer.
She received a workup for suspicion of an epidural abscess due
to her bilateral lower extremity pain, as well as broad spectrum
antibiotic coverage due to "raging cellulitis". She received
CTX, flagyl, ancef, and vanc prior to transfer. She
additionally received multiple doses of morphine and Dilaudid
for pain control.
.
In the ED, initial VS were:
98.0, 102 PR HR: 91 BP: 113/84 Resp: 20 O2Sat: 98
On presentation to the ED, the patient continued to complain of
bilateral lower extremity pain and abdominal pain. On
examination, she had mild ttp around her ostomy site. Her right
thigh abcess was drained and sent for culture. She received a CT
abdomen which demonstrated no acute process but did demonstrate
some gallbladder distention. A followup RUQ ultrasound
demonstrated GB sludge but no significant wall thickening or
other evidence of cholecystitis. The patient's initial lab work
revealed a lactate of 4.3, which improved to 2.6 with IV fluids.
The patient was given a triple-lumen right IJ due to poor
peripheral access. Blood cultures were taken. The patient was
transferred to the MICU due to persistent tachycardia.
.
On arrival to the MICU, the patient was anxious and in visible
distress. She reported her bilateral leg pain as the source of
her discomfort. She denies further abdominal pain, and denies
nausea. Initial vital signs on arrival were 37.2 HR 151, BP
164/64, r19, 94% on RA.
.
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 rashes or skin changes.
Past Medical History:
- peptic ulcer disease
- gastritis
- hypertension
- osteoarthritis
- rheumatoid arthritis
- polymyalgia rheumatica
- ischemic bowel
- ? renal insufficiency (unclear baseline creatinine)
- s/p R hemicolectomy
- illeostomy
- s/p appendectomy
- vein ligation bilateral legs
- torn cartilege R leg
- spinal fusion
-s/p hysterectomy
- s/p bilateral hip replacement
- s/p DVT evacuation from RLE
- SBO
- bilateral cataracts repairs
Social History:
Social History: Lives part of the year in [**Location (un) 86**], part of the
year in [**State **]. Returned from [**State **] 1 week ago. Lives w/
husband of 60 years. Has 4 children, 4 grandchildren. Formerly
smoked 0.5 ppd X 20 years. No current tobacco, ETOH. No illicit
drugs.
Family History:
Mother-CAD, [**Name2 (NI) 499**] cancer
[**Name (NI) 46425**]
[**Name (NI) 108802**] cancer, fibromylagia
[**Name (NI) 108803**] myeloma
Physical Exam:
Vitals: T: 37.2 BP: 103/58 P:93 R:15 O2: 100
General: Alert, oriented, anxious, in moderate distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, CVL RIJ
CV: Regular rate and rhythm, normal S1 + S2, III/IV SEM most
prominent @ RUSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, ileostomy site without erythema or induration
Ext: warm, well perfused, 2+ pulses, no cyanosis or edema, small
(1cmx1cm) ulcer over LLE, 2x2cm abscess @ R lateral hip, minimal
erythema
Neuro: CNII-XII intact, 5/5 strength upper extremities,
difficult to assess lower extremity strength due to pain in
bilateral leg, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred
Pertinent Results:
[**2114-1-27**] 03:36AM BLOOD WBC-26.7* RBC-3.89* Hgb-10.7* Hct-33.1*
MCV-85 MCH-27.5 MCHC-32.3 RDW-20.5* Plt Ct-87*
[**2114-1-27**] 03:36AM BLOOD Neuts-78* Bands-7* Lymphs-6* Monos-2
Eos-0 Baso-0 Atyps-1* Metas-3* Myelos-3* NRBC-5*
[**2114-1-27**] 03:36AM BLOOD Plt Smr-LOW Plt Ct-87*
[**2114-1-27**] 03:36AM BLOOD Glucose-167* UreaN-79* Creat-3.2* Na-132*
K-5.3* Cl-106 HCO3-10* AnGap-21*
[**2114-1-22**] 05:08AM BLOOD ALT-16 AST-61* LD(LDH)-376* AlkPhos-85
TotBili-0.3
[**2114-1-27**] 03:36AM BLOOD TotProt-3.5* Calcium-8.4 Phos-5.0* Mg-2.2
[**2114-1-21**] 04:25PM BLOOD Lipase-27
[**2114-1-21**] 04:25PM BLOOD TSH-8.3*
[**2114-1-24**] 07:40AM BLOOD Cortsol-29.4*
[**2114-1-24**] 08:06PM BLOOD CRP-83.9*
[**2114-1-26**] 09:29AM BLOOD Vanco-22.7*
[**2114-1-26**] 09:50AM BLOOD Type-ART Temp-36.7 Rates-/9 PEEP-5
FiO2-40 pO2-162* pCO2-27* pH-7.28* calTCO2-13* Base XS--12
Intubat-INTUBATED Vent-SPONTANEOU Comment-PS 5
[**2114-1-26**] 03:03AM BLOOD Lactate-1.9
[**2114-1-26**] 03:03AM BLOOD freeCa-1.28
CT abd/pelvis: IMPRESSION:
1. Limited CT examination however significantly distended
gallbladder. Right
upper quadrant ultrasound is recommended for further evaluation.
2. Stable postoperative appearance of subtotal colectomy with
ileostomy and
mucous fistula.
3. Stable appearance of bilateral hip prostheses.
4. Resolution of previously seen right sided hydronephrosis.
5. Small bilateral pleural effusions.
RUQ IMPRESSION: Distended gallbladder with sludge, but no
specific signs for
acute cholecystitis.
TTE: The left atrium is elongated. 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%). There is no ventricular
septal defect. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets are
moderately thickened. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2109-8-5**],
mild AS is now detected.
Hip Xray: IMPRESSION:
1. No evidence of hardware complication or acute fracture.
2. No subcutaneous air identified.
3. Bilateral protrusio acetabuli, not significantly changed.
4. Opaque structure projecting over the left iliac [**Doctor First Name 362**] is of
uncertain
clinical significance but was not present on prior CT from [**6-12**], [**2112**].
Further evaluation could be performed with oblique views or CT,
if clinically
indicated.
Renal US: CONCLUSION: This is a limited study showing small
kidneys with normal vascular flow in the right and no detectable
flow on the left. No evidence for hydronephrosis.
Brief Hospital Course:
Assessment and Plan: 78 yo F with PMH significant for BL hip
replacements c/b revisions and multiple infected hardware, also
ileostomy [**2-15**] SBO, chronic pain, and PMR on steroids who
presented to the MICU with hypotension, tachycardia, and
bloodstream infection.
.
1. Sepsis and Hospital Course: The patient had blood cultures
that grew Strep pneumo and CONS. These also grew out from her
hip abscess, which was the source of the bacteremia. The patient
was taken to the OR by ortho for right hip washout. Also, the
patient was placed on broad spectrum antibiotics including
vancomycin and cefepime. The patient came back from the OR
intubated due to a metabolic acidosis. While intubated, the
patient continued to decompensate including third spacing of
fluids, increased acidosis, worsening pain, kidney injury, and
pressor requirement. The patient continued to be treated for
infection with antibiotics and a wound vac to the R hip. The
patient's other cultures were all negative. Despite aggressive
fluids, pressors, and antibiotics, the patient did not recover.
It was decided by her family to be made CMO. After 18hrs, the
patient expired.
.
Medications on Admission:
metoprolol 25mg 0.5 tab qhs
metoprolol 25mg 1 tab qd
prednisone 5mg tab po
norco 10mg-325mg 1 tab q4-6h
calcium 500 + D 500mg (1250)-400unit tab po qday
methadone 5mg tab tid
methadone 5mg [**1-15**] tab qd
levothyroxine 75mcg po qd
digoxin 125mcg po qd
digestive enzymes 1 tab po qd
lexlansoprazole 60mg delayed release po qd
abatacept 125mg/ml subQ twice monthly
forteo 20mcg/dose (6000 mcg/2.4mL) sub-Q daily
lidoderm 5% patch 2patch qhs
vitamin d3 1,000u po bid
lasix 20mg po q48h
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"288.50",
"V45.4",
"725",
"518.51",
"V88.01",
"V45.72",
"995.92",
"585.9",
"707.19",
"244.9",
"338.29",
"V43.64",
"682.6",
"403.90",
"427.31",
"276.2",
"251.2",
"584.9",
"711.05",
"V15.82",
"287.5",
"288.60",
"V44.2",
"V12.51",
"V58.65",
"E878.1",
"V49.86",
"038.2",
"459.81",
"518.4",
"996.66"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"96.6",
"78.65",
"38.97",
"77.65",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9276, 9285
|
7552, 7837
|
330, 417
|
9336, 9345
|
4395, 7529
|
9401, 9547
|
3384, 3522
|
9244, 9253
|
9306, 9315
|
8734, 9221
|
7854, 8708
|
9369, 9378
|
3537, 4376
|
2203, 2619
|
245, 292
|
445, 2184
|
2641, 3068
|
3100, 3368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,125
| 169,564
|
37155
|
Discharge summary
|
report
|
Admission Date: [**2108-1-5**] Discharge Date: [**2108-2-15**]
Date of Birth: [**2056-4-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Constipation and nausea
Major Surgical or Invasive Procedure:
Pleurex cathether placement
Exploratory laparotomy
PICC placement
History of Present Illness:
(HPI per admitting surgery service)
OSH transfer from LGH. No d/c summary sent with patient.
51 yo male with DM, HTN, gastric cancer, stage 3C colorectal ca
dx [**2105**] with extensive serosal and nodal disease at
presentation. He underwent resection with colostomy. He
underwent chemo + XRT with completion of all treatments 1 year
ago. He then had reversal of the colostomy and at that point was
considered to be free of his disease but with significant risk
given the the amount of disease when he presented. He had a
recurrance this past year with mets to peritoneum. He presented
to an OSH on [**2107-12-18**] with constipation an nausea amd
constipation, emesis. He also had persistent LH which began
after hernia repair in [**2107**] and at this time it was found that
his cancer had recurred. With standing/exercise/and using the BR
he is light headed and feels week. + SOB. No CP.+ Subjective
chills but no fevers.
He was admitted to the OSH from [**2107-12-7**] to [**2107-12-14**] for a ?
of SBO which did not require surgical intervention. He was
treated conservatively with IVF, laxatives and eventually
improved. He was discharged to home. He continues to take
narcotics with fentanyl, percocet, and did not keep taking the
laxative. His abdominal CT on presentation demonstrated a slight
increase in ascites, persistent small bowel dilatation and
transition to decompressed bowel near the prior ventral incision
area. Possible peritoneal implant seen. This was similar to his
chest CT a few weeks prior. His oncologist thought that his sx
were secondary to constipation and not frank mechanical
obstruction. He was treated with an NGT -> suction, IVF, NPO
with plans to start chemotherapy and an agressive bowel regimen.
Thoracentesis performed on L lung on [**12-25**]. Last thoracentesis
[**2108-1-1**]. CT chest negative for PE. P/w N/V, looking
obstructive, seen by [**Doctor First Name **], thought ileus. Non-operative.
Somewhat stable, cycles of N/V, constipation. Somewhat tenuous.
Not stable for chemo. Pleural effusion, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] x 2 with
reaccumulation within days. Feels SOB at rest. NGT last removed
2 weeks ago with failed attempts to advance his diet despite
relief of constipation. In addition to abdominal pain he also
feels pressure as though 10 people are standing on his stomach.
Last episode of emesis was 2 days ago, green brown and smelly.
No blood.
Family requesting transfer, and they request second opionion
about CA treatment. Talked about Pleurex with [**Name (NI) 16814**],
unclear if will do it. Family wants second opinion about CA
treatment. He has not eaten for 18 days. Every time he eats he
has abdominal pain and he is afraid to eat.
-Constitutional: [X]WNL [+]35 lb Weight loss in 3 months
[+]Fatigue/Malaise [-]Fever [-]Chills/Rigors []Nightweats
[]Anorexia
-Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: [X]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: []WNL [-]Chest pain []Palpitations []LE edema
[]Orthopnea/PND [-]DOE
-Respiratory: []WNL [-]SOB [+]Pleuritic pain- b/l upper quadrant
abdominal pain with inspiration []Hemoptysis [+]mild dry
intermittent cough but not new
-Gastrointestinal: []WNL [+]Nausea [-]Vomiting [+]Abdominal pain
- epigastric pain which radiates to the right upper quadrant. He
also has constant abdominal pain which worsens with eating
[+]Abdominal Swelling []Diarrhea [+]Constipation but had some
diarrhea and soft formed stool []Hematemesis []Hematochezia
[]Melena
-Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: [X]WNL []Incontinence/Retention []Dysuria []Hematuria
[]Discharge []Menorrhagia
-Skin: [X]WNL []Rash []Pruritus
-Endocrine: [X]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: []WNL []Myalgias []Arthralgias [+]Back pain
b/l flank pain R>L
-Neurological: [X]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
-Psychiatric: []WNL [+]Depression []Suicidal Ideation
-Allergy/Immunological: [] WNL []Seasonal Allergies
All other ROS negative
Past Medical History:
No h/o MI
DM
HTN
Colorectal cancer diagnosed in [**2105**], s/p chemotherapy and XRT
presented with recurrent disease in [**9-/2107**] found during hernia
repair.
Hyperlipidemia
Anemia
Depression
Stent in right kidney- 3 months ago
Social History:
Lives with his daughter in apartment on [**Location (un) **]. Independent
with standing shower. Walks with a walker in the hospital.
[**Name (NI) 62983**] pt and family deny alcohol abuse, at most one drink per
week.
Illicits- marijuna, cocaine - quit > 9 years ago
Tobacco - 38 years x 10 cigs per day, quit 5 months ago
From DR [**Last Name (STitle) **] [**2092**], was working in contruction.
ADLS: unable to dress without assitance, hygiene Ok, becomes
SOB.
Allergies: NKDA
Family History:
Mother and father have DM and HTN. Family members have gastric
cancer.
Physical Exam:
VS: T = 97.8 P = 121 BP = 137/97 RR = 16 O2Sat = 97% on 3L
GENERAL: Young male
Nourishment: Well nourished
Grooming: OK
Mentation: All
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Decreased BS in the L lung field.
Cardiovascular: RRR, nl. S1S2, tachy, no M/R/G noted
Gastrointestinal: distended, firm, + mass in R middle quadrant
Genitourinary: deferred
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical, lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
No foley catheter/+ NC
Psychiatric: slightly limited affect.
Pertinent Results:
Admission Labs
[**2108-1-5**] 10:12PM BLOOD WBC-9.1 RBC-3.90* Hgb-9.7* Hct-32.1*
MCV-83 MCH-24.8* MCHC-30.1* RDW-13.8 Plt Ct-690*
[**2108-1-5**] 10:12PM BLOOD Neuts-77.0* Lymphs-10.9* Monos-6.5
Eos-5.3* Baso-0.3
[**2108-1-5**] 10:12PM BLOOD PT-14.3* PTT-29.2 INR(PT)-1.2*
[**2108-1-5**] 10:12PM BLOOD UreaN-12 Creat-0.8 Na-143 K-4.0 Cl-100
HCO3-35* AnGap-12
[**2108-1-5**] 10:12PM BLOOD ALT-12 AST-15 LD(LDH)-175 CK(CPK)-27*
AlkPhos-109 Amylase-13 TotBili-0.3
[**2108-1-5**] 10:12PM BLOOD Albumin-3.2* Calcium-8.7 Phos-4.0 Mg-2.2
Iron-20*
[**2108-1-5**] 10:12PM BLOOD calTIBC-216* Ferritn-286 TRF-166*
Most Recent Labs
[**2108-2-13**] 09:56AM BLOOD WBC-21.1* RBC-3.38* Hgb-8.4* Hct-28.5*
MCV-84 MCH-24.8* MCHC-29.5* RDW-16.5* Plt Ct-882*
[**2108-2-13**] 12:47AM BLOOD Neuts-15* Bands-9* Lymphs-22 Monos-36*
Eos-3 Baso-0 Atyps-0 Metas-7* Myelos-6* Promyel-2* NRBC-3*
[**2108-2-13**] 12:47AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Spheroc-1+ Burr-1+
[**2108-2-13**] 09:56AM BLOOD PT-16.3* PTT-89.7* INR(PT)-1.4*
[**2108-2-13**] 09:56AM BLOOD Glucose-239* UreaN-99* Creat-2.9* Na-143
K-4.1 Cl-111* HCO3-17* AnGap-19
[**2108-2-13**] 09:56AM BLOOD ALT-23 AST-23 CK(CPK)-31* AlkPhos-239*
TotBili-1.5
[**2108-2-13**] 12:47AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.2
Other Pertinent Labs
[**2108-1-25**] 12:00AM BLOOD Triglyc-154*
[**2108-1-8**] 06:45AM BLOOD CEA-36*
[**2108-2-13**] 09:59AM BLOOD Type-ART Temp-36.1 pO2-72* pCO2-33*
pH-7.36 calTCO2-19* Base XS--5 Intubat-NOT INTUBA
[**2108-2-13**] 09:59AM BLOOD Lactate-1.7
[**2108-2-13**] 08:15AM BLOOD O2 Sat-87
[**2108-2-13**] 09:59AM BLOOD freeCa-1.29
Pleural Fluid
[**2108-1-6**] 02:28PM PLEURAL WBC-370* RBC-4050* Polys-1* Lymphs-86*
Monos-6* Eos-5* Meso-2*
[**2108-1-6**] 02:28PM PLEURAL TotProt-4.6 Glucose-140 LD(LDH)-192
Ascites Fluid
[**2108-1-18**] 02:50PM ASCITES WBC-175* RBC-[**Numeric Identifier 72496**]* Polys-6* Lymphs-32*
Monos-0 Eos-4* Plasma-2* Mesothe-3* Macroph-53*
[**2108-1-18**] 02:50PM ASCITES TotPro-3.7 Glucose-106 LD(LDH)-264
TotBili-0.4 Albumin-1.7
Most Recent Urinalysis
[**2108-2-13**] 10:23AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2108-2-13**] 10:23AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-SM
[**2108-2-13**] 10:23AM URINE RBC-689* WBC-33* Bacteri-FEW Yeast-NONE
Epi-2
[**2108-2-13**] 10:23AM URINE CastHy-7*
Initial CT C/A/P ([**2109-1-5**]) - IMPRESSION:
1. Small-bowel obstruction with transition point in right lower
quadrant.
2. Diffuse ascites.
3. Large left-sided pleural effusion with mass effect on the
mediastinum pushing it to the right. No pulmonary embolism
present.
Most Recent CXR ([**2108-2-13**]) - There has been a mild increase in
opacification of the infrahilar right lower lobe, but not enough
to call as pneumonia. Small right pleural effusion has
increased. On the left, despite the pleural drain is still small
volume of pleural fluid but no pneumothorax. Heart is normal
size. Left subclavian line ends at the junction of the
brachiocephalic veins and a right subclavian PIC line passes to
the low SVC. Nasogastric tube runs below the diaphragm out
of view.
CTA Chest ([**2108-2-6**]) - IMPRESSION:
1. Acute pulmonary embolus in the lingular and right lower lobe
segmental pulmonary arteries.
2. Moderate bilateral pleural effusion and adjacent atelectasis,
increased since [**2108-1-16**].
3. Intra-abdominal ascites.
CT Head ([**2108-2-11**]) - IMPRESSION: No acute intracranial process.
Brief Hospital Course:
The patient is a 51 year old male with DM, HTN, metastatic
rectal cancer s/p resection, XRT with recurrence presents to an
OSH 20 days prior with sob, abdominal pain, nausea, emesis and
was transferred here for further management.
HOSPITAL COURSE - Presented with nausea, abdominal pain, emesis,
and inability to tolerate po intake. CT scan was consistent with
SBO. Surgery was following patient with consideration of
palliative diversion. Initially, he had an NG tube placed.
Eventually, his bowel improved with enemas, dulcolax, colace and
senna as well as methylnaltrexone. His abdominal pain improved
after he started to move his bowels. He was started on TPN. His
PO intake remained poor secondary to nausea and poor appetite.
His abdomen remained distended. Given that the etiology remained
elusive and he was receiving opoid antagonists, the surgical
team was reconsulted and the GI service was consulted. He
subsequently underwent exploratory laporotomy, with hope of
seeing a small obstruction amenable to surgical treatment.
Unfortunately, the ex lap was remarkable for diffuse
carcinomatosis, with omental caking and an abdominal mass.
Post-operatively, given persistent tachycardia, the patient
spent 1 day in the ICU and then was transferred back to the
floor. His post-op course was complicated a hospital acquired
pneumonia (for which he completed a 14-day course of vanc and
zosyn) and worsening ileus, with minimal flatus and bowel
movements and no po intake for several days post-operatively.
Given that his primary symptomatology was due to his diffuse
cancer, the oncology service was reconsulted and he was
transferred to the oncology service for initiation of
chemotherapy. In the interim, pathology from the ex-lap was
noteable for poorly differentiated adenocarcinoma with signet
cell features.
During the time prior to his transfer to the oncology service,
he was also noted to have a large left pleural effusion. A
pleurex catheter was placed by interventional pulmonology and
drained intermittently throughout his stay. Cytology from this
showed cells consistent with metastatic adenocarcinoma. During
his time on the surgery service, he also underwent a
paracentesis, with removal of 2.5 liters.
After transfer to the oncology service, the patient still had an
NGT tube on suction in place. He was given 1 round of FOLFIRI
in an attempt to shrink his tumor burden and improve his
symptoms. He tolerated this round of FOLFIRI fairly well.
However, he was not noted to significantly improve after this
treatment. He continued to have abdominal pain and nausea,
which would worsen when his NGT tube was clamped. He also
stopped having bowel movements. Of note, on [**2108-2-6**], the
patient developed an episode of tachycardia, which was initially
thought to be SVT. He received adenosine with only minimal
improvement in his heart rate. He was then noted to be in sinus
rhythm. CTA was performed because he did have a slight oxygen
desaturation, and it was significant for a PE. He was started
on a heparin drip. A family meeting was held as the patient's
2nd round of chemotherapy. He was told that his prognosis was
poor and was presented with his options at that time. He opted
to continue with the second round of chemotherapy in the hope
that it would give him some more quality time to spend with his
family. However, prior to this round of chemotherapy being
given, the patient's clinical status worsened. He was noted to
become more somnolent. A CT of the head was performed and
showed no acute process. It was decided to hold the
chemotherapy at that time. During this time, the patient was
also noted to have a brief episode of neutropenia and fever, for
which he was placed on vanc and cefepime for 2 days. In the
early morning of [**2108-2-13**], the patient had vomited and had an
aspiration event. His O2 sats decreased and he was placed on a
face tent, which improved his sats. CXR showed no acute
changes. Later in the morning, the patient began to have
worsening respiatory status. He became severely tachypneic and
tachycardic and was transferred to the ICU. He was started on
vanc and zosyn. Upon ICU transfer, his family was contact[**Name (NI) **] and
decided to make him [**Name (NI) 3225**]. In the ICU, he was initially placed on
BiPAP and then transitioned to non-rebreather. He was then
transferred back to the floor on a "comfort measures only"
status. He was placed on a morphine infusion. On [**2108-2-15**], he
was transferred to an inpatient hospice closer to his home, at
the request of his family.
With respect to his DM, the patient's blood sugars were
reasonably well-controlleed. He was maintained on an insulin
sliding scale until he was made [**Date Range 3225**].
At the time of discharge, the patient still has an NG tube to
suction. He remains NPO with an ileus. He also remains on a
morphine drip.
Medications on Admission:
Medications on Transfer:
Amitriptyline 25 mg qhs
Bisacodyl 10 mg qd
Fentanyl Patch 50 mcg q 72 hours
Insulin SS
Lactulose 30 gm qd
Regalan 10 mg
Lopressor 25 mg po bid
Percocet prn
Protonix 40 mg qd
Senna
Morphine sulfate 15 mg po q 4 hours prn
Morphine sulfate 30 mg po q 4 hour prn
.
Metformin 1000 mg po bid
Glipizide 20 mg po bid
Simvastatin 20 mg po qd
Vitamin B12 po qd
Percocet prn
vitamin B12
fentanyl patch 25 mcg q 72 hours
Metamucil daily
Fentanly Patch 25 mcg q 72 hours
Metamucil 2 scoops
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) unit Rectal
every four (4) hours as needed for fever or pain.
2. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 g
Intravenous Q6H (every 6 hours).
3. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous q48h.
4. Morphine (PF) in D5W 100 mg/100 mL (1 mg/mL) Parenteral
Solution Sig: 5-20 mg/hr Intravenous INFUSION (continuous
infusion): Please uptitrate as needed for pain.
Disp:*1 month's supply* Refills:*0*
5. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q2H (every 2
hours) as needed for pain.
Disp:*600 mg* Refills:*0*
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) patches
Transdermal Q72H (every 72 hours).
Disp:*20 patches* Refills:*0*
7. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) as needed for secretions.
Disp:*10 Patch 72 hr(s)* Refills:*0*
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
9. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) mL
Injection PRN as needed for line flush: PICC, heparin dependent:
Flush with 10mL Normal Saline followed by Heparin as above daily
and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]Hospice
Discharge Diagnosis:
Recurrent, metastatic rectal adenocarcinoma
Malignant pleural effusion
Ileus
Pneumonia
Pulmonary emboli
Acute renal failure
Hypoxic respiratory failure
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic and not arousable
Activity Status:Bedbound
Discharge Instructions:
You were transferred from [**Hospital6 3105**] for
worsening abdominal pain. You were found to have progression of
your cancer on surgical examination in the operating room. You
also underwent placement of a catheter in your chest to drain
fluid in your lungs caused by your cancer. You were transferred
to the Oncology service to receive a cycle of chemotherapy. You
tolerated this relatively well. Unfortunately, your hospital
course has been complicated by many other medical issues,
including bowel paralysis (ileus), pneumonia, blood clots in
lung (pulmonary emboli) with abnormally fast heart rhythm,
worsening kidney failure, and aspiration leading to respiratory
failure. Due to your worsening clinical status, the decision was
made with your family to transition your care to focus on
comfort. Your remain on a breathing mask and with an nasogastric
tube to suction. You will be transferred to a hospice facility
closer to your home.
Thank you for allowing us to take part in your medical care.
Followup Instructions:
You will be followed by the physicians at hospice.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
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Discharge summary
|
report
|
Admission Date: [**2163-4-4**] Discharge Date: [**2163-4-14**]
Date of Birth: [**2081-12-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 year old male on palliative chemotherapy for Stage IV
bronchalveolar carcinoma (navelbine C8D14), neutropenia, DM2 who
initially presented with iatrogenic hypoglycemia, now with
hypoxia requiring CPAP.
.
Patient was hospitalized initially for symptomatic hypoglycemia
caused by glipizide which was supposed to be discontinued.
Initially developed after vomiting, briefly had convulsions, but
blood sugars responded to treatment and home glipizde was
discontinued. On admission he was also noted to have a cough 3L
O2 requirement, equivocal CXR and UTI and was started on
treatment with levofloxacin. During his hospitalization, he
was noted to be ataxic, possibly froma paraneoplastic porcess,
and unsafe to go home unsupervised with plan to d/c today with
24 hour supervision and 2L home O2.
.
This afternoon, patient was noted to be increasingly hypoxic at
84% on 3L. O2 sat increased to 88% on 6L NC, ABG showed
7.47/34/50/25.
.
He was transitioned to NRB 15L with sat up to 90%. There was
concern for mucus plug. RT put him on CPAP (as BiPap not
permitted on teh floor). CXR showed question of new aspiration
PNA. Antibiotics were broadened to Vancomycin and Cefepime. He
was empirically given 20mg IV lasix. He maintained his sats
89%-93% for 3 hours. CPAP was transitioned back to 6L NC,
because patient was hungry. Sats tolerated this for an hour,
before he desatted again to 85%. On arrival to the ICU ,
patient's sats were 97% on NRB 12L.
.
.
Per patient when he feels dyspneic at home, he sometimes uses
his CPAP machine during the day. Dyspnea has been going on for
many years, worse in the last three years, but no acute change
today. He has had a cough for several week. He also reports
dysuria for several weeks. Worsening ataxia that makes it
difficult to ambulate, uses a 4pod cane at home. He reports a
35lb weight loss over the last 3-5 weeks. He has occassional
nausea/vomiting. He has chronic double vision on the right side.
He denies fevers, chills, headache, dizziness, chest pain,
abdominal pain, blood in urine, constipation/diarrhea, blood in
stools, lower extremity edema, new rash. Of note, patient's
last chemotherapy session was 6 days prior to admission.
Past Medical History:
Bronchalveolar carcinoma, dx in [**4-4**] on CT scan for PNA. MRI
brain was negative. He subsequently had recurrent
hospitalization for PNA and ultimately AMS. MRI in [**11-4**]
demonstarted new cortical T2/FLAIR-hyperintensity along left
frontal lobe, and the orbitofrontal gyrus in the anterior
cranial fossa.
Tx: s/p tx with Alimta in [**12-4**] with clinical improvement but
stable imaging. Developed progression of sx on CT, started on
Gemcitabine [**10-6**], utlimately d/c'd [**1-6**] due to side
effect(pneumonitis), restarted on palliative therapy with
Navelbine recently reduced in dose intensity due to tolerance of
side effects (fatigue and hematologic). Most recently received
tx 6 days prior to admission.
- Diabetes mellitus type 2, on glipizide and metformin.
- Coronary artery disease, s/p MI [**2139**], and s/p stent in [**2149**].
- Bladder cancer, followed by [**Doctor Last Name **].
- Prostate ca s/p prostatectomy
- Obstructive sleep apnea on CPAP.
- Hypertension.
- Hyperlipidemia.
- Allergic rhinitis.
- Status post right total knee replacement.
- Chronic back pain/spinal stenosis s/p L4/L5 laminectomy in
[**2113**].
- Status post right ulnar impingement release.
- Erectile dysfunction.
- h/o erysipelas with chronic right lower extremity skin
changes.
- GERD.
- Depression
Social History:
He lives with his wife. [**Name (NI) **] reports relative independence
with activities until recently, now requires a cane to ambulate
and complains of ataxia. He was a three-pack-per-day smoker
until his early 20's (15-20 pack-year hx). He does not drink or
use drugs. He is still occasionally working as a psychiatrist,
but is not working presently. Has two children not living in
[**Location (un) 86**].
Family History:
Lymphoma in his father, mother with rectal cancer. Both parents
had heart disease. Other relatives had diabetes mellitus
Physical Exam:
VS - T100.4 BP130/60 HR 84 94% NRB
GENERAL - Alert, interactive, chronically ill appearing
gentleman with gurgling cough.
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - bilateral crackles to midl lungs bilaterally R>L, R
lower lobe with egophany. good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength 5/5
throughout
Pertinent Results:
ADMISSION LABS:
.
[**2163-4-4**] 08:30PM BLOOD WBC-2.9* RBC-4.38* Hgb-13.1* Hct-39.5*
MCV-90 MCH-29.9 MCHC-33.1 RDW-14.9 Plt Ct-247
[**2163-4-4**] 08:30PM BLOOD Neuts-46.0* Lymphs-47.4* Monos-1.6*
Eos-4.1* Baso-1.0
[**2163-4-4**] 08:30PM BLOOD Glucose-32* UreaN-21* Creat-1.2 Na-139
K-3.6 Cl-106 HCO3-23 AnGap-14
[**2163-4-5**] 05:45AM BLOOD Albumin-3.3* Calcium-9.8 Phos-2.1*
Mg-1.4*
.
DISCHARGE LABS:
.
[**2163-4-13**] 03:07AM BLOOD WBC-17.6* RBC-4.22* Hgb-12.5* Hct-39.2*
MCV-93 MCH-29.7 MCHC-32.0 RDW-16.0* Plt Ct-238
[**2163-4-13**] 03:07AM BLOOD Neuts-62 Bands-5 Lymphs-17* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-2* Promyel-1*
[**2163-4-13**] 03:07AM BLOOD Glucose-210* UreaN-23* Creat-1.2 Na-139
K-4.4 Cl-107 HCO3-22 AnGap-14
[**2163-4-13**] 03:07AM BLOOD Calcium-10.3 Phos-2.8 Mg-1.8
.
CXR [**2163-4-4**]: Stable appearance of chronic lung changes on top of
known
bronchioalveolar cell carcinoma.
.
CXR [**2163-4-5**]: Stable appearance of chronic lung changes from
known
bronchioalveolar carcinoma. An underlying infectious process
cannot be
excluded.
.
CXR [**2163-4-6**]: Bibasilar pneumonia, worse on the right.
.
MRI HEAD [**2163-4-5**]:
There is no evidence of hemorrhage, infarction, edema, mass, or
mass effect. Few scattered T2/FLAIR hyperintensities are seen in
bilateral
periventricular white matter and centrum semiovale, likely
represent small
vessel ischemic disease. There is generalized prominence of
ventricles,
sulci, and extra-axial CSF spaces consistent with age-related
involutional
changes. There is no abnormal enhancement seen. Major
intracranial flow voids
are preserved. Visualized orbits and mastoid air cells are
unremarkable.
There is mucosal thickening in bilateral ethmoidal air cells.
IMPRESSION: No evidence of metastatic disease
Brief Hospital Course:
81 year old male with Stage IV bronchoalveolar carcinoma on
palliative chemotherapy, ataxia, initially admitted to the floor
with hypoglycemia, transferred to the MICU for hypoxia.
.
# Acute on chronic hypoxia: Likely a progression of his known
BAC, with copius secretions and mucous plugging. Initially
thought that there could be a component of pneumonia and was
treated with a course of vanc/cefepime/azithromycin, though our
suspicioun for an infectious process was lower. He was
maintained on PRN guaifensin, nebs, chest PT, and CPAP which
should be continued at rehab. Given the irreversibility of his
disease and worsening symptoms, a family meeting was held with
his primary oncologist and the decison was made to discharge to
rehab with bridge to hospice if no improvement. He required
occasional non-rebreather and hi-[**Last Name (un) **] face mask throughout his
MICU stay, and ultimately was on 6L of NC by discharge. His o2
sats generally ranged in the high 80s-low 90s with occasional
desats to the high 70s-low 80s. He should continue to get
aggressive bronchopulmonary hygeine at rehab along with frequent
nebs and guaifenisin
.
# Delerium: pt became delerious in the MICU secondary to
several sleepless nights. He was started on seroquel 25mg
nightly with improvement in his sleep wake cycle. This should
be continued as needed along with measures to ensure sleep
hygeine and frequent reorientation. Of note, he was started
briefly on ritalin to help with his daytime energy but this was
discontinued in the setting of his delerium.
.
# Hypoglycemia: His poor PO intake and declining nutritional
status in combination with his oral hypoglycemics and underlying
UTI likely precipitated hypoglycemia. Resolved with sevarl amps
of D50 and d/c of oral hypoglycemics. His blood sugars started
to increase on dishcarge and was maintained on HISS. His DM
regimen on discharge was metformin, but plan was to coninue
holding home glipizide. He should be maintained on an insulin
sliding scale as needed
.
#UTI: Positive UA culture grew out coag negative staph. Patient
has history of UTI initally tender suprapubic region. Initial
infection may have contributed to hypoglycemia. He was
maintained on broad spectrum abx as above for his pna which
covered his UTI
.
# Neutropenic fever: Neutropenic [**1-27**] chemotherapy on admission.
Fever likely due to UTI and disease progression. He was covered
with antibiotics as above, and started on neupogen which was
stopped when his counts recovered. Chemo held in-house.
.
#Gait disturbance: Chronic ongoing. Deconditioning vs.
paraneoplastic phenomenon. PT feels that patient is a high fall
risk and very unsteady on his feet. Brain MRI shows no evidence
of metastatic lesions. He should have PT at rehab
.
# Stage IV bronchoalveolar carcinoma: Followed closely by [**Hospital1 18**]
Oncology, currently on palliative chemotherapy after failing two
previous regimens. Chemo was held and neupogen was started
given his neutropenic fever. As above, a family meeting was
held and the decision was made to discharge to rehab with
possible plan for hospice in the future. His outpatient
oncologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] should
be included in these discussions.
.
# Yeast infection: noted in genital area after pulling off
condom catheter. He was given mizonazole powder as needed.
.
# CAD s/p MI: No acute cardiovascular issues. Normotensive. CCB
and statin were stopped during admission. He was maintained on
metoprolol, imdur, and aspirin
.
# Depression: Continued wellbutrin
.
# Transitional issues:
-Pt should continue nebs, Bronchopulmonary hygiene, guaifensin
and supplemental O2 at rehab
-Currently DNR/DNI. There should be ongoing discussion with his
oncologist about possibility of hospice
-Blood sugars should be monitored given his hypoglycemia on
admission, and subsequent restarting of metformin.
Medications on Admission:
-bupropion HCl 300 mg daily
- clonazepam 1 mg qhs prn insomnia
- diltiazem HCl 180 mg daily
- folic acid 1mg daily
- glipizide 10 mg [**Hospital1 **]
- isosorbide mononitrate 120 mg daily
- metformin 850 mg [**Hospital1 **]
- metoprolol succinate 50 mg daily
- ondansetron HCl 8 mg q8h PRN nausea
- ranitidine HCl 300 mg daily
- rosuvastatin 20 mg daily
- acetaminophen 1000 mg [**Hospital1 **]
- aspirin 81 mg daily
- diphenhydramine HCl 50 mg Capsule qhs
- geriatric multivit w/iron-min daily
- guaifenesin/dextromethorphan combination cough syrup dosage
uncertain
- pseudoephedrine dosage uncertain
- loratadine 10 mg daily
- oxygen 4-5 liters/min while sleeping, driving, or with other
activity so as to keep Sa02 >89%. Patient uses it while sleeping
and sporadically throughout the day for fatigue or SOB
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
10. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
11. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for sob/wheeze.
13. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast infection.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY: Hypoglycemia, hypoxemic respiratory failure,
broncheoale
SECONDARY: Non-insulin-dependent diabetes mellitus, Stage 4
bronchoalveolar carcinoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Dr. [**Known lastname 97128**],
You were admitted to the hospital because you had an episode of
low blood sugar at home. While in the hospital, we stopped your
glipizde, but your metformin should be restarted on discharge.
You also had difficulty maintaining your oxygen numbers and
required you to be in the ICU. We treated you with supplemental
oxygen and helped clear your airway. You will continue on
oxygen at rehab in hopes that you may improve.
Please make the following changes to your medications:
1. STOP taking glipizide
2. STOP rosuvastatin
3. STOP diltiazem
4. STARTED miconazole powder for yeast infection
5. STARTED seroquel 25mg nightly for delerium/sleep
Please take all other medications as prescribed.
Please keep all follow-up appointments
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-4-19**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-4-19**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], 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: TUESDAY [**2163-4-19**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"162.8",
"E932.3",
"288.03",
"V46.2",
"599.0",
"507.0",
"799.02",
"E933.1",
"781.3",
"E849.0",
"V49.86",
"V15.82",
"112.3",
"780.09",
"327.23",
"311",
"V10.51",
"250.80",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13436, 13502
|
6938, 10561
|
312, 318
|
13699, 13699
|
5133, 5133
|
14681, 15774
|
4349, 4471
|
11755, 13413
|
13523, 13678
|
10920, 11732
|
13884, 14373
|
5536, 6915
|
4486, 5114
|
14402, 14658
|
260, 274
|
346, 2560
|
5149, 5520
|
13714, 13860
|
10584, 10894
|
2582, 3907
|
3923, 4333
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,130
| 147,273
|
34223
|
Discharge summary
|
report
|
Admission Date: [**2108-6-1**] Discharge Date: [**2108-6-8**]
Date of Birth: [**2074-11-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
suicidal ideation, bleach and alcohol ingestion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 78818**] is a 33 yo recovering alcoholic who presented to the
ED today with suicidal ideation. He says for the past 30 days he
has been trying to kill himself by drinking alcohol. He was
quite intoxicated on arrival to the MICU, but states that he was
not a drinking until 30 days ago when he decided he wanted to
kill himself so he began drinking heavily. Today he drank [**1-18**]
gallon of vodka; he does not say when his last drink was. He
also says he tried to kill himslef by drinking chlorox several
days ago. He denies any other illicit drug use or any other
prescription medications. Today he decided he wanted to live and
therefore called EMS to bring him to [**Hospital1 18**]. His EtOH level on
arrival was 334 but he was noted to be sweaty, tachycardic,
tremulous, and hallucinating. In the ED his presenting vital
signs were 97.8 HR 120 135/71 96% RA, He was given valium 80mg
and a banana bag.
.
Upon arrival to the MICU he was not sweaty, tachycardic, or
agitated. He said he was seeing and hearing things when
questioned directly, but did not say what this was and did not
appear to be hallucinating. He did talk a lot about Buddhist
religious issues and his tatoos. He endorsed some double vision,
nausea, epigastric pain. Denied headache, dizziness, chest pain,
dyspnea, fevers, chills. He was eager to go home.
Past Medical History:
pancreatitis
+ h/o DT's and alcohol withdrawal seizures
Social History:
Lives alone with his cat. Works as a personal trainer
Family History:
unknown
Physical Exam:
T 97.2 HR 65 BP 136/73 RR 12 O2 99% RA
General: slurring speech, hiccuping and yawning frequently.
diaphoretic
HEENT: NCAT. Pupils reactive and symmetric
CV: RRR, no murmurs/rubs/gallops
Abdomen: soft, non-distended, + epigastric TTP
Extremity: no clubing/edema/cyanosis
Neuro: grossly intact. No nystagmus. cannot perform
finger-to-nose. vision. no clonus. Depressed reflexes. moving
all extremities but not following commands
Pertinent Results:
[**2108-6-1**] WBC-6.7 RBC-4.58* Hgb-14.3 Hct-41.1 MCV-90 MCH-31.3
MCHC-34.9 RDW-14.3 Plt Ct-169 Neuts-72.8* Lymphs-20.7 Monos-3.7
Eos-2.5 Baso-0.2 Plt Ct-169
[**2108-6-2**] PT-11.6 PTT-29.5 INR(PT)-1.0
[**2108-6-1**] Glucose-108* UreaN-22* Creat-0.9 Na-142 K-4.3 Cl-102
HCO3-26 AnGap-18
[**2108-6-1**] ALT-146* AST-148* LD(LDH)-293* AlkPhos-71 Amylase-138*
TotBili-0.9 DirBili-0.2 IndBili-0.7 Lipase-60
[**2108-6-2**] Calcium-7.9* Phos-3.8 Mg-1.9
[**2108-6-1**] Osmolal-384*
[**2108-6-1**] TSH-0.94
[**2108-6-1**] BLOOD ASA-NEG Ethanol-373* Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2108-6-2**] Ethanol-151*
[**2108-6-4**] Ethanol-NEG
.
Hepatitis serologies pending
.
Studies:
CT Head ([**6-1**]): Evaluation of the skull base is limited due to
motion. There is no definite intracranial hemorrhage, mass
effect, or shift of normally midline structures. [**Doctor Last Name **]-white
matter differentiation is preserved. The ventricles are normal
in size and symmetric. There is no evidence of acute major
vascular territorial infarction. There is mild ethmoid sinus
mucosal thickening. The mastoid air cells are clear. Surrounding
osseous and soft tissue structures are grossly unremarkable.
IMPRESSION: No evidence of intracranial hemorrhage.
.
CXR [**6-2**]: Single view chest reveals clear lungs. Heart and
mediastinal contours within normal limits. No focal osseous
abnormalities. Pleural space are unremarkable. IMPRESSION: No
active disease. Clear lungs.
.
Abdominal U/S ([**6-3**]): The liver demonstrates normal echotexture.
There is no intrahepatic or extrahepatic biliary dilatation. The
common bile duct
measures 4 mm. The gallbladder is unremarkable. There is no
cholelithiasis
or pericholecystic fluid. The right kidney measures 13.3 cm. The
spleen
measures 9.5 cm. The left kidney measures 13.1 cm. The aorta is
of normal
caliber throughout. The pancreas is unremarkable. The tail of
the pancreas
is obscured by overlying bowel gas. IMPRESSION: Unremarkable
abdominal ultrasound.
.
CT Chest/Abd/Pelvis [**6-3**]:
CT OF CHEST WITH IV CONTRAST: The soft tissue windows
demonstrate normal
appearance of the aorta and major arteries. No pathologically
enlarged
central lymphadenopathy is noted. The esophagus has normal
appearance. No
pneumomediastinum is visualized. No periesophageal stranding is
noted. The
lung windows do not demonstrate any pulmonary nodule,
parenchymal
opacification or pleural effusion.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder,
common bile duct, pancreas, spleen, adrenal glands, kidneys,
stomach, duodenal loops of small bowel and large bowel have
normal appearance. No free air or fluid is noted within the
abdomen and pelvis. No pathologically enlarged mesenteric or
retroperitoneal nodes are noted.
.
CT OF THE PELVIS: The rectum and sigmoid colon have normal
appearance. The
oral contrast material reaches the rectum. The urinary bladder,
distal
ureters are unremarkable. No pathologically enlarged pelvic or
inguinal nodes are noted.
.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.
old right lower rib fracture.
.
IMPRESSION: No acute traumatic injury is identified.
Specifically, there is no evidence of esophageal perforation. No
pneumomediastinum is noted.
Brief Hospital Course:
Mr. [**Known lastname 78818**] is a 33 yo man who presents with recent suicide
attempt by EtOH and bleach ingestion.
.
# Alcohol dependence/withdrawal:
Upon arrival to the ICU, the patient had very high CIWA scores,
exhibiting high levels of anxiety, diaphoresis, tremor and
hallucination. He received high doses of IV valium. His tox
screen was negative for other substances. He received
MVI/folate/thiamine. He was transferred to the medicine floor
with gradual improvement in CIWA scales and use of diazepam as
needed. The social work and psychiatry teams were asked to
evaluate the patient in the hospital. He expressed very strong
interest in stopping alcohol use completely and agreed to
inpatient psychiatric treatment. He did not require any diazepam
for 3 days prior to discharge.
# Suicidal ideation: The patient was monitored with a 1:1
sitter. The psychiatry teame evaluated the patient. He denied
suicidal ideation while he was in the hospital. However, as he
had reported recently ingested bleach and large quantities of
alcohol, it was felt that he was benefit from a short stay in an
inpatient psychiatric facility. The patient agreed and showed a
great deal of initiative to get his life back on track without
alcohol. Upon discharge he denied bleach ingestion and reported
that he said that so that "he would be taken seriously." Due to
his spiritual beliefs he stated that he did not want to take any
psychiatric medications. The patient was discharged to the
psychiatric unit at [**Hospital1 18**] ([**Hospital1 **] 4).
# suicidal Bleach ingestion: The patient initial presented with
epigastric pain. CT scan of the chest, abdomen and pelvis showed
no evidence of esophageal or gastric perforation or fluid
collection. The GI team followed the patient and given that the
ingestion was >5 days prior to presentation and the patient
tolerated a diet of liquids and solids, felt that EGD was not
urgent. Upon discharge, he was taking a regular diet without
difficulty. As above, he denied bleach ingestion.
# Transaminitis: Felt to be consistent with alcoholic hepatitis.
AST/ALT were elevated during his admission to the low 100s.
Hepatitis serologies were done and were elevated during his
stay, though trended down on the day of discharge. He should
have LFTs (including AST, ALT, TBili, AP, LDH) drawn in approx
4-5 days after discharge - results should be faxed to Dr. [**First Name (STitle) 679**]
at [**Hospital1 18**]. He also has an outpatient appt in liver clinic with
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**].
# Hyperbilrubinemia: The patient's total bilirubin rose from 0.9
on admission to 2.7 which was fractionated and found to be
mostly indirect. No evidence of obstruction on RUQ U/S. His
bilirubin trended down. [**Doctor Last Name 9376**] was possible diagnosis due to
prolonged fasting interval initially upon admission. This
trended to normal upon discharge from the hospital.
Medications on Admission:
salt tablets
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Alcohol dependence
Alcohol withdrawal
Bleach ingestion
Suicidal ideation
Alcholic hepatitis
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for suicidal ideation and
alcohol withdrawal. You were initially monitored in the ICU and
treated with medications to counter the effects of alcohol
withdrawal. You did very well and were transfered to inpatient
psychiatry.
.
You should continue to take all medications as prescribed and
keep all health care appointments, in particular, with Dr. [**First Name (STitle) 679**]
from the liver service.
.
If you experience jaundice, difficulty swallowing, abdominal
pain, thoughts of hurting yourself or others, or feel worse in
any way, seek immediate medical attention.
Followup Instructions:
.
Follow-up with your PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - [**Hospital 1263**] Hospital-
[**Telephone/Fax (1) 25350**] upon discharge.
.
You also have an appointment with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] in the liver
clinic on [**6-19**] at 2:45 in the [**Hospital Unit Name **] ([**Last Name (NamePattern1) **]) at [**Hospital1 18**] on the [**Location (un) **] ([**Hospital Unit Name **]).
|
[
"571.1",
"V62.84",
"983.9",
"303.00",
"291.0",
"786.8",
"E849.0",
"E950.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
9030, 9045
|
5670, 8625
|
361, 367
|
9181, 9190
|
2390, 5647
|
9842, 10375
|
1917, 1926
|
8688, 9007
|
9066, 9160
|
8651, 8665
|
9214, 9819
|
1941, 2371
|
274, 323
|
395, 1750
|
1772, 1830
|
1846, 1901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,548
| 190,572
|
37563
|
Discharge summary
|
report
|
Admission Date: [**2124-5-30**] Discharge Date: [**2124-6-8**]
Date of Birth: [**2059-12-10**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Darvocet-N 50 / Fentanyl / Flexeril / Morphine /
Astramorph-Pf / Percocet / Skelaxin / Biaxin / Clindamycin /
Oxaprozin / Diflunisal / Etodolac / Piroxicam / Ketorolac /
Cytotec / Zofran / Reglan / Methadone / Dilaudid / Vicodin /
Prochlorperazine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
[**2124-5-30**] Anterior fusion T12-L5
[**2124-5-31**] Posterior fusion T10-L5
History of Present Illness:
Ms. [**Known lastname 84323**] has a long history of back and leg pain. She has
attempted conservative therapy including physical therapy and
has failed. She now presents for surgical intervention.
Past Medical History:
Carcinoid Tumor
Renal calculi
Scoliosis
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2124-6-5**] 05:55AM BLOOD WBC-3.7* RBC-3.51*# Hgb-10.5*# Hct-31.4*
MCV-90 MCH-30.0 MCHC-33.6 RDW-14.9 Plt Ct-212
[**2124-6-4**] 11:05PM BLOOD Hct-30.6*#
[**2124-6-4**] 03:54AM BLOOD WBC-4.3 RBC-2.63* Hgb-8.2* Hct-24.1*
MCV-92 MCH-31.1 MCHC-33.9 RDW-15.4 Plt Ct-164
[**2124-6-3**] 04:14PM BLOOD WBC-5.5 RBC-2.54* Hgb-7.8* Hct-23.1*
MCV-91 MCH-30.7 MCHC-33.8 RDW-15.4 Plt Ct-130*
[**2124-6-3**] 01:52AM BLOOD WBC-5.4 RBC-2.60* Hgb-7.9* Hct-23.7*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.4 Plt Ct-106*
[**2124-6-2**] 01:40AM BLOOD WBC-10.1 RBC-3.31* Hgb-10.1*# Hct-29.0*
MCV-88 MCH-30.6 MCHC-35.0 RDW-16.0* Plt Ct-120*
[**2124-6-1**] 04:11AM BLOOD WBC-12.7* RBC-4.35 Hgb-13.3 Hct-38.2
MCV-88 MCH-30.5 MCHC-34.7 RDW-16.5* Plt Ct-134*
[**2124-5-30**] 05:59PM BLOOD WBC-8.3# RBC-2.88* Hgb-9.3* Hct-26.7*
MCV-93 MCH-32.4* MCHC-35.0 RDW-13.7 Plt Ct-210
[**2124-6-5**] 05:55AM BLOOD Glucose-107* UreaN-16 Creat-0.4 Na-140
K-3.5 Cl-105 HCO3-27 AnGap-12
[**2124-6-4**] 03:54AM BLOOD Glucose-96 UreaN-19 Creat-0.4 Na-142
K-3.5 Cl-105 HCO3-28 AnGap-13
[**2124-6-3**] 01:52AM BLOOD Glucose-83 UreaN-18 Creat-0.7 Na-140
K-3.9 Cl-106 HCO3-26 AnGap-12
[**2124-6-1**] 01:58PM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-138
K-3.8 Cl-104 HCO3-27 AnGap-11
[**2124-5-31**] 10:05PM BLOOD Glucose-153* UreaN-10 Creat-0.6 Na-139
K-4.1 Cl-108 HCO3-25 AnGap-10
[**2124-6-5**] 05:55AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.5*
[**2124-6-3**] 04:14PM BLOOD Calcium-7.9* Phos-1.9* Mg-1.7
[**2124-5-31**] 10:05PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.4*
Brief Hospital Course:
Ms. [**Known lastname 84323**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2124-5-30**] and taken to the Operating Room for T12-L5 release
through an anterior approach. Please refer to the dictated
operative note for further details. The surgery was without
complication and the patient was transferred to the PACU in a
stable condition. Chest tube was placed for drainage
TEDs/pnemoboots were used for postoperative DVT prophylaxis. The
Acute and Chronic Pain Services were consulted due to her
multiple medication allergies. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a dilaudid PCA and ketamine infusion. On HD#2 [**2124-5-31**] she
returned to the operating room for a scheduled T10-L5 posterior
fusion as part of a staged 2-part procedure. Please refer to the
dictated operative note for further details. The second surgery
was also without complication and the patient was transferred to
the T/SICU in stable condition. Postoperative HCT was low and
she was transfused PRBCs. A bupivicaine epidural pain catheter
placed at the time of the posterior surgery remained in place
until postop day 2 when it was removed. She was kept NPO until
bowel function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#4 from the second procedure.
She was for for a TLSO brace for ambulation. Physical therapy
was consulted for mobilization OOB to ambulate. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
Tizanidine
Ativan
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for pain.
14. Meperidine 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for pain.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Discharge Disposition:
Extended Care
Facility:
Center for Extended Care at [**Location (un) 5169**]
Discharge Diagnosis:
Scoliosis
Acute post-op blood loss anemia
Post-op pain
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Thoracic lumbar spine orthoses: when ambulating
Treatments Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2124-6-8**]
|
[
"787.01",
"292.81",
"721.3",
"338.18",
"780.52",
"275.41",
"285.1",
"737.30",
"458.29",
"E938.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.04",
"81.63",
"81.05",
"84.51",
"84.52",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
6046, 6125
|
3014, 4724
|
532, 613
|
6224, 6231
|
1485, 2991
|
8399, 8478
|
945, 950
|
4794, 6023
|
6146, 6203
|
4750, 4769
|
6255, 6361
|
965, 1466
|
8223, 8307
|
8329, 8376
|
6397, 6590
|
483, 494
|
6626, 7093
|
7105, 8205
|
641, 841
|
863, 905
|
921, 929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,891
| 176,918
|
34772
|
Discharge summary
|
report
|
Admission Date: [**2192-9-18**] Discharge Date: [**2192-10-19**]
Date of Birth: [**2168-12-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
CBD injury after lap ccy at OSH
Major Surgical or Invasive Procedure:
[**2192-9-27**] ex lap for nectrotic roux limb with takeback for
bleeding
[**2192-9-18**] roux en y hepaticojejunostomy
pelvic drains placed
History of Present Illness:
23 y.o. female with h/o roux en y gastric bypass and CBD injury
s/p lap ccy at OSH [**8-24**] who had PTC placed at confluence for
mild intrahepatic dilatation, left greater than right with a
dead end at the hepatic duct confluence here now for roux en y
hepaticojejunostomy. Other than some pain at the PTC site, she
has been well and eating well.
Past Medical History:
Roux-en-Y gastric bypass
Abdominoplasty
Lap cholecystectomy
[**2192-9-18**] Roux-en-Y hepaticojejunostomy with biliary
catheter placement.
[**2192-9-27**] Small bowel obstruction with
necrotic and jejunal Roux limb from gastric bypass.
[**2192-9-27**] Exploratory laparotomy with control of
hemorrhage.
Social History:
supportive parents. engaged. ETOH socially. Non-smoker.
Family History:
non-contributory
Physical Exam:
wt 47.6 kg, height 154.9cm
temp- HR 100 BP 121/87 RR O2 sat 100% RA
appears well
lungs clear
heart regular
abd soft, ND, tender at drain sites
Pertinent Results:
[**2192-10-18**] 05:30AM BLOOD WBC-10.4 RBC-3.10* Hgb-9.5* Hct-27.7*
MCV-89 MCH-30.7 MCHC-34.5 RDW-16.2* Plt Ct-527*
[**2192-10-10**] 06:55AM BLOOD PT-14.2* PTT-32.6 INR(PT)-1.2*
[**2192-10-18**] 05:30AM BLOOD Glucose-96 UreaN-12 Creat-0.5 Na-136
K-4.0 Cl-101 HCO3-29 AnGap-10
[**2192-10-16**] 05:38AM BLOOD ALT-38 AST-25 AlkPhos-154* TotBili-0.3
[**2192-10-18**] 05:30AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.8
Brief Hospital Course:
On [**2192-9-18**] she underwent Roux-en-Y hepaticojejunostomy with
biliary catheter placement. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please
see operative note for complete details. The biliary catheter
was then placed into the jejunum as an internal-external stent.
A JP was placed below the biliary anastomosis. Postop, pain was
controlled with an epidural. She had mild tachycardia with heart
rates in the 110-120 range. Hct was stable and maintenance IV
fluid was given. She required IV fluid boluses for low urine
outputs. She was kept npo with an NG tube. Epidural was removed
on pod 3 with pain med switched to Morphine IV. The t tube
averaged 155cc/day and the JP averaged 60cc/day. She had
persistent belching with abdominal distension. On pod 6, a
cholangiogram was done showing the existing catheter had been
displaced in comparison to the previous images obtained during
placement of the catheter on [**2192-9-18**]. The distal aspect of the
drain was located outside of the liver parenchema external to
the biliary tree with contrast flowing superiorly beneath the
dome of the diaphragm. Given these findings, the drain was
removed.
Diet was slowly advanced and tolerated. LFTs improved. She was
moving her bowels and ambulating. The incision appeared clean,
dry and intact.
On [**2192-9-26**], she complained of left lower leg edema greater than
the right leg with L groin pain. An US was done to evaluate for
DVT. This was negative. As the day progressed, she developed
increased lower abdomenal pain for which she was medicated with
percocet without relief. Intermittent IV dilaudid was given with
some decrease in abdominal pain. She was also noted to have
oliguria. The foley catheter was flushed and changed without
improved output despite a bolus. She became tachycardic and
diaphoretic. An EKG showed sinus tachycardia and she was bolused
with IV fluid. An ABD CT was done to evaluate pain and this
demonstrated a large rim-enhancing fluid collection extending
from the right upper quadrant into the pelvis, measuring
approximately 27 x 11 x 7 cm, dilated gastric pouch with
fecalization of adjacent jejunum as well as markedly dilated
fluid-filled loops of small bowel, which appeared to represent
the prior excluded gastric limb. The distal small bowel loops
appeared more collapsed distal consistent with obstruction.
There was free air within the abdomen likely from recent
surgery. She became tachycardic to 150s. WBC 25.2. Given this
presentation, Dr. [**Last Name (STitle) 816**] took her to the OR for exploration.
On [**2192-9-27**] she underwent ex lap with findings of small bowel
obstruction with necrotic and jejunal Roux limb from gastric
bypass. Dr. [**Last Name (STitle) 816**] was the primary surgeon assisted by Dr.
[**Last Name (STitle) 79659**] [**Name (STitle) **]. Most of the jejunum was resected and the
gastric hole was oversewn. Given the degree of infection and
primary reattachment was deferred and an esophageal tube was
placed as well as a gastrostomy tube in through the gastric
remnant for drainage and feeding. While in PACU, she became
tachycardic with a hct drop to 14 for which she was transfused
and taken back to the OR for exploratory laparotomy with control
of hemorrhage. Postop, she was transferred to the SICU and
stayed there for 5 days.
She was febrile on pod 1 to 101.3. Blood cutures were done. This
grew VRE. Vanco, Fluconazole and Zosyn were initially started.
Vanco was switched to Linezolid on [**9-27**]. She was kept NPO and
TPN was started. The esophageal tube and G tube were kept to
gravity drainage. WBC trended down and she remained afebrile.
WBC started to trend up (to 19 on POD 7). An abdominal CT scan
was done on [**10-4**] demonstrating a large fluid collection in the
pelvis with an enhancing rim consistent with abscess and a small
area anterior to the stomach, which contained some air, with
marked thinning of the wall of the stomach. A 10 French pigtail
drainage catheter was placed into this collection. Fluid was
sent for culture. This grew VRE and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **]. Given
these findings, Fluconzole was switched to Caspo to cover
[**Female First Name (un) **].
On [**10-5**], after reviewing the CT she was sent back to CT for
repositioning of the pigtail catheter. A 2nd catheter was placed
transgluteally given that the fluid collections in the pelvis
did not appear to connect. Fluid was sent from this collection
and grew [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **] and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **]. Drainage from
these catheters was low averaging ~ 10cc/day of murky, brown
thick fluid. On [**10-12**] the posterior drain was upsized for a 10
French catheter with 120cc of purulent fluid drained and 40cc of
purulent drainage was cleared from the anterior drain.
On pod 19/10, tube feedings were started via the G tube and TPN
was weaned off. The dietary recommended Nutren Pulmonary with a
goal rate of 50cc/hour. She tolerated this well. Attempt was
made to get her to a cycling rate (60cc/hr x19 hours), but she
continued to have complaints of distension, therefore the rate
was left at 50cc/hour with water boluses of 100cc every 4 hours.
This was well tolerated.
Around pod 21/12 ([**10-9**]), the incision started draining fluid
that resembled the tube feeding. The TF was stopped and a CT was
done noting the G-tube extending 1.5 cm into the gastric
remnant. There was increased amount of air extending from the
open inferior esophagus/gastric pouch defect to the surgical
incision site with no definitive fistula identified and there
were multiple rim-enhancing fluid collections within the abdomen
and pelvis mildly decreased in size. A culture of this fluid
grew 2+ pmns and no microorganisms. She continued on Linezolid,
zosyn and caspo. Zosyn was stopped on [**10-18**] after 21 days. The G
tube was advanced further into the stomach.
On [**10-18**], a surveillance CT showed considerable interval
improvement in all pelvic fluid collections, including
resolution of collection at the site of the anterior pelvic
pigtail catheter in the right lower quadrant. This catheter was
removed.
There was a small residual posterior pelvic collection
containing a transgluteal drain in suitable position.
PT followed her and recommended use of a cane for ambulation.
She was able to ambulate with a cane with supervision.
She was sent home with VNA of Southeastern MA ([**Telephone/Fax (1) 79660**] and
NEHT ([**Telephone/Fax (1) 79661**] for assist with wound care, picc line
antibiotic infusion, and drain care.
Medications on Admission:
cipro 500mg [**Hospital1 **], percocet 1-2 tabs prn q 4 hours, vitamin B 12
500mcg tab 2x/week, Pediatric mvi 1 [**Hospital1 **]
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*200 ML(s)* Refills:*0*
2. Linezolid 100 mg/5 mL Suspension for Reconstitution Sig:
Thirty (30) ml PO every twelve (12) hours: called in to
pharmacy, CVS in [**University/College **].
Disp:*840 * Refills:*2*
3. Nutren Pulmonary Liquid Sig: Fifty Five (55) ml PO per
hour via the G tube.
Disp:*140 cans* Refills:*2*
4. Tube Feeding Supplies
pump, tubing, syringes
1 month supply
Refills: 2
5. Alternating Pressure Mattress Pad with pump
DX: Stage II sacral decubitus
6. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection
twice a day: flush anterior and posterior drains. aspirate back
first then forwar flush.
Disp:*56 * Refills:*2*
7. Caspofungin 50 mg Recon Soln Sig: One (1) Intravenous once a
day: via picc line.
Disp:*42 doses* Refills:*0*
8. Outpatient Lab Work
weekly labs: cbc, chem 10, ast, alt, alk phos, tbili, albumin
Fax results to [**Telephone/Fax (1) 697**] attn: [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN Coordinator
9. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection
pre and post antibiotic for 6 weeks: via picc line.
Disp:*100 syringes* Refills:*0*
10. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous
[**Hospital1 **]: post antibiotic infusion after flushing with saline via
picc.
Disp:*42 doses* Refills:*2*
11. PICC line supplies
pump, tubing, dressing kits
supply 6 weeks
refill 1
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] HOME THERAPIES
Discharge Diagnosis:
CBD injury s/p ccy at OSH
roux en y hepaticojejunostomy
necrosis of gastric bypass roux limb
VRE bacteremia
Stage II decubitus
pelvic collections
Discharge Condition:
fair
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, malfunction of G tube, abdominal
distension/increased abdominal pain, incision wound
redness/drainage, drain insertion sites red/draining, increased
drainage via the drains or drainage stops
Flush pelvic drains twice daily with 5-10cc of sterile saline
after aspirating first
Labs: every week
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2192-10-22**]
8:30
Completed by:[**2192-10-19**]
|
[
"707.22",
"V09.80",
"560.9",
"707.03",
"997.4",
"614.3",
"568.81",
"785.0",
"790.7",
"E870.0",
"E878.2",
"996.59",
"998.2",
"112.89",
"278.00",
"458.29",
"998.11",
"V45.86",
"568.0",
"E878.1",
"537.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.01",
"87.51",
"99.07",
"54.91",
"54.19",
"00.14",
"51.37",
"99.04",
"96.6",
"99.15",
"45.13",
"97.55",
"97.29",
"43.19",
"54.59",
"44.69",
"45.62",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
10297, 10363
|
1920, 8617
|
348, 491
|
10553, 10560
|
1490, 1897
|
11008, 11195
|
1286, 1304
|
8796, 10274
|
10384, 10532
|
8643, 8773
|
10584, 10985
|
1319, 1471
|
277, 310
|
519, 870
|
892, 1197
|
1213, 1270
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,243
| 127,492
|
6717
|
Discharge summary
|
report
|
Admission Date: [**2131-10-31**] Discharge Date: [**2131-11-10**]
Date of Birth: [**2067-3-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Prednisone / Penicillins / Iodine; Iodine
Containing
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Patient presents with increasing shortness of breath.
Major Surgical or Invasive Procedure:
[**2131-10-31**] Mitral Valve Replacement utilizing a 27mm [**Last Name (un) 3843**]
[**Doctor Last Name **] Pericardial Thermafix Valve
History of Present Illness:
Mrs. [**Known lastname 25582**] is a 64 year old female with history of mitral
valve endocarditis in [**2128-3-17**]. She was diagnosed with mitral
regurgitation at that time. Since then, she has been
experiencing progressive shortness of breath and lower extremity
edema. She denies chest pain, orthopnea, PND, palpitations and
syncope. A cardiac catheterization in [**2131-8-18**] confirmed
severe mitral regurgitation. She had normal coronary arteries.
Findings were also notable for moderate to severe pulmonary
hypertension. Based on the above results, she was referred for
cardiac surgical intervention.
Past Medical History:
Mitral regurgitation
History of mitral valve endocarditis
Congestive heart failure
Chronic renal insufficiency - baseline creatinine 3.0
Nephrotic syndrome
Hypertension
Hyperlipidemia
Diabetes
Hypothyroidism
Anemia
Obesity
Gout
Cataracts
History of Bells Palsy
Social History:
The patient denies any tobacco, or intravenous drug use. She
drinks about [**1-19**] glasses of wine per year. She lives at home
with her family.
Family History:
Father was a diabetic, died at age 89. Mother suffered from
[**Name (NI) 11964**].
Physical Exam:
BP 180/90, Pulse 80 regular. Weight 202 lbs. Height 61 inches.
General: Obese female in no acute distress. Appears older that
stated age.
Skin: good turgor, no rashes
HEENT: Oropharynx benign
Neck: supple, without JVD
Chest: clear bilaterally, slightly decreased at bases
Heart: regular rate, s1s2, 3/6 systolic murmur best heard LLSB
Abdomen: obese, no pulsatile masses, soft, nontender
Extremities: warm, tr edema
Varicosities: none
Neuro: alert and oriented, no focal deficits noted
Pulses: 2+ distally
Pertinent Results:
[**2131-10-31**] 12:41PM BLOOD WBC-18.7*# RBC-2.96* Hgb-8.8* Hct-26.0*
MCV-88 MCH-29.6 MCHC-33.7 RDW-15.0 Plt Ct-151
[**2131-10-31**] 01:50PM BLOOD UreaN-57* Creat-2.4* Cl-110* HCO3-23
[**2131-11-1**] 12:00AM BLOOD Calcium-8.0* Phos-4.3 Mg-3.5*
[**2131-11-2**] 10:17AM BLOOD Cyclspr-68*
Brief Hospital Course:
Mrs. [**Known lastname 25582**] was admitted on [**10-31**] and underwent a
mitral valve replacment with a pericardial thermafix valve. The
operation was uneventful and she was brought CSRU on minimal
inotropic support. Within 24 hours, she awoke neurologically
intact and was extubated. She weaned from pressort support
without difficulty. By postoperative day one, she experienced
oliguria and developed acute respiratory distress which required
reintubation. The renal service was consulted and recommended to
hold cyclosporine and continue Lasix trials. Her creatinine
peaked to 3.9. Her acute on chronic renal failure was attributed
to acute tubular necrosis. K+ levels remained within normal
limits and there was no inidication to proceed with
hemodialysis. Over the next several days, she gradually
responded to Lasix drip. By postoperative day three, she was
re-extubated. She was concomitantly started on Amiodarone for
paroxsymal atrial fibrillation. She otherwise maintained stable
hemodynamics and remained mostly in a normal sinus rhythm. She
was gradually transitioned to oral Lasix and transferred to the
SDU on postoperative day five. Due to poor IV access, the
central venous line was left in place and changed appropriately.
She continued to remain mostly in a normal sinus rhythm,
tolerating beta blockade and Amiodarone. Her renal function
continued to improve. Cyclosporine was eventually continued on
postooperative day 7.
She continued to make clinical improvements and was cleared for
discharge on postoperative day 10. At discharge, her oxygen
saturations were 95% with the chest x-ray showing ****. Her
heart rate was in sinus rhythm and blood pressure was well
controlled. All surgical wounds were clean, dry and intact.
Medications on Admission:
Aspirin 325 qd, Protonix 40 qd, Prandin 2 [**Hospital1 **], Colace, Senna,
Lopressor 50 qam and 25 qpm, Synthroid, Nifedocal, Cyclosporine,
Lasix 120 qam and 80 qpm, KCL 10 qd, Hydralazine 10 qid, Imdur
30 qd, Lantus 6 units each evening
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
4. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO TIDAC (3
times a day (before meals)).
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
8. 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*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
12. Repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3
times a day (before meals)).
Disp:*55 Tablet(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Take for 2 weeks, Then 200mg daily until stopped by
cardiologist.
Disp:*72 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Partners home care
Discharge Diagnosis:
Mitral regurgitation s/p Mitral Valve Replacement with Tissue
Valve History of mitral valve endocarditis
Postoperative Atrial Fibrillation, First degree AV block
Congestive heart failure
Chronic renal insufficiency - baseline creatinine 3.0
Nephrotic syndrome
Hypertension
Hyperlipidemia
Diabetes
Hypothyroidism
Anemia
Obesity
Gout
Cataracts
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month.
No lifting more than 10 lbs for at least 10 weeks from the date
of surgery.
No driving for 1 month.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**2-20**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17996**] in [**12-21**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**12-21**] weeks.
[**Hospital 10701**] clinic in [**11-19**] weeks after discharge.
|
[
"997.1",
"278.00",
"424.0",
"403.91",
"518.5",
"426.11",
"584.9",
"427.31",
"250.00",
"272.4",
"585.9",
"V58.67",
"276.2",
"581.9",
"428.0",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"89.68",
"96.71",
"96.04",
"88.72",
"35.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6350, 6399
|
2577, 4326
|
398, 537
|
6784, 6790
|
2266, 2554
|
7132, 7441
|
1641, 1725
|
4614, 6327
|
6420, 6763
|
4352, 4591
|
6814, 7109
|
1740, 2247
|
305, 360
|
565, 1176
|
1198, 1460
|
1476, 1625
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,219
| 127,114
|
46043
|
Discharge summary
|
report
|
Admission Date: [**2176-12-4**] Discharge Date: [**2176-12-14**]
Date of Birth: [**2109-5-15**] Sex: F
Service: SURGERY
Allergies:
Ampicillin / Penicillins / Bactrim / Lisinopril / Shellfish
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy
lysis of adhesions
reduction of internal hernia
History of Present Illness:
67 y/o female with a h/o sigmoid colon adenocarcinoma, HTN, and
sarcoidosis who presented to clinic for her 8th cycle of
irinotecan with worsening epigastric pain radiating to her back
which is worse with eating, also reports not feeling well. She
has been having loose stools, 2-4X/day, for the past several
weeks. She also reports a decreased appetite. She admits to
nausea but no vomiting. A KUB and CT abdomen after her visit did
not reveal any evidence of obstruction but did reveal an
internal hernia. She received IVF and had some improvement of
her symptoms and was sent home. Her pain persists and does
report nausea with the pain.
.
Her complaint of dyspnea is at her baseline and she denies chest
pain, [**First Name3 (LF) **], fever, chills, or night sweats. Denies arthralgias
or myalgias. No chestpain or shortness of breath. Reports
diarrhea x ~2weeks controlled to 2-3x daily with imodium. Denies
hematochezia but reports dark stools secondary to iron pills.
She was admitted to the hematology/oncology service but
transferred to the colorectal surgery service for management of
her small bowel obstruction.
Past Medical History:
Mucinous adenocarcinoma (>50%), pT3, pN2, and M1 (stage IV) with
mets to the omentum and peritoneum, s/p sigmoid resection on
[**2175-6-9**], s/p 5 cycles of FOLFOX, began irinotecan on [**2176-5-24**] c/b
hypercapnic respiratory failure on the first day of her sixth
cycle ([**2176-10-8**]) and was admitted to the ICU and required
intubation, on [**2176-10-18**] she received another dose of irinotecan
which was c/b a SBO which resolved and she was discharged on
[**2176-11-3**]. She had her seventh cycle on [**2176-11-5**] and subsequently
returned to clinic for her 8th cycle and was not feeling well.
PMH/PSH:
1. Sigmoid colon adenocarcinoma as noted above.
2. Complete small bowel obstruction 5 weeks ago.
3. Respiratory failure requiring brief intubation in late
[**9-17**]. Asthma
5. HTN
6. Sarcoidosis/Pulm HTN - She remains on 1.5 L/min of O2. She
remains on inhaled iloprost about 5-6 times a day per Pulmonary.
She continues on prednisone.
7. History of hypercalcemia.
8. Osteopenia
9. Hypercholesterolemia
10. Decreased T4 s/p thyroid adenoma resection
11. History of steroid induced hyperglycemia
Social History:
Lives with daughter. Former [**Name2 (NI) 1818**], quit smoking 25 yrs ago (10
pack years). No ETOH/drugs.
Family History:
Negative for any colon, uterine, or any other type of
malignancy.
.
Physical Exam:
Vital Signs: Blood Pressure: 111/77, Heart Rate: 136, Weight:
143.1 Lbs, BMI: 26.6 kg/m2, Temperature: 97.3, Resp. Rate: 16,
O2
Saturation%: 96.
GENERAL: Alert, no apparent distress.
HEENT: Sclerae anicteric. Normal conjunctivae. Oropharynx
clear.
LUNGS: Clear to auscultation and percussion bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Firm, nondistended. Bowel sounds are present and of a
gurgling quality. She has tenderness in the epigastrium and
right side of the abdomen with associated guarding and rebound.
EXTREMITIES: No clubbing, no cyanosis. There is bilateral
lower
extremity edema, left greater than right.
LYMPH NODES: No cervical, supraclavicular, axillary, or
epitrochlear adenopathy. She has a 2.5 cm hard, fixed lymph
node
in her right inguinal region and two 1 cm hard, fixed nodes in
her left inguinal region that are unchanged.
NEURO: Alert and oriented. Motor and sensory exam intact.
Pertinent Results:
LABS:
[**2176-12-3**] 09:30AM WBC-4.5 RBC-3.32* HGB-9.9* HCT-31.4* MCV-95
MCH-29.7 MCHC-31.4 RDW-16.4*
[**2176-12-3**] 09:30AM GRAN CT-2550
[**2176-12-3**] 09:30AM CEA-125*
[**2176-12-3**] 09:30AM TOT PROT-6.4 ALBUMIN-4.0 GLOBULIN-2.4
CALCIUM-8.2*
[**2176-12-3**] 09:30AM ALT(SGPT)-8 AST(SGOT)-14 LD(LDH)-213 ALK
PHOS-45 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2176-12-3**] 09:30AM GLUCOSE-88 UREA N-22* CREAT-1.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-34* ANION GAP-9
[**2176-12-9**] 10:30AM BLOOD Type-ART Temp-37.0 pO2-66* pCO2-81*
pH-7.20* calTCO2-33* Base XS-1 Intubat-NOT INTUBA
[**2176-12-9**] 01:05PM BLOOD Type-ART pO2-111* pCO2-45 pH-7.38
calTCO2-28 Base XS-0
[**2176-12-11**] 02:08AM BLOOD Type-ART pO2-127* pCO2-48* pH-7.45
calTCO2-34* Base XS-8 Intubat-NOT INTUBA
.
ABDOMEN (SUPINE & ERECT) [**2176-12-3**] 10:09 AM
No radiographic evidence of bowel obstruction. Given the paucity
of gas within the small bowel and distal large bowel and
[**Hospital 228**] medical history, can consider CT examination if high
clinical suspicion.
.
CT PELVIS W/CONTRAST [**2176-12-3**] 3:19 PM:
1. Marked wall edema involving loops of jejunum and proximal
ileum with proximal and distal transition points, mesenteric
engorgement, and rotation/"swirling" of the mesentery all
suggestive of an internal hernia with vascular compromise. No
bowel obstruction at this time though finding are concerning for
impending closed loop obstruction
2. No significant interval change to the amount of
intra-abdominal and intrapelvic ascites. Worsening peritoneal
disease evidences by growing left paracolic nodule.
3. Stable sarcoidosis of the lung and necrotic/ calcified
retroperitoneal lymphadenopathy.
4. Unchanged hypoattenuating hepatic and renal lesions, some of
which are too small to characterize and some of which are simple
cysts. Stable inguinal lymphadenopathy.
.
PATHOLOGY [**2176-12-6**] Subcutaneous nodule, excision:
1. Skin and superficial subcutis with foreign body giant cell
reaction and fat necrosis with focal calcification.
2. No carcinoma is seen.
.
CHEST (PORTABLE AP) [**2176-12-9**] 12:11 PM
No evidence of acute cardiopulmonary process. Severe
infiltrative process, likely secondary to chronic sarcoidosis,
is not changed.
.
ECG Study Date of [**2176-12-9**] 10:31:38 AM
Sinus rhythm. Baseline artifact. Compared with prior tracing of
[**2175-10-26**]
no major change is evident.
Brief Hospital Course:
Medical Service:She was initially admitted to the medical
service for managment with NPO status, IVF, bowel rest, and pain
management. Dr.[**Name (NI) 1863**] [**Name (STitle) **] Surgery service was
consulted. At that point, it appeared she would require surgical
reduction of the hernia & lysis of adhesions. She was consented
and prepped for the OR.
.
Ms. [**Known lastname 97994**] operative course was uncomplicated. She was
routinely observed in the PACU, and transferred to [**Hospital Ward Name **] for
post-op care.
.
VOLUME STATUS: Post-operative marginal urine output, which
responded to fluid boluses. Due to her compromised respiratory &
cardiac function, she had difficulty processing the additional
intravascular fluid. She was found to be lethargic at the
bedside on POD1, somewhat responsive to stimuli, but unable to
answer questions. An ABG was collected revealing respiratory
acidosis. She was immediately transferred to the ICU for
ventilatory support. She was intubated for a day, and extubated
successfully once her respiratory status returned to baseline.
In addition, she was aggressively diuresed with adequate
response.
.
RESP/Sarcoidosis:She uses 2 liters of oxygen at home at
baseline. Her home regimen includes Hydroxychloroquine &
Sildenafil for management of her sarcoidosis. Her pulmonar
hypertension is well controlled with Nifedipine & Atenolol. She
was able to wean to her baseline oxygen requirement, and resumed
on all her home medications. She continues to be tachypneic
which is also her baseline, RR-24-30. She was evaluated per
Physical Therapy. She will be discharged home with PT for
further strenghtening & respiratory re-conditioning.
.
ABD: Her incision is closed with staples and OTA. She had an
unremarkable postoperative course in regards to her abdomen.
.
NUT:She was NPO post-op. She remained NPO post-op while
intubated. Once extubated, she was advanced to a regular,
cardiac healthy diet. She has been tolerating regular food
without complaints of nausea/vomiting.
.
ELIM:She had a foley catheter inserted in the operating room.
Once her urinary output stabilized, her foley was removed. She
received two doses of AcetaZOLamide IV on [**Hospital Ward Name **], which provided
ample diuresis. She is currently urinating adequate amounts.
.
PAIN: Her pain is controlled on oxycodone and tylenol.
Dispo:she was discharged home with services on [**12-14**] tolerating a
diet, pain well controlled, VS stable
Medications on Admission:
Atenolol
Hydroxychloroquine
Levothyroxine
Nifedipine
Prednisone 10 mg
Imodium AD after each BM
Oxycodone 5 mg Q4-6 hrs PRN
Omeprazole 40 mg daily
Iron pills daily
PRN Compazine
.
ALLERGIES: Penicillin, bactrim, lisinopril, shellfish
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Sildenafil Oral
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 4 weeks.
Disp:*56 Capsule(s)* Refills:*0*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
9. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1) Tablet
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary:
- small bowel obstruction
- internal hernia
- post-operative respiratory failure, transferred to ICU for
ventilation
- post-operative volume overload, managed with diuretics
secondary:
- metastric peritoneal mucinous adenocarcinoma
- sarcoid
- hypertension
- hypothyroidism
- osteopenia
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2176-12-31**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2176-12-31**] 9:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2176-12-31**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1864**] Follow-up
appointment should be in 2 weeks. Please call for appointment
Completed by:[**2176-12-16**]
|
[
"552.8",
"518.5",
"401.9",
"135",
"244.9",
"416.0",
"197.6",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"96.04",
"38.91",
"53.9",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9837, 9895
|
6326, 8787
|
334, 407
|
10236, 10314
|
3876, 6303
|
11530, 12182
|
2841, 2911
|
9071, 9814
|
9916, 10215
|
8813, 9048
|
10338, 11168
|
11183, 11507
|
2926, 3857
|
280, 296
|
435, 1561
|
1583, 2699
|
2715, 2825
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,676
| 164,479
|
52111
|
Discharge summary
|
report
|
Admission Date: [**2138-10-29**] Discharge Date: [**2138-11-19**]
Service: MEDICINE
Allergies:
Penicillins / Aspirin / A.C.E Inhibitors
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None. (Nuclear stress test)
History of Present Illness:
[**Age over 90 **] yo female wityh hx chronic renal failure Stage III, diabetes,
hyperlipidemia, spinal stenosis, legally blind, glaucoma,
arthritis, and signif PVD s/p LE bypass grafts in [**2135-8-13**], and
very recent lingular pneumonia s/p treatment with Levofloxacin,
presents with c/o acute onset SSCP, on R chest. Pt is a
difficult historian, however, sx onset last night approx 7:30 to
8pm, located on R chest, severe (estimate [**2139-8-20**]), not
respirophasic, no radiation. Denies associated SOB, diaphoresis,
paresthesias. Pt does state that she had associated severe
maliase; and caused her to lay down to rest. Pt presented to ED
(approx 11pm). Pt unable to state if changes with food, as did
not eat while with CP.
.
Cardiac enzymes in ED negative. Pt noted to be tachycardic in ED
104-120, and remains tachy.
.
ROS:
+: as above, cough, constipation
.
Denies:
weight changes, fever, chills/rigors, night sweats, anorexia,
photophobia, loss of vision, sore throat,
palpitations, DOE, SOB, nausea, vomiting, abdominal pain,
abdominal swelling, diarrhea. ROS otherwise negative.
[**Hospital Unit Name 92800**]: History of Present Illness: The patient is a [**Age over 90 **] yo
female with hx of chronic renal failure, diabetes,
hyperlipidemia, spinal stenosis, legal blindness, glaucoma,
arthritis, PVD, and recent lingular pneumonia s/p treatment wth
Levofloxacin who presents from medicine floor due to an increase
in oxygen requirement, confusion, somnolence, and lethargy. She
was originally admitted to the medicine floor with an acute
onset SSCP 3 days prior to current admission. Cadiac enzymes
have been negative. Nuclear stress test done [**2138-10-30**] showed
moderate fixed inferior wall defect exteding to the apex with
normal function and ventricular size with LVEF of 60%. No
anginal symptoms or ischemic ST changes were noted. Patient
continues to complain of diffuse pains in lieu of her chronic
pain syndrome, mainly at the site of her left arm keloid.
.
On day of admission, patient was noted to have an increasing O2
requirement, satting in low 90s on 3L, and was noted to be more
lethargic, confused, and somnolent. An urgent CXR was done
which revealed large pleural effusion. She has remained
afebrile with no cough. Respiratory therapy was called and ABG
revealed 7.28/72/116. Lasix 100mg IV x1 was ordered and she was
transfered to [**Hospital Unit Name 153**] for ventilatory monitoring.
.
Her vitals on transfer were: T97.2, BP 150/80, HR 101, RR 20,
sat 88% on 2L.
.
On the floor, another ABG was acquired, which revealed
7.21/85/60, at which point, she was intubated by anesthesia.
Past Medical History:
-Chronic renal insuffiency baseline cr 1.4.
-Diabetes with neuropathy
-Left atrial thrombus on warfarin dx [**2136**], not seen on repeat
ECHO in [**2137**]
-Dyslipidemia
-Polymotor sensory deficit
-Spinal stenosis
-Hypertension
-Cardiomyopathy (Echo: [**9-/2137**], EF55%, Mild mitral regurgitation,
-Minimal aortic stenosis, Moderate pulmonary hypertension)
-Peptic ulcer disease
-GERD
-Hypothyroidism/goiter
-Chronic constipation due to puborectalis dysfunction
-Arthritis
-Glaucoma
-Legally blind in both eyes
-Bilateral cataracts s/p surgery
-s/p TAH
-s/p cholecystectomy
-peripheral [**Year (4 digits) 1106**] disease history:
-[**7-20**]: non-healing left great toe ulcer
-[**2135-6-28**]: right great toe ulcer excision, bone biopsy
-[**2135-6-22**]: right above-knee popliteal to DP bypass with NRSVG & R
[**Doctor Last Name **] aneurysm ligation for a critically ischemic right foot
-[**2136-5-8**]: right proximal SFA to DP bypass with L NRSVG c/b
dehiscence of RLE incision on POD7, requiring re-suturing
Social History:
Originally from [**Location (un) 4708**]. She has 5 children. She denies
smoking, alcohol or drug use.
Family History:
No known history of stroke, mother with diabetes, and nearly all
with hypertension.
Physical Exam:
VS: afebrile 152/84 90 18 92 3LNC
GEN: Elderly female, blind, non-toxic. Breathing comfortably.
HEENT: blind, MMM.
Neck: No LAD. JVP WNL.
RESP: CTA B. No WRR. Fair resp effort.
CV: RRR. No mrg. CP not reproducible on exam.
ABD: obese. +BS. Soft, NT/ND.
Ext: 1+LE edema B. +periperal pulses, feet warm, perfused.
Neuro: CN 2-12 grossly intact. No focal defecits. Difficult
historian, unable to recall times, details.
.
Pertinent Results:
[**2138-10-28**] 11:30PM BLOOD WBC-8.2 RBC-3.75* Hgb-10.5* Hct-34.5*
MCV-92 MCH-28.1 MCHC-30.5* RDW-16.2* Plt Ct-298
[**2138-10-30**] 06:05AM BLOOD WBC-7.4 RBC-3.87* Hgb-11.3* Hct-35.8*
MCV-93 MCH-29.3 MCHC-31.7 RDW-15.2 Plt Ct-269
[**2138-10-28**] 11:30PM BLOOD Glucose-287* UreaN-29* Creat-1.6* Na-139
K-5.9* Cl-104 HCO3-27 AnGap-14
[**2138-10-30**] 06:05AM BLOOD Glucose-166* UreaN-25* Creat-1.3* Na-140
K-5.1 Cl-103 HCO3-29 AnGap-13
[**2138-10-28**] 11:30PM BLOOD CK(CPK)-102
[**2138-10-29**] 05:30AM BLOOD CK(CPK)-72
[**2138-10-28**] 11:30PM BLOOD CK-MB-4 cTropnT-<0.01
[**2138-10-29**] 05:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2138-10-30**] 06:05AM BLOOD CK-MB-4 cTropnT-<0.01
[**2138-10-30**] 06:05AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9
[**2138-10-30**] 09:19AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2138-10-30**] 09:19AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2138-10-30**] 09:19AM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
URINE CULTURE (Final [**2138-10-30**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
EKG: Marked baseline artifact. The rhythm is regular and appears
to be sinus bradycardia, rate 120. Poor R wave progression.
Marked left axis deviation. Left anterior hemiblock. Compared to
the previous tracing of [**2138-5-30**] the rate has increased from 98
to 121 and there are some non-specific ST-T wave changes but no
other diagnostic interim change.
Repeat EKG: Compared to tracing #1 no diagnostic interim change
other than
slowing of the rate.
CXR IMPRESSION: Bibasilar air opacities, worsened compared to
the prior study with worsening bilateral pleural effusion. These
finding could be seen in pneumonia, or atelectasis. Please
correlate with clinical symptoms.
Cardiac Stress: IMPRESSION: No anginal symptoms or ischemic ST
segment changes. Nuclear report sent separately.
Nuclear: IMPRESSION: Moderate fixed inferior wall defect
extending to the apex. Normal fucntion and ventricular size.
LVEF:60%
Brain MRI ([**11-7**]): IMPRESSION: No evidence of acute infarct.
Small vessel disease. Soft tissue changes in the ethmoid and
sphenoid sinuses could be related to intubation.
Brain MRA ([**11-7**]): IMPRESSION: No significant abnormalities on
MRA of the head.
CT Head ([**11-6**]): IMPRESSION: No new intracranial hemorrhage. MR
is more sensitive in the detection of acute stroke.
Sputum Culture ([**11-15**]): RESPIRATORY CULTURE (Final [**2138-11-18**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Please contact the Microbiology Laboratory ([**8-/2435**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Sputum Culture ([**11-1**]): RESPIRATORY CULTURE (Final [**2138-11-5**]):
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Please contact the Microbiology Laboratory ([**8-/2435**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
The patient is a [**Age over 90 **] yo female with hx of chronic renal failure,
diabetes, hyperlipidemia, spinal stenosis, legal blindness,
glaucoma, arthritis, PVD, and recent lingular pneumonia s/p
treatment wth Levofloxacin who was originally admitted to the
medicine floor with an acute onset substernal chest pain. She
was ruled out for MI with negative enzymes x3. Nuclear stress
test was done [**2138-10-30**] showed moderate fixed inferior wall defect
exteding to the apex with normal function and ventricular size
with LVEF of 60%. No anginal symptoms or ischemic ST changes
were noted. Patient continued to complain of diffuse pains in
lieu of her chronic pain syndrome, mainly at the site of her
left arm keloid. Pt was also noted to have bilateral pleural
effusions, which appeared to Radiology to be related to
resolving pneumonia or atelectasis.
.
On HD 4 the patient became acutely hypoxic, associated with
confusion, somnolence, and lethargy. She was transferred to the
ICU:
.
ICU Course:
.
# Respiratory Failure
Ms. [**Known lastname **] was transferred to the ICU for an increased oxygen
requirement, altered mental status and lethargy. She was
intubated upon transfer to the Medical ICU for hypercapneic and
hypoxic respiratory failure in addition to somnolence.
Thoracentesis was performed and pleural effusions were
transudative and not infected. The patient's respiratory status
did not improve after thoracentesis and her pleural effusions
reaccumulated quickly. Sputum sample grew MSSA, and due to
patient's PCN allergy the patient was treated with 8 days of
Vancomycin. Despite treatment with antibiotics, the patient had
difficulty weaning from the vent. A trial of extubation was
attempted but the patient was apneic. The patient was very
difficult to bag mask until jaw thrust was performed. She was
re-intubated by anesthesia. It was felt that the patient was
oversedated at extubation so we tried to wean sedation over the
next week. The patient was agitated and required zyprexa and
propofol. We also increased her pain medications, however she
was still unable to wean after the vent. After two weeks of
intubation, a family meeting was held and then patient had a
bedside tracheostomy and PEG tube were done. Her sedation was
slowly weaned without event. She remained stable on pressure
support with low settings. She was unable to perform well on
trach collar trials but did not wean due to low tidal volumes
and tachypnea.
.
Approximately 6 days prior to discharge, patient developed low
grade fevers and an elevated white count, and an increased
opacity in her left upper lobe. It was felt she was developing a
ventilator associated pneumonia. She was empirically started on
Vancomycin [**2138-11-15**], and on day of discharge sputum cultures grew
MSSA. Since patient has a penicillin allergy, she is to finish
the course of her vancomycin for a full 8 day course. She should
have her last dose on [**2138-11-21**]. She will need vancomycin trough
drawn on the morning of [**2138-11-20**] with goal 15-20.
.
# Hypertension: Patient had some increases in blood pressure, so
her home blood pressure medications were re-introduced,
including Losartan, Metoprolol, and Lasix. Because nifedipine
could not be crushed into her PEG, she was transitioned to
Amlodipine 5 mg daily. She was then started on losartan, and
transitioned to metoprolol XL (in addition to amlodipine).
.
# History of atrial thrombus, peripheral [**Date Range 1106**] disease, s/p
bypass: PAtient had an atrial thrombus noted on intra-op TEE in
[**2136**] (no history of a-fib), so she was started on coumadin. Of
note, a TTE in [**2137**] did not show a thrombus but she was
continued on lifelong anticoagulation per her cardiologist.
Coumadin was held for her thoracentesis and for her trach/PEG
due to risk of bleeding. She did not require heparin bridge.
Her goal INR is [**3-18**].
.
# Chronic pain syndrome; post-surgical: During frequent turnings
patient would grimace, worse as sedation was weaned. She was
started on standing tylenol and tramadol q 12 hours as needed
for pain. On the day of discharge, patient was withough pain.
.
# Glaucoma/Blindness: Her home eye drops were continued of
atropine, cosopt, and brimonidine.
.
# Diabetes, T2, controlled with complications: Patient
maintained appropriate blood sugars with regular insulin sliding
scale. Her glipizide was held during inpatient but should be
restarted after discharge.
.
# GERD: Stable throughout admission. Continued on famotidine.
.
# Hypothyroidism; recent TSH 2.2; Her home levothyroxine dosage
was continued. TSH was not repeated as results would likely not
be accurate as she has been quite ill for some time. Further
management of this will be deferred to the outpatient.
# Access: A PICC line was placed during her stay and this was
kept in at time of discharge due to the need for IV antibiotics.
Medications on Admission:
atropine eye gtt 1% 1 drop OS q day
Brimonidine 0.15% 1 drop OU [**Hospital1 **]
Calcitonin spray 1 spray q day
Compression stockings: knee length, 20-33mm comprssion
Cosopt 0.5,2% drops 1 drop OU [**Hospital1 **]
Vit D2 50,0000 units po q week x 8 wks (unclear when started)
Flurandrenolide (Cordran) 4mcg/cm2 tape apply to affected area
[**Hospital1 **]
Lasix 60 mg po q day
Glipizide 5 mg po q day
Latanoprost 0.005% drops 1 drop each eye [**Hospital1 **]
Levoxyl 25 mcg po q day
Losartan 100 mg po q day
Metoprolol tartrate 100 mg po q am ? (vs [**Hospital1 **], per notes there is
a discrepancy b/w Rx and what pt takes)
Nifedipine XR 90 mg po q day
omeprazole 20 mg po q day
Prednisolone 1% 1 drop OU QID
Simvastatin 40 mg po q day
Warfarin 4 mg po q day except 6 mg po qFriday.
Tylenol 1000 mg po Q8hr
Discharge Medications:
1. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic once a day:
Left eye.
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): both eyes.
3. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily).
4. Continue compression stockings as previously ordered.
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): both eyes.
6. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week: resume as previously prescribed.
7. Cordran 4 mcg/cm2 Tape Sig: One (1) tape Topical twice a day:
as previously prescribed.
8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day): both eyes.
11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day): both eyes.
16. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Warfarin 6 mg Tablet Sig: One (1) Tablet PO DAYS (FR).
18. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,SA).
19. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
20. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
# Chest pain, non-cardiac NOS
# Hypertension, benign
# Sinus tachycardia, resolved
# Peripheral [**Hospital6 1106**] disease, s/p bypass grafts
# Chronic pain syndrome
# Glaucoma
# Diabetes T2, controlled with complications
Discharge Condition:
Stable, intubated.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a pneumonia that make it
difficult for you to breath and as a result you were intubated.
Since you were intubated for a long time, it was felt you needed
a tracheostomy for breathing and a PEG for feeding. This
procedure was without incident. Since you continued to need
ventilatory support, you remained on the breathing maching. You
developed another pneumonia while you were ventilated, and we
treated you with antibiotics. Since you did remained stable in
the ICU, it was felt you could be safely transferred to an
extended care facility, [**Hospital 100**] Rehab.
Please seek medical attetion if you develop fever, chills,
shortness of breath, chest pain, or any other concerns.
Followup Instructions:
please follow up with your primary care provider next week as
scheduled. Please consider checking a follow up chest xray to
assess for improvement in her pleural effusions which are likely
the result of her resolved pneumonia.
Please also note that pt has proteinuria, and may benefit from a
second [**Doctor Last Name 360**] for BP/proteinuria; pt already on losartan,
consider aliskiren for example.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2138-11-6**]
12:20
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2138-11-26**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 23733**], M.D. Date/Time:[**2138-12-26**] 11:10
Completed by:[**2138-11-19**]
|
[
"585.9",
"724.00",
"511.9",
"272.4",
"365.9",
"440.20",
"564.00",
"240.9",
"584.9",
"357.2",
"518.81",
"369.4",
"427.89",
"486",
"250.60",
"530.81",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.04",
"31.1",
"33.23",
"43.11",
"96.6",
"38.93",
"96.72",
"44.13"
] |
icd9pcs
|
[
[
[]
]
] |
16235, 16301
|
8641, 13549
|
261, 291
|
16569, 16590
|
4680, 8618
|
17368, 18275
|
4136, 4221
|
14409, 16212
|
16322, 16548
|
13575, 14386
|
16614, 17345
|
4236, 4661
|
211, 223
|
1474, 2957
|
2979, 4000
|
4016, 4120
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,408
| 126,593
|
53843
|
Discharge summary
|
report
|
Admission Date: [**2148-5-16**] Discharge Date: [**2148-5-24**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Symptomatic right carotid stenosis
Major Surgical or Invasive Procedure:
[**2148-5-17**]: Right carotid endarterectomy
[**2148-5-19**]: Evacuation of right neck hematoma
History of Present Illness:
87 yo M w/ h/o multiple lacunar infarcts & HLD presented to
[**Hospital3 **] ED [**2148-5-14**] after two eposides of dysarthria
and left sided weakness, each lasting about 15 minutes, which
occured on the morning of admission. This was witnessed by both
the pt's son and wife. Family notes that pt had word finding
difficulties and left leg weakness. On presentation to the ED,
the pt's symptoms had resolved. An ultrasound at [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 110482**] 70-79% proximal right ICA stenosis. He was
transferred to [**Hospital1 18**] for surgery.
Past Medical History:
BPH, HLD, osteopenia, basal ganglial and cerebellar lacunar
infarcts, first lacunar infarct ~20 years ago
Past Surgical:
herniorrhaphies, tonsillectomy
Social History:
Lives with wife in one bedroom apartment. Two sons live nearby
and help with ADLs.
Family History:
n/c
Physical Exam:
Alert and oriented x 3
VS:BP156/71 HR78
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Left Femoral palp, DP palp ,PT palp
Right Femoral palp, DP palp ,PT palp
Feet warm, well perfused. No open areas
Incision: Right neck, steristripped. Soft, no hematoma but there
is ecchymosis.
Pertinent Results:
[**2148-5-21**] 01:00PM BLOOD TSH-2.2
[**2148-5-24**] 07:30AM BLOOD WBC-10.1 RBC-3.71* Hgb-10.7* Hct-31.2*
MCV-84 MCH-28.8 MCHC-34.3 RDW-14.5 Plt Ct-276
[**2148-5-24**] 07:30AM BLOOD Glucose-113* UreaN-10 Creat-1.0 Na-140
K-4.0 Cl-106 HCO3-26 AnGap-12
[**2148-5-24**] 07:30AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0
MR HEAD W/O CONTRAST [**2148-5-18**]
IMPRESSION:
1. New small foci of slow diffusion, in the left parietal lobe,
which may
relate to small acute infarcts.
2. Stable small acute-subacute infarct in the right internal
capsule.
3. Moderate ventriculomegaly, which may relate to volume loss,
with or
without a superimposed component of NPH/obstruction at cerebral
aqueduct. No significant interval short-term change compared to
the recent study. Follow up as clinically indicated and
correlate clinically.
CTA: [**2148-5-18**]
1. CT HEAD: small vessel ischmic changes. No hemorrhage.
2. CTA: Moderate to severe aortic arch atheropsclerosis. changes
of R CEA. Moderate atherosclerotic calcification and
non-calcified plaque in the left CCA bifurcation and left
proximal ICA, with approximately 40 % stenosis. Moderate
calcification in both cavernous ICA. Moderate stensis at the
origin of one of right M2 branches. Mild irregularity of the
left M1, without occlusion. Mild narrowing of the right P1
segment.
Brief Hospital Course:
87 year old man with symptomatic right carotid stenosis was
brought to the operating room on [**2148-5-17**] and underwent a right
carotid endarterectomy. The procedure was without
complications. Postoperatively, he had several issues.
1.TIA
On POD # 1 he developed a mild fluent expressive aphasia,
significant for neologisms, with paraphasic errors (word
substitution) and slight right facial asymmetry and dysarthria,
without other focal deficits. MRI showed a New small foci of
slow diffusion, in the left parietal lobe, which may relate to
small acute infarcts and stable small acute-subacute infarct in
the right internal capsule.
His symptoms completely resolved within a few hours after being
started on a Heparin infusion. Later in the day patient was
noted to have new right neck swelling requiring surgical
revision with hematoma evacuation.
2.Atrial Fibrillation
On POD # 5 Mr. [**Known lastname 31686**] had episodes of artrial fibrillation with
rapid venticular response. He was briefly on amiodarone.
Cardiology was consulted who recommended anticoagulation as his
[**Country **] score was 4. They felt the bilateral nature of his
original neurological deficet, dysarthria and left sided
weakness, may have been secondary to atrial fib. He was started
on pradaxa and is presently in sinus rhythm.
3.Urinary Retention/UTI
Mr. [**Known lastname 31686**] had several episodes of urinary retention with post
void residuals of 250-300cc. He had not been on his home med of
doxazosin and he also had a urinary tract infection. We
restarted the doxazosin and treated his UTI with cipro. He will
follow up with his PCP regarding issue.
He was cleared by speech and swallow for a regular diet. He has
no signs of aspiration. He is ambulatory with a slightly
unsteady gait. He worked with physical therapy who recommended
home with services. She was discharged to home on POD #7 in
stable condition. Follow-up has been arranged with Dr.
[**Last Name (STitle) **] in one month with surveillance carotid duplex.
Medications on Admission:
Exelon 3 mg [**Hospital1 **]
Folic acid 1 mg qday
Aspirin 81 mg daily
Doxazosin 4 mg po daily
Plavix 75 mg
ASA 81 mg
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day: for the next 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
7. Exelon 3 mg Capsule Sig: One (1) Capsule PO once a day.
8. doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day.
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Symptomatic right internal carotid artery stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Hospital3 4107**] for surgery
to remove a blockage in your right carotid artery. This was
felt to be the cause of the left sided weakness and speech
problems, called TIAs, that you had the day of admission.
While you were in the hospital you had problems with an
irregular heart rate called atrial fibrillation.
We have started you on new medications
1.pradaxa-blood thinner to prevent complications of clots
associated with this irregular heart rate.
2.atorvastatin-for cholesterol
We have arranged follow up with a new cardiologist, Dr. [**First Name (STitle) **].
You also had a problem with urinary tract infection and urinary
retention, the inability to fully empty your bladder.
We have added new medications, Cipro, for the next 7 days to
treat the infection.
Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? 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!
5. 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
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
Followup Instructions:
Please call Dr.[**Name (NI) 110483**] office (PCP) to make an appointment
for next week. She will review/monitor the new medications we
have started you on.
Dr. [**Last Name (STitle) **](cardiology): Tuesday, [**6-11**] at 11AM.
Dr. [**Last Name (STitle) 40860**](neurology): Tuesday, [**6-18**] at 3PM.
Department: VASCULAR SURGERY
When: WEDNESDAY [**2148-7-10**] at 11:30 AM
With: VASCULAR LMOB (NHB) [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: WEDNESDAY [**2148-7-10**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2148-5-24**]
|
[
"434.11",
"600.00",
"287.5",
"V12.54",
"867.0",
"788.20",
"997.1",
"272.4",
"599.71",
"998.12",
"E878.8",
"E928.9",
"733.90",
"427.31",
"285.9",
"433.11",
"599.0",
"784.3",
"600.01",
"294.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"00.40",
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
5992, 6049
|
3003, 5035
|
285, 383
|
6144, 6144
|
1660, 2501
|
9349, 10287
|
1295, 1300
|
5203, 5969
|
6070, 6123
|
5061, 5180
|
6327, 9326
|
1315, 1641
|
211, 247
|
411, 1002
|
2510, 2980
|
6159, 6303
|
1024, 1178
|
1194, 1279
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,548
| 154,088
|
34436
|
Discharge summary
|
report
|
Admission Date: [**2187-7-28**] Discharge Date: [**2187-8-3**]
Date of Birth: [**2105-3-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Endovascular repair of ruptured aortic aneurysm using
stent graft and femoral-femoral cross-over graft.
2. Introduction of catheter modifier 50.
3. Bilateral femoral artery exposure, modifier 50.
4. Endograft bifurcated modular
5. EndoAUI.
6. Endo left common iliac artery occlusion device.
7. Proximal aortic cuff extension.
8. Endo AAA, S and I, extension S and I.
9. Femoral-femoral cross-over graft using 6-mm ring PTFE
Endograft
History of Present Illness:
The patient is an elderly male who was med flighted from [**Hospital **]
Hospital with back pain and hypertension. He was found to have a
contained rupture of
abdominal aortic aneurysm. He had a rapid sequence and was taken
to the operating room
Past Medical History:
PMH: Afib, HTN, LBP, syncope, PVD
PSH: s/p AICD, LLE bypass
Social History:
non smoker
non driner
Family History:
n/c
Physical Exam:
a/o nad
grossly intact
cte
irreg / irreg
abd benign
plap pulse
b/l groin slight weepy / non purulent / no odor
Pertinent Results:
[**2187-8-3**] 05:45AM BLOOD
WBC-4.8 RBC-2.84* Hgb-8.9* Hct-26.0* MCV-91 MCH-31.4 MCHC-34.4
RDW-15.8* Plt Ct-113*
[**2187-8-3**] 05:45AM BLOOD
PT-12.8 INR(PT)-1.1
[**2187-8-3**] 05:45AM BLOOD
Plt Ct-113*
[**2187-8-3**] 05:45AM BLOOD
Glucose-100 UreaN-19 Creat-1.0 Na-140 K-3.7 Cl-106 HCO3-25
AnGap-13
[**2187-8-3**] 05:45AM BLOOD
Calcium-8.0* Phos-2.5* Mg-2.2
[**2187-7-29**] 12:53AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050*
URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
URINE RBC-4* WBC-0 Bacteri-NONE Yeast-NONE Epi-<1
Brief Hospital Course:
Pt admitted emergently for ruptured AAA
Taken to the OR
PROCEDURE:
1. Endovascular repair of ruptured aortic aneurysm using
stent graft and femoral-femoral cross-over graft.
2. Introduction of catheter modifier 50.
3. Bilateral femoral artery exposure, modifier 50.
4. Endograft bifurcated modular
5. EndoAUI.
6. Endo left common iliac artery occlusion device.
7. Proximal aortic cuff extension.
8. Endo AAA, S and I, extension S and I
9. Femoral-femoral cross-over graft using 6-mm ring PTFE
Endograft
Transfered to the CVICU intubated in critical condition
POD # 1: Pt with increase creat post op to 1.6 , thought to be
related to contrast neuropathy. On DC stable. hydration and
renal med adjustments made.
Prophylactic Antibiotics used / Intubated / FFP FOR inr
Lopressor for afib / fentynal and versed for sedation / PPI
POD # 2: Extubated / DC aline / DC Perioperative AB / OOB to
chair / CPT and IS support / Diet advanced / Creatinine improved
/ Swan for monitering left in / Pt positive, Diuresis started /
HCT stable PO
POD # 3: PT consult for mobilization / Swan DC'd / Transfered to
the VICU / Diuresis continued / Creat improved / Coumadin
restarted for Afib / INR monitered
POD # 4 - 5: Floor status / improved with PT / Taking all home
meds / INR monitered / Diet improves
POD # 6: PT clears for home / Dc in stable condition / follow -
up arranged
Medications on Admission:
Atenolol 12.5', Lipitor 10', Isosorbide 30', Coumadin 4mg
5days/wk, 3.5 mg T/Th 2days/wk, allopurinol 200', Lasix 20',
Cardura 4', zoloft 50mg', [**Doctor First Name 130**] 60mg prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,WE,FR,SA).
8. Warfarin 2 mg Tablet Sig: 1.5 tabs Tablets PO 2X/WEEK (TU,TH)
for 1 days: Tu / Thurs.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. [**Last Name (un) 1724**]
Atenolol 12.5', Lipitor 10', Isosorbide 30', Coumadin 4mg
5days/wk, 3.5 mg T/Th 2days/wk, allopurinol 200', Lasix 20',
Cardura 4', zoloft 50mg', [**Doctor First Name 130**] 60mg prn
13. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day:
prn.
14. Atenolol 25 mg Tablet Sig: .5 tabs Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
comuunity vna
Discharge Diagnosis:
AAA
Afib, HTN, PVD
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-11**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-15**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-8-10**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2187-8-10**] 10:45
You should have your INR checked in the usual manner for atrial
fibrillation. You should makle an appointment with your PCP
[**Name Initial (PRE) **].
Completed by:[**2187-8-3**]
|
[
"568.81",
"997.5",
"V45.02",
"441.3",
"443.9",
"442.2",
"427.31",
"401.9",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.71",
"89.64",
"39.29",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
4872, 4916
|
1976, 3359
|
317, 774
|
4980, 4987
|
1339, 1953
|
7594, 8034
|
1188, 1193
|
3592, 4849
|
4937, 4959
|
3385, 3569
|
5011, 7014
|
7040, 7571
|
1208, 1320
|
274, 279
|
802, 1049
|
1071, 1133
|
1149, 1172
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,234
| 128,174
|
147
|
Discharge summary
|
report
|
Admission Date: [**2160-12-25**] Discharge Date: [**2161-1-10**]
Date of Birth: [**2095-10-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with a
history of ischemic dilated cardiomyopathy who presents with
five days of shortness of breath. He developed the shortness
of breath in the setting of cough, lethargy and subjective
fevers. He presents to the Emergency Room where he was found
to be significant dyspneic. Physical examination revealed
evidence of pulmonary edema and a chest x-ray showed
bilateral infiltrates. His oxygen saturation was 86% on room
air. His ABG was 7.54, 48, 27. He was given supplemental
oxygen and 60 mg of IV Lasix with a good response and his
oxygen saturation increased to 90% on three liters. He was
admitted to the cardiac floor with a diagnosis of a CHF
exacerbation.
About one hour after arriving on the floor, about five hours
after presentation, he was found to be acutely hypoxic with
an oxygen saturation in the low 80's despite being on 100%
non rebreather. EKG showed possible inferior ST elevations
in the setting of a paced left bundle branch block. He
continued to be hypoxic despite an additional 200 mg IV of
Lasix, Heparin and a Nitro drip. For this reason he was
emergently intubated and transferred to the CCU.
On arrival to the CCU he was noted to have a temperature of
103.5. His heart rate was increased and his blood pressure
was low. His urine output dropped off. He was started on
Dopamine and his Nitro drip was stopped. He was also started
on Vanco, Levo and Flagyl. As he defervesced, his vital
signs stabilized and he began to have normal urine output
again.
PAST MEDICAL HISTORY: 1) Coronary artery disease status post
anterior MI times two in [**2136**], in [**2145**] with an IMI in [**2150**].
Cath in [**2160-7-16**] revealed two vessel coronary artery
disease with a left ventricular apical aneurysm. 2)
Congestive heart failure with an EF of 20%. 3) Status post
AICD placement for monomorphic ventricular tachycardia
upgraded in [**2160-2-14**]. 4) Atrial fibrillation, status post
ablation in [**2160-2-14**], currently on Amiodarone. 5)
Hypertension. 6) Hypercholesterolemia. 7) Chronic
obstructive pulmonary disease. 8) Obstructive sleep apnea on
bi-pap of 15 and 10 at home.
MEDICATIONS: Amiodarone 400 mg q day, Lasix 120 mg q a.m.,
Lipitor 20 mg q day, Aspirin 81 mg q day, Potassium Chloride
16 mEq q day, Captopril 12.5 mg tid, recently decreased from
25 mg tid, Coreg 18.75 mg [**Hospital1 **], Xanax 0.25 mg tid,
Multivitamin, Vitamin E, Coumadin 2.5 mg q day except for 5
mg on Tuesday and Saturday, Zaroxolyn 2.5 mg po q week,
Mirapex 0.125 mg q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Works as a private investigator. Is
separated from his wife. [**Name (NI) **] a 55 pack year history of
smoking and quit in [**2155**]. Uses alcohol socially. Has no
history of drug abuse.
PHYSICAL EXAMINATION: This is a 65-year-old man who was
intubated and sedated with a blood pressure of 93/42 on 5 of
Dopamine. Heart rate is 60 and he is satting 100% on 100%
FIO2. His HEENT exam is unremarkable. His neck is supple
with bounding carotid pulses. His chest is clear
anterolaterally. His heart is regular with no murmurs, rubs
or gallops. His abdomen is benign. His extremities are
without edema with 2+ distal pulses. His neuro exam is non
focal.
LABORATORY DATA: He has a white count of 18.8, hematocrit
26.6 and platelet count 286,000. His dip shows 96% polys, 2%
lymphs and 2% monos. His Chem 7 is remarkable for a sodium
of 130 and a creatinine of 2.2, up from his baseline of 2.0.
His INR is 3.6 on Coumadin. His fibrinogen is 519 and
d-dimer is less than 500. His reticulocyte count is 1.6.
His EKG showed a paced left bundle branch block with a rate
of about 70.
HOSPITAL COURSE: Mr. [**Known lastname 1549**] was admitted to the coronary
care unit and started on antibiotics for presumed pneumonia
given his presentation with cough and fever. He was
intubated for hypoxic respiratory distress. He was
maintained on pressors for his hypotension. He was continued
on the Levofloxacin of his antibiotics an defervesced after
about 24 hours. He was diuresed about 3 liters and his
pressors were able to be weaned off. He was successfully
extubated two days after intubation. The next day his
Captopril was restarted at 6.25 mg. He tolerated his first
dose. With his second dose, his blood pressure dropped into
the 70's/30's. He was started on Dopamine and Levophed. At
this point he spiked a fever. Fluid boluses were given to
try to augment his pressure. However, he again began to
suffer from hypoxic respiratory arrest with a gas of 7.4, 32
and 47. A PA catheter was placed to better assess his
hemodynamics. His CVP was 8, wedge pressure was 35, cardiac
index was 2.0. At this point Dobutamine was started in
addition to the Dopamine and Levophed. He was reintubated.
His PA pressures were in the 70's/40's. His systolic blood
pressure was in the 70's and diastolic blood pressure was in
the 50's. He received Lasix and Morphine overnight. He
spiked again the following day. He was diuresed down to [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 1554**] in the low 20's and a pulmonary capillary wedge pressure
of 17. On the Dobutamine he was able to be weaned. He had
cardiac index of 2.1 to 2.2 and was able to be weaned off of
pressors. Vancomycin was started with concern for either
nosocomial pneumonia or line infection. On the Vancomycin,
he defervesced.
LFTs were checked to see if there was any hidden source of
infection that we might be missing. His LFTs, amylase and
lipase were increased and abdominal CT was obtained which
showed no signs of pancreatic inflammation or liver or
gallbladder pathology.
After his pressors were weaned off, he was also weaned off
the Dobutamine. His Swan was removed and he was successfully
extubated again five days after his second intubation. He
did well initially but was approximately 1?????? liters positive
by the next morning and had an episode where he desatted with
an increase in his respiratory rate. He did not respond to a
60 mg shot of IV Lasix and his sats continued to drop into
the 80's. He was reintubated a third time. At this point
his blood pressure once again dropped and he was restarted on
Dopamine. After this he spiked again. Over the next three
days he was continued to be diuresed and he was kept on
minimal sedation to try to avoid any medicine that would
lower his blood pressure. Frequent family meetings were held
during his course. Decision was made to have one last try
with Milrinone to try to improve his cardiac index. On
Milrinone he was able to be weaned off of pressors and he had
good Swan parameters as the Swan was refloated after his
third intubation. However, multiple attempts to wean him off
the ventilator failed.
The team addressed the possibility of trach placement in a
long-term wean with the family. The family stated that he
would not have wanted that kind of quality of life and so the
decision was made to withdraw ventilatory support. He passed
away peacefully with his family at his side on [**2161-1-10**] at
3:05 p.m.
[**Known firstname **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2161-1-27**] 21:22
T: [**2161-1-29**] 16:36
JOB#: [**Job Number 1555**]
|
[
"518.81",
"496",
"038.9",
"486",
"577.0",
"428.0",
"427.31",
"414.8",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.71",
"99.15",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3873, 7522
|
2977, 3855
|
158, 1683
|
1706, 2743
|
2760, 2954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,744
| 189,259
|
40961
|
Discharge summary
|
report
|
Admission Date: [**2161-6-14**] Discharge Date: [**2161-7-1**]
Date of Birth: [**2075-7-23**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 21193**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
Right frontal craniotomy for excision of mass
History of Present Illness:
85 year-old right-handed woman with a histor of renal cell
CA s/p L nephrectomy in [**2149**] who presented on [**6-13**] to an OSH
after a fall as well as with left sided weakness. Over the last
8
months she has noted increasing difficulty with her balance and
the continual worsening of left sided weakness. She has had
numerous falls in the last months yet had not sought out medical
attention. On [**6-13**], she fell in her garage and was taken to an
OSH by her neighbor where a [**Name (NI) 72787**] showed a right intracerebral
bleed with edema.
She denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, Denies difficulties
producing or comprehending speech. Denies focal numbness,
parasthesiae. Denies bowel or bladder incontinence or retention.
Past Medical History:
PMHx: CAD, HLP, DM (diet controlled), HTN, osteoporosis, renal
cell carcinoma s/p left nephrectomy on [**2149-9-9**], vertigo
Social History:
smoked for two years in her 20s, no EtOH or illicit drugs. Lives
alone. 2 sons
Family History:
all 5 siblings died of some sort of cancer including "blood"
cancer, breast and lung.
Physical Exam:
PHYSICAL EXAM:
O: T: 96.6 BP: 144/61 HR: 52 R 16 O2Sats 100 RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-19**] Bilaterally EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
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.
No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone on R with mildly decreased tone on
L.
No abnormal movements, tremors. Strength full power [**5-21**] on R,
[**4-21**]
on L.
Sensation: Intact to light touch bilaterally.
On Discharge: AOx3, following commands, speech intact
Right upper and lower extremity weakness more pronounced:
Right upper extremity [**2-21**] throughout
Right lower extremity 3-4/5 throughout
Pertinent Results:
[**2161-6-14**] 09:10AM WBC-7.5 RBC-3.49* HGB-11.8* HCT-35.5*
MCV-102* MCH-34.0* MCHC-33.4 RDW-16.8*
[**2161-6-14**] 09:10AM PLT COUNT-150
[**2161-6-14**] 09:10AM PT-12.0 PTT-21.0* INR(PT)-1.0
MRI [**2161-6-14**]: Enhancement of dominant right posterior frontal
lesion, with extensive surrounding white matter edema. Taken
together, these findings are of concern for a neoplastic
process, either metastatic or primary in origin. Other lesions
relating to the right lateral ventricular choroid plexus and
posterior aspect of the right temporal lobe are not as
characteristic for neoplastic disease, though this etiology is
not entirely excluded.
CT Torso [**2161-6-15**]: 1. 1.6 cm Left upper lobe mass within the
perihilar area abutting the major fissure, concerning for
malignancy. Atelectasis within the posterior left upper lobe
distal to this likely represents post-obstructive atelectasis or
infection. Biopsy of the central nodule by bronchoscopy could be
considered. 2. 4 mm lateral right middle lobe nodule, which is
indeterminate. A followup CT in three months is recommended. 3.
Left thyroid lobe hypodense nodule. Further evaluation with
ultrasound may be obtained. 4. Left breast mass concerning for
breast cancer or metastasis. Biopsy is recommended. 5. Status
post left nephrectomy. No mass within the surgical bed to
suggest metastasis or recurrence.
Thyroid U/S [**2161-6-16**]: 1. Spongiform left lower lobe thyroid
nodule, which could be followed in one year time to evaluate for
stability. 2. Colloid cyst within the right lobe of the
thyroid, which is otherwise normal.
Bone Scan [**2161-6-17**]: No evidence of osseous metastatic disease.
fMRI [**2161-6-18**]: 1. Unchanged right frontal mass lesion with
associated vasogenic edema. The functional MRI, demonstrates
areas of activation at more than 5 mm from the mass lesion
during the movement of the left hand. The dominance for the
language apparently is located on the left cerebral hemisphere
with activation areas in the left operculum.
MRI WAND [**2161-6-21**]: FINDINGS: There is re-demonstration of the
previously noted enhancing lesion within the posterior aspect of
the right frontal lobe superiorly, as well as its surrounding
edema. There are no other areas of pathological contrast
enhancement seen. CONCLUSION: Pre-operative planning study, as
noted above.
Post op CT head [**2161-6-24**]: Interval resection of a right frontal
lesion via a right craniotomy, with expected postoperative
changes, and no evidence of new hemorrhage or large vascular
territorial infarction.
Post op MRI [**2161-6-25**]: 1. The patient is status post right frontal
craniotomy and resection of right frontal enhancing mass.
Intrinsic T1 hyperintensity is present within the surgical
cavity, likely representing postoperative blood products and
proteinaceous material. There is a thin rim of peripheral
enhancement which is likely related to postoperative change and
also corresponds with a thin rim of restricted diffusion, likely
representing postoperative change(although residual tumor in
this thin rim of enhancement cannot be excluded). With the
exception of local mass effect, there is no mass effect upon the
lateral ventricles or shift of midline structures. The
surrounding white matter edema is stable compared with the
preoperative study. 2. Minimal volume of pneumocephalus
overlying the right frontal lobe. 3. Stable changes of atrophy
(NPH may have this appearance) and likely sequela of chronic
small vessel ischemic disease.
Brief Hospital Course:
Neurology: Mrs. [**Known lastname **] is an 85 yo F who was admitted to the
neurology service on [**2161-6-14**] for progressive L sided weakness,
found on MRI to have a R frontal mass on MRI most consistent
with a metastasis, especially given the patient's history of
RCC. Over the next few days, she [**Date Range 1834**] various tests as part
of a metastatic workup including a CT of the chest, abdomen, and
pelvis, bone scan, and thyroid ultrasound. She was found to have
two lung nodules, a thyroid mass as well as a breast mass in
addition to her brain lesion. She was seen in consultation by
radiation oncology and neuroncology who felt that a resection of
the mass would give the best information as to the source of the
metastasis. For this she was planned to undergo resection of the
mass on [**2161-6-21**], however, during the preparation for the OR, the
brainlab guidance system malfunctioned and the operation was
aborted. She was rescheduled and [**Date Range 1834**] resection on [**2161-6-24**]
after which she was transferred to the ICU, extubated. After
surgery, the previous weakness in her left upper extremity was
acutely worsened and was plegic with persistent weakness in her
left lower extremity. Given the proximity of her lesion to the
motor areas of the brain and her preoperative weakness, this was
not an unexpected short term complication and function of the
left leg and arm should improve over time. She was able to eat
and her pain was well controlled on oral medications. She worked
with physical therapy and rehab was recommended. She is being
discharged on a dexamethasone taper and will continue on
dexamethasone 2 mg [**Hospital1 **] until follow-up in Brain [**Hospital 341**] Clinic.
She will follow-up with oncology as an outpatient in order to
discuss chemotherapy. She will also follow-up next week to get
a biopsy of her breast mass, though it is not lkely to be
related to the renal cell cancer.
At the time of discharge, Ms. [**Known lastname 89386**] movement of her left side
has improved and is better than it had been at the beginning of
her admission.
Oncology: As noted above, Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a resenction of
her mass on [**6-21**]. Preliminary pathology reveals that this
is most likely representative of metastasis from her renal cell
carcinoma. We consulted oncology, who will see her as an
outpatient to discuss options including chemotherapy.
A CT torso revealed masses in her LUL and RML of her lungs, a
nodule in her thyroid and a small mass in her breast. A biopsy
of her LUL nodule was considered, but after consultation with
both interventional [**Month (only) **] and interventional pulmonology, it
was deemed too risky to go after as it was near the hilum. The
thyroid mass was felt to be most likely consistent with a
colloid cyst and thought to be benign after an ultrasound was
obtained and reviewed with [**Month (only) **]. In discussion with the
oncology service, it was felt that the breast mass was likely
unrelated and that her PCP could [**Name Initial (PRE) **]/u it up in the future.
Hematology: Ms. [**Known lastname **] had a slowly decreasing hematocrit during
her admission with it being 36.9 during admission and decreasing
to a nadir of 27.9. As this appeared to be consistent with a
macrocytic anemia (MCV ~100), she was tested for methylmalonic
acid, B12 and folate which were all normal. However, because of
the drop, hematology was consulted and felt that this anemia was
most likely related to anemia of chronic disease, though
myelodysplastic syndrome could not be ruled out.
On [**6-26**], her PTT was elevated which was felt to be secondary to
heparin flushes through her IJ. Those were discontinued, but
her platelets decreased afterwards to 82. Concerned about the
formation of HIT antibodies, her heparin was stopped and she was
switched to fondaparinaux for DVT prophylaxis. This was
continued through [**6-29**], when her HIT antibody [**Doctor First Name **] came back
negative. On [**6-30**] heparin SC was restarted. Her platelets have
remained stable.
ID: Ms. [**Known lastname **] has remained afebrile during her admission. She
is currently on a course of keflex for her scalp incision and
will complete treatment on [**7-6**]. She is being dosed every eight
hours for renal-based dosing.
FEN/GI: Ms. [**Known lastname **] has a history of renal insufficiency. Her
creatinine was been elevated but improving during her admission
with the most recent creatinine value being 1.1. Per her PCP's
office, her baseline is around 1.3.
Around [**6-26**], her potassium levels began to slowly increase to a
peak of 5.4 Renal was curbsided who felt this was likely due to
the heparin flush as that is a known effect of heparin. It has
been stable for several days now. Her BUN has been elevated,
which is thought to be secondary to steroids.
Respiratory: Other than a brief intubation post-operatively, Ms.
[**Known lastname **] has remained stable on room air.
Medications on Admission:
enalipril 5 mg PO daily, folic acid 1 mg PO daily, pravastatin
40 mg PO daily, Propranolol 10 mg [**Hospital1 **], ASA 81 mg PO daily,
Vitamin C 500 mg PO BID, Vit D 600 mg PO BID, vitamin E 400
units PO daily, Multi-vitamin daily
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. insulin regular human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection ASDIR (AS DIRECTED).
8. dexamethasone 1 mg Tablet Sig: per taper Tablet PO twice a
day: Take 3 mg dexamethasone po qid for 12 doses, followed by 2
mg dexamethasone po qid for 12 doses, followed by 2 mg
dexamethasone po bid until follow up in Brain tumor clinic.
Disp:*120 Tablet(s)* Refills:*2*
9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain fever.
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. heparin (porcine) 5,000 unit/mL Cartridge Sig: 5000 (5000)
units Injection three times a day.
15. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
Disp:*50 Tablet(s)* Refills:*0*
16. propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 2 days: last day: [**7-3**].
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain.
22. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) for 3 days: please give through [**7-2**].
23. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 3 days: please give [**7-3**], [**7-4**], and [**7-5**].
24. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): please continue through appointment with brain tumor
clinic on [**7-13**].
25. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**] Hospital Network
Discharge Diagnosis:
R frontal mass
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 because you had an acute onset of left sided
weakness. After a thorough evaluation, it appears that this
weakness was due to a mass in the right frontal lobe of your
brain. This mass appears to be consistent with metastatic renal
cell carcinoma. You also have masses in your lungs that are
likely to be related. It is likely that you will need
chemotherapy in the future. You will follow up with oncology as
well as the brain tumor clinic. At that time, your options for
treatment will be discussed.
You also appear to have a mass in your thyroid and breast that
are not likely to be related to the renal cell carcinoma. We
will set up an appointment for you to have the breast mass
biopsied. Your thyroid mass is likely a benign mass called a
colloid cyst. There is nothing acutely to be done about this
mass.
It is important that you continue to drink plenty of fluids as
your kidney function appears to be consistent with mild
dehydration.
Instructions from neurosurgery:
?????? 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 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2161-7-13**]
at 2:00. 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.
You will need to have a biopsy of the mass in your breast. You
will need to come to [**Hospital Ward Name 23**] 4 at the following times for
imaging (ultrasound/mammogram) and then biopsy of your breast
mass.
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-7-7**] 1:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-7-7**] 1:55
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-7-7**] 3:00
You will followup with Oncology on [**7-8**] at 4pm. Please come
to [**Hospital Ward Name 23**] 9 on the [**Hospital1 18**] [**Hospital Ward Name **]. Phone number:
[**Telephone/Fax (1) 13016**]
[**Name6 (MD) 3523**] [**Name8 (MD) 3524**] MD [**MD Number(2) 21196**]
|
[
"431",
"240.9",
"414.01",
"790.92",
"403.90",
"733.00",
"198.3",
"585.9",
"250.00",
"272.4",
"V10.52",
"E934.2",
"342.00",
"287.5",
"611.72",
"V45.89",
"276.7",
"348.5",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
14481, 14545
|
6418, 11446
|
325, 372
|
14604, 14604
|
2870, 6395
|
17588, 18845
|
1463, 1550
|
11727, 14458
|
14566, 14583
|
11472, 11704
|
14780, 17565
|
1580, 1824
|
2668, 2851
|
266, 287
|
400, 1202
|
2040, 2654
|
14619, 14756
|
1224, 1351
|
1367, 1447
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,680
| 173,101
|
5662
|
Discharge summary
|
report
|
Admission Date: [**2159-5-8**] Discharge Date: [**2159-5-14**]
Date of Birth: [**2085-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Lower extremity edema.
Major Surgical or Invasive Procedure:
1. Joint aspiration, right knee ([**2159-5-8**]).
2. Hydrocortisone injection, right knee ([**2159-5-9**]).
3. s/p ORIF
4. Intubation
History of Present Illness:
Pt is a 73yo F w/ PMH of HTN, ESRD on HD, diastolic dysfunction,
who presented to the ED with increased BLE edema. Her LE have
been getting more and more edematous, to the point where she is
unable to wear her shoes. She is now on rehab with the purpose
of getting her functional enough to undergo a R TKR (per the
patient). At rehab, she has been limited due to her LE edema.
Her R knee has been more painful and more swollen over last
month. No h/o trauma or falls. She denies any recent fevers or
chills and has not had swelling this bad in her knees in the
past. They have been trying to run her dry at HD, but the
swelling persists. Denies any recent CP, SOB. + palpitations.
Sleeps on 3 pillows behind her head and 2 underneath her feet,
which is stable. Mild DOE - has 15 stairs to climb at her house,
sometimes has to sit between flights. No n/v recently. Still w/
profuse diarrhea. Swelling in LE as noted above.
.
Pt was recently admitted [**4-13**] - [**4-24**] with diagnosis of AF with
RVR, abd pain and distention, as well as an elevated INR.
Briefly, she was rate controlled with IV and PO medicines, had a
paracentesis for ascites felt to be due to CHF induced hepatic
congestion, and then ultimately found to have C diff for which
she was treated with PO vanco/flagyl. There was a question of
mesenteric ischemia vs. IBD as well, given that she frequently
had bloody stools. It was recommended to undergo a colonoscopy
as an outpatient for further evaluation. She continues on PO
vanco, to finish her course on [**5-8**].
.
In the ED, VS showed T 98.4, BP 120/60, HR 75, RR 20, sats 99%
on RA. Arthrocentesis was performed on her R knee. She was given
morphine for pain relief. CXR was performed. Labs revealed a BNP
of 54K. She was admitted to medicine for management of her CHF.
Past Medical History:
1) Type 2 diabetes mellitus: Started insulin in [**2157**].
2) Hypertension: Poorly controlled with many admissions to
MICU/CCU for hypertensive urgency.
3) Renal artery stenosis: Last MRA [**1-6**] revealed 3 left renal
arteries, superior with question of stenosis and middle with
stenosis.
4) Hypercholesterolemia
5) ESRD on HD M/W/F. Followed by Dr. [**First Name (STitle) 805**]
6) Diastolic CHF, last echo [**2159-4-5**] with mildly reduced systolic
function (TEE)
7) Osteoarthritis
8) Depression
9) Anxiety
10) Sickle cell trait
11) Hiatal hernia
12) Gastroesophageal reflux disease
13) Chronic constipation
14) History of mechanical falls.
15) Chronic anemia: Presumed secondary to renal failure.
16) Status post hysterectomy in [**2132**].
Social History:
Lives at home with her husband, but since d/c on [**4-24**] has been
at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Originally from Barbados, but lived in [**Location **]
for 20 years as well. She used to work as a medic in the PACU at
[**Hospital1 18**], then later as a recreational assistant at another
facility. Denies any alcohol use, no history of smoking, no
IVDU.
Family History:
Mother alive at 89, with DM2, HTN. Father died of Alzheimer's
Disease. Brother with hypertension.
Physical Exam:
VS - T 97.8, BP 156/84, HR 107, RR 22, sats 100% on 2L (on RA on
exam)
Gen: Thin, AfAm female in NAD.
HEENT: Sclera anicteric, EOMI, OP clear, MMM. No JVD.
CV: Irreg irreg, normal S1, S2. II/VI SEM best heard at LUSB, no
r/g. Dynamic precordium.
Lungs: Crackles at L base, otherwise clear.
Abd: Soft, protuberant abdomen. + BS throughout. No appreciable
fluid wave, but with some lower abdominal dullness to
percussion. + hepatomegaly w/ liver edge percussed to [**3-4**]
fingerbreadths below RCM.
Ext: 2+ pitting edema to knees bilaterally, RLE slightly worse
than LLE. R knee is swollen, with effusion. No warmth or
erythema. Bandaid in place over arthrocentesis site. AVF in LUE
+ thrill.
Neuro: AAOx3. CN II-XII grossly intact. Strength grossly intact
- pt able to move around in bed on her own.
Pertinent Results:
CBC: [**2159-5-7**]
WBC-8.2 RBC-4.45 Hgb-11.9* Hct-37.9 MCV-85 MCH-26.9* MCHC-31.5
RDW-20.8* Plt Ct-301 Neuts-77* Bands-0 Lymphs-17* Monos-5 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
COAGS: [**2159-5-8**]
PT-17.8* PTT-34.4 INR(PT)-1.7*
CHEMISTRIES: [**2159-5-7**]
Glucose-71 UreaN-14 Creat-2.7* Na-141 K-3.2* Cl-95* HCO3-37*
AnGap-12
Calcium-8.4 Phos-5.2*# Mg-1.9 UricAcd-3.8
LFTS: [**2159-5-8**]
ALT-HEMOLYSIS AST-37 LD(LDH)-391* CK(CPK)-40 AlkPhos-102
TotBili-0.5
CARDIAC STUDIES: [**2159-5-7**]
CK-MB-2 cTropnT-0.23* proBNP-[**Numeric Identifier 22636**]*
CXR ([**2159-5-8**]):
Long-standing severe cardiomegaly, particularly left atrial and
right ventricular enlargement is unchanged. Pulmonary
vasculature is unremarkable and there is no edema or pleural
effusion. Enlargement of the pulmonary arteries suggests
pulmonary hypertension perhaps related to mitral valve disease.
Lungs are clear of any focal abnormality. Stomach is moderately
distended with gas.
RIGHT KNEE PLAIN FILM ([**2159-5-8**]):
1. There are severe osteoarthritic changes comparable in
appearance to [**1-5**].
2. The degree of lateral subluxation of the tibia is less than
on that study.
3. No acute fracture is identified, although there is
considerable preexisting deformity of the subarticular bone.
.
ct pelvis [**5-10**]:
IMPRESSION: Minimally impacted fracture through the
intertrochanteric region of the proximal right femur
.
[**5-13**] head ct:
FINDINGS: There is no evidence of hemorrhage, mass effect, or
shift of normally midline structures. There is no evidence of
infarction. Mild low attenuation in the periventricular white
matter is consistent with chronic microvascular infarction. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The surrounding
soft tissue and osseous structures are unremarkable. The
visualized paranasal sinuses and mastoid air cells are clear.
.
IMPRESSION: No evidence of hemorrhage or mass effect. No
significant change from prior study
Brief Hospital Course:
Floor course:
1. Femeral neck fracture: The patient fell morning of [**5-10**].
Plain film shows fracture. On [**5-11**]: ORIF with ortho, and on
[**5-12**]: Hct drop post-op with clear hematoma in right leg. The
patient was given blood with no issues
.
2. Congestive heart failure: Presented with elevated BNP of
~54K, LE edema, and crackles on exam, but pt had stable O2 sats
on RA. Unclear that this was true CHF exacerbation because she
appeared dry on exam. Per HD notes, pt has been getting dialyzed
to below her dry weight (59.5 kg -> 55.5 kg on [**5-4**]). She
remained stable with HD M/W/F and renal meds
.
3. Gout: WBC in tap elevated with 96% polys, but gram stain w/o
PMNs or orgs. Afebrile, no peripheral leukocytosis. Crystals are
c/w gout and/or pseudogout. Was injected by rheum on [**5-9**], and
did well with tylenol prn. Was not given colchicine given ESRD
.
4. Hypertension: The patient was continue on outpatient
antihypertensives, with no issues
.
5. ESRD: The patient had no issues on the floor and had HD on
MWF.
.
6. CDIFF: Completed course of PO vancomycin for now.
.
Micu transfer and course:
Code blue called late [**5-12**] for unresponsiveness, pt's blood
sugar was found to be 8. Bradycardia down to thirties, sbp
dropped as low as 80s. Given atropine one mg x1 and [**1-2**] amp D50.
HR recovered to 90s-110s, irreg rhythm. Repeat sugar 47 and a
full amp D50 was given. During the code a central line was
placed in L femoral. Her mental status returned to baseline and
pt transferred to MICU for further management.
.
The patient was initially stable in the unit, but during her
course she developed several hypotensive episodes and received
boluses of IVF. The patient was on diltiazem and metoprolol for
afib, but her pressure dropped so these were stopped. During
this episode of hypotension, the patient was not moving her left
leg, but her head ct was negative so stroke was unlikely. She
was intubated for confusion, at that time. Originally her
hypotension was attributed to her nodal agents, but then given
her white count and clinical picture she was likely septic so
vanc and levo were started. With IVF, and antibiotics she
remained hypotensive so she was requiring 3 pressors
vasopressin, levophed and neosynephrine. Her pressure continued
to drop despite pressors, and she had cardiac arrest. Once her
DNR/DNI status was confirmed life saving measures were stopped
and the patient expired.
Medications on Admission:
Acetaminophen 325-650 mg PO Q4-6H:PRN
Heparin 5000 UNIT SC TID
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Diltiazem 90 mg PO QID
Isosorbide Dinitrate 10 mg PO TID
Metoprolol 100 mg PO TID
Insulin SC
Losartan Potassium 50 mg PO DAILY
Clonazepam 0.5 mg PO BID
Aspirin EC 81 mg PO DAILY
Sevelamer 400 mg PO TID
Cyanocobalamin 50 mcg PO DAILY
FoLIC Acid 1 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Atorvastatin 10 mg PO DAILY
CloniDINE 0.1 mg PO BID
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"719.06",
"820.09",
"998.11",
"E884.4",
"038.9",
"585.6",
"428.0",
"995.92",
"427.31",
"286.7",
"573.9",
"V58.67",
"008.45",
"403.91",
"250.80",
"274.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"39.95",
"38.93",
"79.35",
"99.60",
"99.62",
"81.91",
"81.92"
] |
icd9pcs
|
[
[
[]
]
] |
9552, 9561
|
6455, 8901
|
337, 473
|
9612, 9621
|
4439, 5872
|
9677, 9687
|
3505, 3604
|
9523, 9529
|
9582, 9591
|
8927, 9500
|
9645, 9654
|
3619, 4420
|
275, 299
|
501, 2302
|
5881, 6432
|
2324, 3073
|
3089, 3489
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,149
| 176,022
|
54350
|
Discharge summary
|
report
|
Admission Date: [**2136-2-29**] Discharge Date: [**2136-3-7**]
Date of Birth: [**2052-1-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
left hip fracture
Major Surgical or Invasive Procedure:
open reduction and internal fixation of left femoral
intertrochanteric fracture.
History of Present Illness:
The patient is an 84 year-old female with a history of dementia,
RA, PVD, osteoporosis and recent right femoral intertrochanteric
fracture s/p ORIF [**2136-1-3**] who presents with left hip fracture.
The patient was previously admitted to [**Hospital1 112**] after a mechanical
fall on [**2135-12-31**] and found to have a right hip fracture. She also
had some chest pain, mildly elevated trop 0.02, but no ECG
changes. She was transferred to [**Hospital1 18**] because her PCP and
rheumatologist are here. She underwent ORIF on [**2136-1-3**] and
tolerated the procedure. However, she did develop post-op
delerium for which she was treated with seroquel 12.5 qhs and
prn. The patient was discharged to rehab.
.
Today the patient had a witnessed mechanical fall while reaching
for her walker. She presented to the ED and found to have a left
intertrochanteric fracture. She had a CT-head and C-spine that
did not show any fracture or acute bleed. She also had CE x1
that were negative. The patient became very agitated in the ED
with tachycardia to the 140's with lateral ST depressions. She
was given a total of 10mg morphine (2mg x3, 4mgx1) and 3mg
haldol (0.5mg x3, 1.5mg x1). She also was given ASA 325mg x1 and
a total of 2L IVF. The patient continued to be agitated and
tachycardic and felt that she would be unsafe on the floor.
.
On the floor the patient was calm and denied any pain. She was
only oriented to self, but denied any other complaints.
Past Medical History:
Right femoral intertrochanteric fracture, s/p ORIF [**December 2135**]
Rheumatoid arthritis
Osteoarthritis
Dementia
Peripheral vascular disease - Left femoropopliteal bypass
revised with a patch and several angioplasties for restenosis
possibly due to intimal hyperplasia.
S/p bypass surgery
Osteoporosis - Bone density [**2135-6-23**] with T-score of spine
minus 4.7
Chronic onychocryptosis
Low back pain
Social History:
Smoke: 1 ppd x about 65 years
EtOH: None
Drugs: None
Lives/works: Lives alone in [**Last Name (NamePattern1) 18764**] in [**Location (un) **]. Lived
here for about 50 years. Does not remember where she used to
work.
Patient has no children. She has two cousins nearby -- one in
[**Location (un) 686**], Mass and one in [**State 531**] state. She is originally
from [**Country **] and grew up speaking [**Hospital1 100**], Polish, and [**Doctor First Name 533**].
Family History:
Non-contributory
Physical Exam:
Tc:97.5 BP:158/82 HR:84 RR:16 O2Sat:100% on RA
GEN: Elderly, cachectic, no acute distress, mumbling and
incoherent, but occasionally more clear. Responding to
questions. Appears MUCH improved from yesterday.
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MM appear dry, OP Clear.
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Limited exam due to lack of cooperation, but lungs appear
CTAB.
ABD: Soft, NT, ND, +BS, guarding, but no apparent tenderness.
EXT: No C/C/E, no palpable cords. Pedal pulses symmetric. Feet
slightly cool bilaterally but dry, left side csm intact. Left
thigh incision c/d/i with staples
NEURO: Alert, oriented to person only. CN II ?????? XII grossly
intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2136-2-29**] 02:10PM WBC-12.5*# RBC-4.07*# HGB-12.4# HCT-39.1#
MCV-96 MCH-30.5 MCHC-31.7 RDW-15.0
[**2136-2-29**] 02:10PM PLT COUNT-337
[**2136-2-29**] 02:10PM PT-11.5 PTT-38.6* INR(PT)-1.0
[**2136-2-29**] 02:10PM GLUCOSE-112* UREA N-26* CREAT-0.8 SODIUM-136
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
[**2136-2-29**] 11:12PM CK-MB-8 cTropnT-<0.01
[**2136-2-29**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
# Left femoral intertrochanteric fracture: The patient was
admitted initially to the MICU for IV fluids, observation, and
medical stabilization. She improved significantly after fluids,
analgesia, and anti-psychotics. She was taken to the OR on
hospital day #2 for ORIF by the orthopedics service. The
procedure was performed without immediate complications, but she
was noted in post-op labs to have a markedly reduced hematocrit,
and was therefore transfused 2 units PRBC the evening following
surgery. Patient is cleared for full weight bearing.
# Anemia: The patient had a hematocrit of 39 on admission, 31
following significant fluid hydration, and then 23.5 following
surgery. There was not evidence of ongoing blood loss aside
from peri-operative losses, so this drop was attributed to fluid
hydration combined with some traumatic loss, combined with
surgical blood loss. The patient's hematocrit increased
appropriately following transfusion, and remained stable
thereafter.
# Tachycardia: The patient was substantially tachycardic on
admission, and mildly tachycardic post-operatively. EKG's
showed sinus tachycardia, with some mild ST depressions, thought
to represent demand ischemia. Troponins were negative, cycled
x3. Following surgery she also became hypoxic, which combined
with tachycardia prompted concern for possible PE. CTA
performed on the evening of hospital day #2 showed no evidence
of significant PE, and only very mild pleural effusions, no
large consolidation. Her tachycardia has improved markedly
overtime.
# Leukocytosis: Likely reactive in the setting of pain, hip
fracture, surgery. Blood cultures were drawn, and urinalysis
showed no signs of infection. She was given peri-operative
antibiotics. She did not spike a fever, showed no other signs
of infection.
# Dementia, agitation: She was continued on her prior regimen
of low-dose Seroquel, with QHS dose for sleep. She also
required occasional low dose Haldol for increased agitation,
trying at one point to pull out her IV.
# Disposition: the patient's family and HCP initially have
arranged to transfer her to a facility in [**Location (un) 15739**], NY in order
to be closer to family members.
Medications on Admission:
Folic Acid 1 mg daily
Acetaminophen 1g TID
Toprol XL 100 mg daily
Cholecalciferol (Vitamin D3)800U daily
Clopidogrel 75 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Multivitamin,Tx-Minerals daily
Ibuprofen 400 mg q8 prn
Thiamine HCl 100 mg daily
Quetiapine 12.5 mg Tablet Sig: 0.5 qhs
Quetiapine 6.75 mg PO Q6H prn agitation
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily): Complete total of 4 wks.
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Home of [**Location (un) 15739**], Inc.
Discharge Diagnosis:
left hip fracture.
Discharge Condition:
Fair condition, alert but disoriented
Discharge Instructions:
You were admitted to the hospital after falling and breaking
your left hip. You were initially admitted to the ICU because
your heart rate was very fast, but this improved with IV fluids
and with medicines. Your hip was surgically repaired on the 2nd
day of your hospital stay, and you were then transferred to the
medicine service. You received two units of blood following the
surgery, after which your blood levels returned to near normal
levels.
Followup Instructions:
You should call to schedule a followup appointment with your
primary care doctor in the next 1-2 weeks and an orthopedist in
[**1-28**] weeks.
|
[
"724.2",
"799.02",
"288.60",
"714.0",
"443.9",
"293.0",
"285.1",
"564.09",
"820.21",
"E885.9",
"785.0",
"E849.7",
"294.8",
"V12.04",
"276.51",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
7978, 8061
|
4247, 6459
|
331, 414
|
8124, 8164
|
3722, 4224
|
8665, 8811
|
2834, 2852
|
6868, 7955
|
8082, 8103
|
6485, 6845
|
8188, 8642
|
2867, 3703
|
274, 293
|
442, 1901
|
1923, 2330
|
2346, 2818
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,610
| 162,478
|
28937
|
Discharge summary
|
report
|
Admission Date: [**2103-7-9**] Discharge Date: [**2103-7-12**]
Date of Birth: [**2042-6-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p fall/trauma
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
This is a 61 year old man with a history of depression and
alcoholism who was witnessed to fall down approximately 7 stairs
directly onto his face. Patient was intoxicated. Patient
denied LOC and was complaining of facial pain on arrival to ED.
He was transported to the ED by EMS boarded and collared.
Past Medical History:
Depression
Right 5th finger amputation
Right eye injury with prosthesis age 12
ETOH abuse
Social History:
Works at BU as administrative assistant. History of alcohol
abuse.
Family History:
NC
Physical Exam:
99.2, 99, 112/94, 16, 98% RA
Neuro: GCS 13, A&Ox2, moving all four extremities equally
HEENT: R eye prosthesis, L pupil round and reactive to light,
trachea midline, forehead abrasion, dried blood in mouth and
nares
CV: RRR, normal S1, S2
Resp: Equal BS bilaterally
Abd: soft, NT/ND, FAST negative
Rectal: normal tone
Ext: abrasion R shoulder
Pertinent Results:
Admission Labs:
WBC-6.6 RBC-4.76 HGB-15.5 HCT-43.1 MCV-91 MCH-32.6* MCHC-36.1*
RDW-15.0 PLT COUNT-261
PT-11.9 PTT-22.6 INR(PT)-1.0 FIBRINOGE-325
GLUCOSE-92 LACTATE-2.0 NA+-150* K+-3.6 CL--112 TCO2-24 UREA N-13
CREAT-1.1
AMYLASE-97
ASA-NEG ETHANOL-372* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 BLOOD-NEG
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-NEG bnzodzpn-POS barbitrt-NEG
opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG
CT Head:
1. Several facial fractures - fracture through the right
frontal sinus, with a tiny amount of subdural hemorrhage
adjacent to the fracture.
2. Soft tissue hematomas in the right frontal region.
3. Blood within the maxillary sinuses.
CT facial:
1. Fracture through the right frontal sinus, with a small amount
of subdural hemorrhage adjacent to the fracture line.
2. Fracture of the right nasal bone.
3. Fracture of the medial rim of the orbit in two places.
Inferior fractureline in the region of the nasolacrimal duct.
4. Left maxillary sinus anterolateral wall fracture.
5. Posterolateral left orbital wall fracture (Series 2, Image
20)
6. Right eye prosthesis
CT Chest:
1. No aortic injury seen.
2. Small single PE to a segmental branch of the right [**MD Number(3) 69793**]
posterior RLL.
3. Anterior wedging of the T8 vertebral body - consistent with a
compression deformity of uncertain chronicity.
CT C-Spine: No fractures or spondylolisthesis.
CXR: wide superior mediastinum
CTA chest: small PE within a segmental branch of the R [**MD Number(3) 69794**]
to the posterior aspect of the right lower lobe
LSpineXR:
1. Wedging of lower thoracic vertebra, worrisome for fracture.
2. Wide triangular shaped lucency at posterior element of L5/S1
CT T/L spine: slight wedging of the anterior portion of the T8
vertebral body, which is of uncertain chronicity, without
associated soft tissue abnormality, B pars articularis defects
at L5
Echo [**7-10**]: L atrium is mildly dilated. No thrombus/mass in
L atrium, R atrium. No ASD. LVEF>55%. L/R ventricular wall
motion normal. Asd aorta is mildly dilated. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal. No aortic regurg. The mitral valve
structurally normal c/ trivial mitral regurg. Mod. pulm artery
systolic HTN. No pericardial effusion.
LENIs: Acute occlusive thrombus within the left greater
saphenous vein, extending to the sapheno-femoral junction.
Brief Hospital Course:
This is a 61 year old man admitted to [**Hospital1 18**] after a traumatic
fall that resulted in numerous facial fractures; on admission he
was intoxicated but hemodynamically stable. He was admitted to
the T-SICU for frequent neurologic checks and monitoring for
alcohol withdrawal; neurosurgery, plastic surgery, opthalmology
and hematology consults were obtained.
Mr. [**Known lastname **] was evaluated by plastic surgery who determined that
the facial fractures are non-operable. Opthalmology recommended
opthalmologic ointment applied to his prosthetic eye.
Neurosurgery re-evaluted the head CT and felt that the subdural
hemorrhage noted on the admission CT may actually be the result
of volume-averaging.
A CTA was preformed as the CXR demonstrated mediastinal
widening. The CTA showed a small segmental PE. LENIs were
performed that showed a supericial thrombosis in the left
greater saphenous vein. Due to the presence of VTEs and the
relative contraindication to anticoagulation in the setting of
an acute SDH, an IVC filter was placed. Hematology was
consulted to consider appropriate work-up and provide advice
regarding anticoagulation. Given the risk of a significant bleed
should Mr. [**Known lastname **] have another traumatic injury, the Hematology
team recommended that the decision regarding starting
anticoagulation be delayed to the outpatient setting and be made
in conjunction with his PCP with whom he has had a longstanding
relationship. Mr. [**Known lastname **] will need to follow up with his PCP to
ensure continued, appropriate cancer surveillance (including
colorectal and prostate screening). Mr. [**Known lastname **] and his PCP will
discuss further Hematology evaluation and whether to start
anticoagulation - Mr. [**Known lastname 69795**] risk for fall should be a factor
in this decision.
While in the TSICU, Mr. [**Known lastname **] developed atrial fibrillation but
converted to NSR without intervention.
Mr. [**Name13 (STitle) **] was discharged on HD#3 with follow-up appointments
with his PCP, [**Name10 (NameIs) **] eye clinic, plastic surgery, and Hematology.
Medications on Admission:
Zoloft, antabuse, campral
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
3. Erythromycin 5 mg/g Ointment Sig: [**12-20**] (one quarter) inch
Ophthalmic twice a day: to right eye for total of 7 days.
Disp:*1 tube* Refills:*0*
4. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p fall
facial fractures
subdural hemorrhage
Secondary diagnoses:
pulmonary embolism
superficial venous thrombosis
atrial fibrillation (now resolved)
Compression fracture T8 vertebral body
Discharge Condition:
Good.
Discharge Instructions:
You were seen in the Emergency Department following a fall down
stairs. You landed directly on your face. As a result of this
fall, you have numerous facial fractures, however they are small
and do not require surgery. As a result of the fall, you also
had a small bleed in your brain (subdural hemorrhage). You also
have a compression fracture in your lower spine, but it is not
clear if this is new or old.
You were also found also have a small clot in your lung and a
clot in a vein in your leg. To help prevent the leg clot from
traveling from traveling to other parts of your lung, a filter
was placed in your inferior vena cava (IVC). You will need to
follow-up with a Hematologist to discuss whether to start
anticoagulation (medications to prevent future clots, but
increase your risk of bleeding if you fall or hurt yourself).
During your stay in the hospital, your heart went into an
abnormal rhythm called "atrial fibrillation" but this resolved
on its own.
Due to the facial fractures, you need to protect your nose and
sinuses. You should not blow your nose, you should not use
straws, you should not use nasal sprays and you should not put
anything up in your nose. Additionally, you should sleep with
your head elevated (i.e. on at least two pillows).
You should gently wash the abrasions (scrapes) on your face with
soap and water and can apply bacitracin to the abrasions.
You should apply erythromycin 0.5% Ophth Oint [**12-20**]" to your right
eye (the prosthesis) twice a day for a total of 7 days (to
finish [**7-16**]) and clean your prosthesis per routine.
You should be seen by your primary care physician next week to
discuss your fall, your fractures, your brief episode of atrial
fibrillation and the clots in your leg and lung.
You will need to follow-up with Plastic Surgery for your facial
fractures as specified below.
You should follow-up in the eye clinic in 2 weeks as specified
below.
For pain control you have been prescribed ibuprofen and
percocet. Percocet can make you sleepy, so you should not drive
or operate heavy machinery while taking this medication. You
should also not drink alcohol while taking percocet.
You should be seen by a physician/return to the hospital for:
*worsening headaches
*changes in your vision
*persistent nausea or vomiting
*trouble moving your arms or your legs, or difficulty walking
*numbness or tingling in your arms or your legs
*if you have a seizure
*if you develop high fevers (>102)
*if you become short of breath or a productive cough
*if you develop chest pain
*if you notice redness, swelling, or warmth around the cuts on
your face.
*other symptoms that concern you
Followup Instructions:
You should be seen by your primary care physician [**Name Initial (PRE) 176**] 1 week
to discuss your hospitalization, the clots in your leg and lung,
and your resolved atrial fibrillation.
You need to follow up with your primary care physician and
possibly [**Name Initial (PRE) **] hematologist regarding the clots in your lung and
leg. They will need to complete the workup evaluating why you
developed clots in the first place and to decide when/whether to
start anticoagulation. This work-up will include appropriate
cancer screening, including screening for colorectal cancer and
prostate cancer.
You should have a repeat Head CT in [**12-18**] weeks and this should be
performed before you meet with a hematologist.
You should follow up in the Plastic Surgery Clinic in [**2-17**] weeks.
You can call the clinic at [**Telephone/Fax (1) 4652**] to make an appointment.
You should follow-up with the eye clinic within 2 weeks. Please
call [**Telephone/Fax (1) 253**] to make an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2103-7-12**]
|
[
"311",
"805.2",
"802.0",
"453.40",
"E880.9",
"801.21",
"415.19",
"427.31",
"303.91",
"802.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
6556, 6562
|
3829, 5950
|
329, 352
|
6797, 6805
|
1282, 1282
|
9520, 10683
|
900, 904
|
6026, 6533
|
6583, 6630
|
5976, 6003
|
6829, 9497
|
919, 1263
|
6651, 6776
|
274, 291
|
380, 686
|
1842, 3806
|
1298, 1833
|
708, 799
|
815, 884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,574
| 114,529
|
10406
|
Discharge summary
|
report
|
Admission Date: [**2126-8-5**] Discharge Date: [**2126-8-16**]
Date of Birth: [**2080-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
transfer for sepsis, DKA
Major Surgical or Invasive Procedure:
triple lumen catheter placement
intubation
History of Present Illness:
HPI: 46 yo M with IDDM presented to an OSH after being found
unresponsive in bed by parents at 10am. Per parents, FS "too
high", no h/o trauma, no empty bottles or suicide attempt. Pt
reported to be nauseated in the past 2-3 days.
OSH Course: Initial VS: 95.6 BP 83/34 HR 118 RR 12 Shallow
breaths 93% on NRB. Initial glucose 2150, AG 33, Cr 4.3. ABG:
7.05/22/211/6.03 on 100%O2-Ambu bag. Pt received Ceftriaxone
2gm, Vanco 1gm x1, acyclovir 500mg x1, narcan 2mg, insulin 14U
IV x1, 16 U IV, 20IV, + Insulin gtt 7 units/hr-->10units/hr,
NaHCO3 2amps x1. At time of transfer AG 26, gluc 1645, BUN/Cr
74/3.8, Calcium 7.3, K 3.4. Head CT negative but + for
sinusitis, LP done and treated for possible bacterial/viral
meningitis, and PNA. Pt transferred to [**Hospital1 18**] for further
management of severe DKA, ARF, MS changes, septic shock on
levophed and dopamine gtt prior to transfer.
Past Medical History:
-IDDM
-Medullary sponge kidney
-Nephrolithiasis
-nueropathy
-chronic back pain
Social History:
-Divorced, lives at home with parents, 2 children.
-Tob 1/2ppd, No ETOH use, no other drug use or IVDU
Family History:
M: Leukemia, currently undergoing chemotherapy
F: CAD, HTN
Physical Exam:
VS: 97.5 BP 90/66 HR 96 RR 27 95% AC 600X12 FiO2 1.00 PEEP 10
GEN: Intubated, shivering off sedation
HEENT: ETT in place, PERRL 3-2mm, anicteric sclera
RESP: coarse BS throughout, no wheezing
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft, Distended, +tenderness noted with grimacing,
diminished BS
EXT: Non pitting peripheral edema, warm, 1+ DP pulses
NEURO: not following commands, hyporeflexic (sedated)
Pertinent Results:
[**2126-8-5**] 10:25PM GLUCOSE-668* UREA N-47* CREAT-2.1*#
SODIUM-152* POTASSIUM-3.4 CHLORIDE-133* TOTAL CO2-11* ANION
GAP-11
[**2126-8-5**] 10:25PM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-158
CK(CPK)-232* ALK PHOS-80 AMYLASE-140* TOT BILI-0.1
[**2126-8-5**] 10:25PM LIPASE-24
[**2126-8-5**] 10:25PM ALBUMIN-2.7* CALCIUM-5.5* PHOSPHATE-1.9*
MAGNESIUM-1.9
[**2126-8-5**] 10:25PM TSH-0.37
[**2126-8-5**] 10:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-8-5**] 10:25PM WBC-12.9* RBC-3.28* HGB-9.9* HCT-31.4* MCV-96
MCH-30.1 MCHC-31.4 RDW-13.7
[**2126-8-5**] 10:25PM NEUTS-56 BANDS-10* LYMPHS-31 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*
[**2126-8-5**] 10:25PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
[**2126-8-5**] 10:25PM PLT COUNT-298
[**2126-8-5**] 10:25PM PT-14.7* PTT-29.3 INR(PT)-1.3*
Brief Hospital Course:
AP: 46 yo M with hx of IDDM with DKA & sepsis, initially
intubted on pressors and admitted to the ICU for further care
and management.
1. Respiratory failure/MRSA pneumonia: Patient was initially
placed on broad spectrum antibiotics with vancomycin,
ceftriaxone, and flagyl for hypotension in the setting of DKA.
A sputum culture was obtained that grew out MRSA. He was
continued on vanc for a total 10 day course. All blood cultures
taken at our hospital were negative. He was sucessfully weaned
off of mechanical ventilation and then diuresed with resulting
return to baseline function and no oxygen requirement. At the
time of discharge the patient had resolved leukocytosis and was
afebrile with a markedly improved CXR.
2. DKA: Patient was initially placed on an insulin gtt per
protocol and was followed with serial chem 10s and ABGs until
his anion gap closed. He was then transitioned to Lantus and a
humalog sliding scale. Patient initially had early morning
hypoglycemia on a dose of Lantus 20 units daily and this was
decreased to 16 units. However the patient's BG then was
consistently in the mid 200s. In consultation with [**Last Name (un) **] DM
management team who have been following the pt during this
hospitalization it was decided to increase the lantus dose to 18
units daily and titrate the humalog scale. He has follow up
appointments with [**Last Name (un) **] on [**8-19**].
3. Thrombocytopenia: Patient had transient thrombocytopenia
while in the ICU that resolved prior to transfer to the floor.
A HIT-Ab was sent which was negative. He had no evidence of
petechiae or easy bruising.
4. Skin lesions: S/p fluid overload & edema with blisters. He
was followed by the wound consult nurse and had dressing changes
daily. There were no signs of ceullulitis at these sites. He
will have VNA follow up at home for continued dressing changes.
.
5. ARF: Patient experienced ARF on admission most likely
secondary to profound volume depletion. He was aggressively
hydrated with IVF and his serum cr returned to baseline upon
arrival to the general floor.
6. Depression--Pt was placed back on his prior dose of Celexa.
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*11 * Refills:*2*
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Insulin Glargine 100 unit/mL Solution Sig: One (1) 18
Subcutaneous at bedtime.
Disp:*1 18* Refills:*2*
5. humalog sliding scale
For breakfast, lunch and dinner:
BG 0-50 1 glass of OJ
51-100 0 units
101-150 7 units Humalog SC
151-200 10 units Humalog SC
201-250 12 units Humalog Sc
251-300 14 units Humalog SC
301-350 16 units Humalog SC
351-400 18 units Humalog SC
For Bedtime, if BG is >200
201-250 2 units Humalog SC
251-300 3 units Humalog SC
301-350 4 units Humalog SC
351-400 5 units Humalog SC
>400 call your PCP
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
7. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**1-22**] Tablet,
Delayed Release (E.C.)s PO daily PRN as needed for constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
DKA
sepsis
MRSA PNA
bilateral UE blisters
Discharge Condition:
good
Discharge Instructions:
Patient will have VNA nursing to help with dressing changes. He
will follow up with the [**Last Name (un) **] center for further DM. He should
return to the ER or call his PCP if he develops fevers, chills,
nausea or vomiting. He should monitor his BG 4 times daily and
call his PCP if he has a BG >375.
Followup Instructions:
[**8-19**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], NP - 10 am [**Hospital **] Clinic
[**8-20**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN - 8:30 am.
He should follow up with his PCP [**Last Name (NamePattern4) **] [**1-22**] weeks.
|
[
"038.11",
"995.92",
"518.81",
"362.01",
"357.2",
"276.2",
"276.6",
"300.4",
"482.41",
"584.9",
"709.8",
"785.52",
"250.33",
"250.53",
"287.4",
"250.63",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6280, 6348
|
2972, 5129
|
338, 383
|
6434, 6441
|
2037, 2949
|
6796, 7100
|
1541, 1602
|
5152, 6257
|
6369, 6413
|
6465, 6773
|
1617, 2018
|
274, 300
|
411, 1301
|
1323, 1404
|
1420, 1525
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,987
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52717
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Discharge summary
|
report
|
Admission Date: [**2150-4-8**] Discharge Date: [**2150-4-21**]
Date of Birth: [**2102-1-10**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Lisinopril
Attending:[**First Name3 (LF) 22990**]
Chief Complaint:
Fatigue, poor appetite
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 yo AA male with DMII on insulin, depression/anxiety, history
of alcohol abuse, presents with hyperglycemia. Poor historian,
but change of status seems to have started up to 1 month ago
with feeling apathy, weakness, good appetite but not eating.
Then about 2 wks PTA, pt stopped taking insulin - unable to
clarify why, and continued all his other medications. He became
very thirsty, drank a lot of water, following which he developed
nausea/vomiting - nonbloody/nonbilious and watery diarrhea.
Urine output was decreased and brown in color. Then 5d PTA pt
developed pain in his LUQ radiating to back. Overall feeling
weak, ROS other than above neg (fevers, chills, NS, CP, SOB).
.
On arrival to ED, initial vs were: T97.8 86 162/115 18 100% RA.
Glucose 514 on admission. WBC 11, with 23%bandemia. Initial gap
29 with correct sodium, ABG without acidosis. Utox neg, LFTs neg
except AP 150, LDH 560. Creatinine of 1.6, with urine ketones,
serum acetone and lactate 2.8. Lipase added on, elevated to 532.
Blood cultures and urine cultures sent. CXR with linear
bibasilar atelectasis. Pt started on insulin gtt and received 3L
IVF.
.
Recheck FS after 2hrs 110, AG closed. K 2.9, given K PO and in
D51/2. VS on transfer were 97.8, 76, 124/60, 16, 100%.
.
Past Medical History:
1) LOWER BACK PAIN
2) DIABETES TYPE II
3) HYPERTRIGLYCERIDEMIA
4) Depression/Anxiety with anger management issues and possible
schizoaffective disorder
5) H/O ALCOHOL ABUSE
6) GOUT
7) HIP PAIN
8) ANEMIA: s/p bone marrow biopsy, has responded to procrit in
past.
9) CHRONIC RENAL FAILURE
10) RECURRENT OTITIS MEDIA
11) KNEE PAIN
12) H pylori + on EGD [**2145**], unknown if treated
13) HYPERTENSION
14) H/O ATYPICAL CHEST PAIN: EKG, echo, stress normal, mild
symmetric LVH
15) SLEEP DISORDER: nightmares
16) ERECTILE DYSFUNCTION
17) RECTAL BLEEDING: no colonoscopy
Social History:
Prior alcohol use of about three drinks per day. Denies any
alcohol for the last month. No IV drug abuse.
Lives alone. Has family in the area.
Patient has positive tobacco use at 1/2 pack per day x25 years.
Family History:
NC
Physical Exam:
Vitals: T: 99.3 BP: 110/76 P: 85 R: 20 18 O2: 100RA
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender in LUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Imaging
[**2150-4-8**] CXR
IMPRESSION: Bibasilar atelectasis, otherwise, unremarkable chest
x-ray.
.
[**2150-4-9**] RUQ CONCLUSION: Normal right upper quadrant ultrasound
apart from the presence of trace ascites.
.
[**2150-4-9**] CT abdomen and pelvis
IMPRESSION: Homogeneneous enhancing pancreas with a massive
adjacent
pseudocyst. No evidence of pancreatic necrosis. Malrotation, as
noted on prior CT examination.
.
[**2150-4-11**] CT abdomen and pelvis
IMPRESSION:
1. Stable changes of pancreatitis with stable large
multiloculated fluid
collection.
2. New small bilateral pleural effusions and new trace ascites.
The study and the report were reviewed by the staff radiologist.
.
[**2150-4-13**] CXR
FINDINGS: In comparison with study of [**6-8**], there is increased
opacification at both bases, consistent with pleural fluid and
atelectasis. In view of the clinical impression of fever, the
possibility of supervening pneumonia must be seriously
considered.
.
[**2150-4-17**] Head CT
IMPRESSION: No acute abnormalities. No significant change
compared with previous CT of [**2146-7-6**].
.
[**2150-4-17**] Bilateral Lower Extremity Doppler
IMPRESSION: No evidence of DVT in the bilateral lower
extremities.
.
[**2150-4-20**] Right Ankle Films
IMPRESSION: No evidence of acute fracture.
.
Microbiology Data
[**2150-4-17**] CLOSTRIDIUM DIFFICILE TOXIN A & B -negative
[**2150-4-15**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-15**] URINE URINE CULTURE- negative
[**2150-4-15**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-13**] BLOOD CULTURE Blood Culture, Routine- negative
[**2150-4-13**] URINE URINE CULTURE-negative
[**2150-4-12**] STOOL FECAL CULTURE-negative; CAMPYLOBACTER
CULTURE-negative; CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2150-4-12**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-11**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-10**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-10**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-10**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-9**] URINE URINE CULTURE-negative
[**2150-4-8**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-8**] BLOOD CULTURE Blood Culture, Routine-negative
[**2150-4-8**] URINE URINE CULTURE-negative
.
Laboratory Data
[**2150-4-8**] 09:10PM BLOOD WBC-11.7* RBC-4.23* Hgb-11.8* Hct-36.1*
MCV-85 MCH-28.0 MCHC-32.8 RDW-13.1 Plt Ct-441*
[**2150-4-9**] 07:14AM BLOOD WBC-9.5 RBC-3.22* Hgb-9.0* Hct-27.2*
MCV-84 MCH-27.8 MCHC-33.0 RDW-13.0 Plt Ct-330
[**2150-4-10**] 05:30AM BLOOD WBC-10.8 RBC-3.08* Hgb-8.7* Hct-26.1*
MCV-85 MCH-28.1 MCHC-33.2 RDW-13.1 Plt Ct-327
[**2150-4-10**] 09:30PM BLOOD WBC-9.2 RBC-2.59* Hgb-7.3* Hct-21.9*
MCV-84 MCH-28.1 MCHC-33.3 RDW-13.1 Plt Ct-273
[**2150-4-10**] 09:30PM BLOOD WBC-9.2 RBC-2.59* Hgb-7.3* Hct-21.9*
MCV-84 MCH-28.1 MCHC-33.3 RDW-13.1 Plt Ct-273
[**2150-4-12**] 05:55AM BLOOD WBC-9.0 RBC-2.61* Hgb-7.5* Hct-22.3*
MCV-85 MCH-28.7 MCHC-33.6 RDW-13.5 Plt Ct-306
[**2150-4-14**] 01:10AM BLOOD Hct-20.8*
[**2150-4-14**] 07:05AM BLOOD WBC-7.9 RBC-2.60* Hgb-7.3* Hct-22.7*
MCV-87 MCH-28.0 MCHC-32.1 RDW-13.7 Plt Ct-388
[**2150-4-15**] 04:55AM BLOOD WBC-11.6* RBC-2.73* Hgb-7.8* Hct-23.4*
MCV-86 MCH-28.6 MCHC-33.4 RDW-13.8 Plt Ct-406
[**2150-4-17**] 06:39AM BLOOD WBC-7.3 RBC-2.54* Hgb-7.1* Hct-21.6*
MCV-85 MCH-28.0 MCHC-32.9 RDW-13.8 Plt Ct-494*
[**2150-4-17**] 12:40PM BLOOD WBC-5.7 RBC-2.69* Hgb-7.7* Hct-23.1*
MCV-86 MCH-28.7 MCHC-33.4 RDW-13.7 Plt Ct-452*
[**2150-4-21**] 05:45AM BLOOD WBC-5.2 RBC-3.40* Hgb-9.8* Hct-30.0*
MCV-88 MCH-28.7 MCHC-32.5 RDW-13.7 Plt Ct-689*
[**2150-4-8**] 09:10PM BLOOD Neuts-55 Bands-23* Lymphs-12* Monos-4
Eos-3 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2150-4-9**] 07:14AM BLOOD Neuts-78.3* Bands-0 Lymphs-18.2 Monos-2.6
Eos-0.8 Baso-0.2
[**2150-4-10**] 05:30AM BLOOD Neuts-83.3* Lymphs-14.0* Monos-2.0
Eos-0.5 Baso-0.1
[**2150-4-15**] 04:55AM BLOOD Neuts-82.7* Lymphs-13.4* Monos-2.5
Eos-1.3 Baso-0.2
[**2150-4-9**] 09:50AM BLOOD PT-13.5* PTT-23.9 INR(PT)-1.2*
[**2150-4-12**] 05:55AM BLOOD PT-19.0* PTT-28.1 INR(PT)-1.7*
[**2150-4-17**] 06:39AM BLOOD PT-14.7* PTT-22.9 INR(PT)-1.3*
[**2150-4-19**] 05:55AM BLOOD PT-13.0 PTT-25.5 INR(PT)-1.1
[**2150-4-8**] 09:10PM BLOOD Glucose-514* UreaN-40* Creat-1.6* Na-128*
K-3.7 Cl-76* HCO3-29 AnGap-27*
[**2150-4-8**] 11:40PM BLOOD Glucose-94 UreaN-33* Creat-1.3* Na-135
K-2.9* Cl-91* HCO3-29 AnGap-18
[**2150-4-11**] 09:00AM BLOOD Glucose-61* UreaN-8 Creat-0.8 Na-135
K-3.8 Cl-106 HCO3-21* AnGap-12
[**2150-4-15**] 04:55AM BLOOD Glucose-122* UreaN-7 Creat-0.9 Na-134
K-4.2 Cl-104 HCO3-23 AnGap-11
[**2150-4-21**] 05:45AM BLOOD Glucose-120* UreaN-6 Creat-0.8 Na-140
K-4.3 Cl-103 HCO3-29 AnGap-12
[**2150-4-8**] 09:10PM BLOOD ALT-12 AST-20 LD(LDH)-561* AlkPhos-157*
TotBili-0.4
[**2150-4-10**] 09:30PM BLOOD ALT-12 AST-26 LD(LDH)-410* AlkPhos-96
Amylase-88 TotBili-0.2
[**2150-4-14**] 07:05AM BLOOD ALT-22 AST-38 LD(LDH)-432* AlkPhos-105
TotBili-0.4
[**2150-4-17**] 06:39AM BLOOD ALT-19 AST-40 LD(LDH)-674* CK(CPK)-188
AlkPhos-121 TotBili-0.2
[**2150-4-18**] 04:30AM BLOOD ALT-14 AST-19 LD(LDH)-349* CK(CPK)-172
AlkPhos-107 TotBili-0.1
[**2150-4-20**] 06:12AM BLOOD ALT-12 AST-15 LD(LDH)-297* AlkPhos-109
TotBili-0.1
[**2150-4-8**] 11:40PM BLOOD Lipase-532*
[**2150-4-9**] 07:14AM BLOOD Lipase-473*
[**2150-4-10**] 09:30PM BLOOD Lipase-194*
[**2150-4-11**] 09:00AM BLOOD Lipase-142*
[**2150-4-12**] 05:55AM BLOOD Lipase-93*
[**2150-4-20**] 06:12AM BLOOD Lipase-79*
[**2150-4-17**] 06:39AM BLOOD CK-MB-2 cTropnT-<0.01
[**2150-4-18**] 04:30AM BLOOD CK-MB-4 cTropnT-<0.01
[**2150-4-9**] 07:14AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
[**2150-4-19**] 05:55AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9
[**2150-4-17**] 12:40PM BLOOD calTIBC-207* VitB12-621 Folate-18.9
Hapto-407* Ferritn-594* TRF-159*
[**2150-4-8**] 11:40PM BLOOD Triglyc-330*
[**2150-4-9**] 07:14AM BLOOD Triglyc-301*
[**2150-4-17**] 12:40PM BLOOD TSH-2.7
[**2150-4-8**] 11:59PM BLOOD Glucose-88 Lactate-2.8*
Brief Hospital Course:
Mr. [**Known lastname 89072**] is a 47 year old man with depression, alcohol abuse,
and diabetes who presented with hyperglycemia and pancreatitis.
His hospital course was complicated by an acute gout flare.
.
# Pancreatitis: On admission Mr. [**Known lastname 89072**] had an elevated lipase
and left sided abdominal pain radiating towards the back. A CT
scan showed a loculated fluid collection around the pancreas. He
was kept NPO, given aggressive IV fluids, and pain control.
Given the severity of his pancreatitis he was placed on Zosyn.
In the first 48 hours he continued to have severe pain,
significant hematocrit decrease, and persistent fevers. A repeat
CT scan showed no significant improvement. There was no evidence
of necrosis. He was continued on antibiotics and given
aggressive fluid hydration. The GI service was following.
Eventually his pain began to improve and his diet was advanced.
The exact etiology of his pancreatitis was unclear. There was no
evidence of gallstones. He had a history of
hypertriglyceridemia, but was on therapy. He has a past history
of alcohol abuse, but denied consumption over the last month.
.
# Fevers: Mr. [**Known lastname 89072**] had several days of elevated temperatures.
Multiple cultures were taken, but all were negative. On
admission, he had 23% bands on a manual count. However, the
bandemia resolved by the following morning. He was followed by
the ID service. His fevers were thought to be from a combination
of pancreatitis and gout.
.
# Hyperglycemia: He was initially place on an insulin gtt in the
emergency department. This was transitioned to subcutaneous
insulin. The [**Last Name (un) **] diabetes service was consulted. He was
continued on glargine. He was not eating a consistent diet and
had several episodes of hypoglycemia. He was on a D10 gtt with
glargine for 3 days. Once his PO intake increased, the D10 was
discontinued.
.
# Acute Renal Insufficiency: He was volume depleted on
admission. This improved after hydration.
.
# Gout: During his hospitalization he developed an acute gout
flare in the right ankle, left ankle, and right wrist.
Rheumatology was consulted. They attempted a joint aspiration in
the right ankle, but did not obtain any fluid. They injected
steroids in the right ankle. His right wrist pain and left ankle
pain resolved. His right ankle pain persisted. Once his GI
complaints subsided, he was started on colchicine [**Hospital1 **]. This was
eventually increased to TID.
.
# Anemia: He has baseline anemia. Initially his hematocrit
decreased following aggressive fluid hydration. He received two
transfusions for symptomatic anemia. He was having some
shortness of breath. This did not improve following transfusion.
His hematocrit was increasing prior to discharge.
.
# Possible alcohol abuse: He was initially placed on a CIWA
scale. He did not score. He was started on thiamine and folate.
.
# Depression: Initially he was continued on his home
medications. Psychiatry was consulted given his depressive
symptoms and concern that his depression and or medications may
have contributed to his poor appetite prior and during the
hospitalization. His Wellbutrin dose was decreased, then
scheduled to be stopped.
.
# Hypertension: Initially all anti-hypertensives were held given
low blood pressures. These were gradually restarted. On
discharge spironolactone and hydrochlorothiazide had not yet
been restarted.
.
# Vision Complaints: Initially he stated he vision was better
than normal, then he stated his vision appeared blurry
intermittently. No abnormalities were seen on exam or head CT.
He was scheduled for outpatient followup. Some of the vision
complaints were thought to be related to blood glucose control.
.
Medications on Admission:
ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth once a day
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
BUPROPION HCL [WELLBUTRIN SR] - 150 mg Tablet Sustained Release
- 1 Tablet(s) by mouth qam
COLCHICINE - (Dose adjustment - no new Rx) - 0.6 mg Tablet - 1
Tablet(s) by mouth once a day
GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth three times a
day
GEMFIBROZIL - 600 mg Tablet - 1 Tablet(s) by mouth twice a day
30 minutes before breakfast and dinner
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 56 units
subcutaneously at bedtime
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use as sliding
scale directs twice a day use 4 units if sugar 200-250, 6 units
if 250-300, 8 units if300-350, 10 units if 350-400. [**Name8 (MD) **] MD if
over 400
MIRTAZAPINE [REMERON] - 15 mg Tablet - 3 (Three) Tablet(s) by
mouth at bedtime
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours as needed for pain. Do
not mix with alcohol or other sedating medicaionts. Do not drive
after use.
QUETIAPINE [SEROQUEL] - 25 mg Tablet - 3 (Three) Tablet(s) by
mouth qd prn anxiety
QUETIAPINE [SEROQUEL] - 100 mg Tablet - 1.5 (One and a half)
Tablet(s) by mouth at bedtime
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
TIZANIDINE - 2 mg Tablet - 1 Tablet(s) by mouth up to three
times a day as needed for muscle spasm **may be sedating, do not
drive after use or mix with alcohol*
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning))
for 4 days: Take for four days starting [**4-22**], then stop.
Disp:*4 Tablet Sustained Release(s)* Refills:*0*
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for before breakfast and dinner - HOLD if NPO.
8. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day: Please take in the morning.
9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for muscle spasm: Do not drive or operate
machinery while taking.
12. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO once a day
as needed for anxiety.
16. Quetiapine 100 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
17. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*15 Tablet(s)* Refills:*2*
18. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: Do not drive or operate machinery
while taking.
Disp:*30 Tablet(s)* Refills:*0*
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Hyperglycemia
Gout
Pancreatitis
Diabetes Mellitus type II
Secondary Diagnosis:
Depression
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:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with high blood sugars and
pancreatitis. Pancreatitis is an inflammation of your pancreas.
While you were in the hospital you required two blood
transfusions for anemia (low blood count). You were also treated
for a flare of your gout.
We made several changes to your medications:
Please decrease the amount of Wellbutrin that you take to 100 mg
daily. Please take this for four days, then stop taking
Wellbutrin (bupropion).
We added morphine to your medications. Please take this as
needed for pain in your ankle. Please do not drive or operate
machinery while taking this medication.
We added pantoprazole to help with your stomach.
We decreased the Lantus (glargine) that you take to 12 units in
the MORNING. As your appetite improves, you may need to increase
this and also give yourself sliding scale coverage. Please be
sure to check your fingersticks at least four times per day. You
already received your dose today (Tuesday, [**4-21**]).
We added docusate and senna to help mover your bowels while you
are taking narcotics.
We also added thiamine and folate which are both vitamins.
We added metoclopramide (Reglan) to help improve nausea.
We stopped your aspirin. Please discuss with Dr. [**Last Name (STitle) **] when to
restart this.
We increased your colchicine dose to twice daily.
We temporarily stopped your hydrochlorothiazide and
spironolactone. Please discuss with Dr. [**Last Name (STitle) **] when to restart
these medications.
Please eat a low fat diet and do NOT drink any alcohol as this
may worsen your pancreatitis.
Followup Instructions:
We have scheduled the following appointments for you:
Ophtho (blurred vision): Dr [**Last Name (STitle) **] Date/Time:[**2150-4-27**] @ 3:30pm
Phone:[**Telephone/Fax (1) 253**]
PCP (general): Dr [**Last Name (STitle) **] Date/Time:[**2150-4-29**] @ 10:10am
Phone:[**Telephone/Fax (1) 250**]
Rheum (gout): Dr [**Last Name (STitle) **] Date/Time:[**2150-5-7**] @ 11:30am
Phone:[**Telephone/Fax (1) 1228**]
[**Last Name (un) **] (diabetes): Dr [**Last Name (STitle) 818**] Date/Time: [**2150-5-7**] @ 1pm
Phone:[**Telephone/Fax (1) 2378**]
Psychiatry (depression): Dr [**First Name (STitle) 452**] Date/Time:[**2150-5-12**] @ 2:00pm
Phone:[**Telephone/Fax (1) 1387**]
GI (pancreatitis): Dr [**First Name (STitle) 1255**] Date/Time:[**2150-6-2**] @ 3:30pm
Phone:[**Telephone/Fax (1) 1983**]
|
[
"250.12",
"584.9",
"577.2",
"V58.67",
"518.0",
"403.90",
"577.0",
"274.01",
"511.9",
"585.9",
"285.9",
"305.00",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"81.92",
"99.23"
] |
icd9pcs
|
[
[
[]
]
] |
16567, 16625
|
8953, 12680
|
304, 310
|
16785, 16785
|
2966, 8930
|
18631, 19427
|
2423, 2427
|
14315, 16544
|
16646, 16646
|
12706, 14292
|
16965, 17305
|
2442, 2947
|
17335, 18608
|
242, 266
|
338, 1594
|
16745, 16764
|
16665, 16724
|
16800, 16941
|
1616, 2182
|
2198, 2407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,970
| 128,930
|
50632+50633+50634
|
Discharge summary
|
report+report+report
|
Admission Date: [**2198-5-15**] Discharge Date: [**2198-5-17**]
Date of Birth: [**2134-6-28**] Sex: F
Service: PSYCHIATRY
Allergies:
Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose
Attending:[**First Name3 (LF) 1678**]
Chief Complaint:
"I was at [**Hospital3 **] and then came here because I was told I may
have had seizure."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63yo married white woman with reported h/o multiple
personality disorder, depression, PTSD, and recently documented
h/o bipolar disorder, also with a medical h/o sleep apnea,
ehlers-danlos, and previous seizure due to intracranial
hematoma,
who was transferred form [**Hospital3 417**] hospital at husband of
patient's request for psychiatric evaluation and possible psych
admission.
Per [**Hospital3 **] notes (sent on transfer), the patient was
recently admitted to [**Hospital3 **] on [**2198-5-12**] for question of
seizure.
Labs, MRI/MRA, Head CT were all negative. EEG was negative for
seizure activity, but showed some generalized slowing. Patient
was also seen by psychiatry while there for expansive affect and
pressured speech. Diagnosed with bipolar disorder with hypomanic
episode, likely secondary to taking antidepressants wrong
(taking
more wellbutrin than she was supposed to). Also had a
subtherapeutic VPA level. Psych planned to taper
antidepressants,
and [**Month (only) **] dose of wellbutrin to 150 daily and celexa 20 daily.
Patient was discharged home [**2198-5-14**] with plan to follow-up with
outpt neuro and psych (though doesn't have any outpt psych
treaters in place).
Per the husband, the patient continued to have pressured
speech, [**Month (only) **] sleep, only 10minutes at a time for a total of 30
minutes. Was restless in bed. He became concerned about her and
felt he was unable to contain her and called 911. She was taken
back to [**Hospital3 **]. Repeat labs and head imaging was negative.
[**Hospital3 **] recommended inpt psych admit, but the husband wanted
transfer
to [**Hospital1 18**] which the hope that the patient could be admitted if
needed psychiatrically at [**Hospital1 18**] and set up with outpt behavioral
health treaters at [**Hospital1 18**].
Per the patient, she reports feeling "hyper" meaning that
she has more energy than usual, has a hard time sleeping, and
feels she talks faster than usual. She reports having similar
"hyper" episodes throughout her life. Unable to give an accurate
history about the frequency, length or when the last episode
was.
Denies increased spending, promiscuity or goal directed
behaviors
during these episodes. However her husband endorses that she
will
have [**2-22**] "manic" episodes over a year, then not have any for a
few years since he has known her for 38 years. He endorses that
at her worst, she does have disorganized thoughts, rapid speech,
increased goal directed behavior (such as scrubbing floor in
middle of night) and decreased need for sleep (though would
sleep
some each night). He noticed that this "manic" episode started
about the same time as the potential seizure like activity on
[**2198-5-12**].
Patient is unable to give a accurate account of her meds,
but she is the one who self administers them. She endorses that
she often changes her meds on her own and endorses needing help
with accurately taking her meds.
Psych ROS: Patient denies any current depressed mood or
neurovegetative symptoms. Denies any suicidality. Denies any
current or past psychotic symptoms. Denies any dissociate
episodes. Denies any active sx of PTSD except an occasional
trauma related nightmare.
Past Medical History:
PSYCH HX: (per patient, verified with husband)
DX: Multiple personality disorder since teens diagnosed by
counselor at [**Doctor First Name **], due to trauma history. Reports this has not
been active for many years. Reports h/o depressive episodes that
required hospitalization. History of PTSD, not currently active.
Denies Bipolar disorder, however recent psych eval at [**Hospital3 **]
reports diagnosis of Bipolar disorder (hypomanic episodes)
HOSP: multiple (up to 10) at [**Doctor First Name **]. 1st at age 15. Most recent
was [**2188**]. Mostly for depressive episodes.
MED TRIALS: unknown (reports Seroquel once, but caused
significanat inc appetite).
SA/SIB: twice: first age 15 (ASA overdose 85 tablets). Admitted
to hospital. Second (unknown age, but not recent) was by psych
med ingestion.
TREATERS: previously was seen at [**Doctor First Name **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80749**]
(psychopharm) and Dr. [**First Name8 (NamePattern2) 1258**] [**Last Name (NamePattern1) **] (therapist) for many years
until [**2197-11-20**] (at which time they suggested patient get
treaters at Southbay MHC, closer to her home, bc the patient had
a bad MVA due to her driving and didn't want to put the patient
further at risk by making her drive to [**Location (un) 10059**] from [**Location (un) 701**]).
Currently, the patient is in the intake process at Southbay, but
does not have an actual therapist or psychiatrist.
PAST MED HX: Ehlers Danlos syndrome, HTN, ANgina, Sleep apnea
(refuses CPAP), ? h/p TIAs, Cataracts, h/o seizure [**2-21**] to
intracrania hematoma, s/p l5-s1 fusion and laminectomy
Social History:
SUBSTANCE ABUSE HX:
ETOH: h/o etoh abuse drinking 1 bottle wine daily up until 6
months ago, at which time she self tapered with help of her
outpt
psychiatrist. Has not used since. No h/o blackouts or inpt
detoxes.
TOB: smoked 2ppd for 40 yrs, quit in [**2195**]
DRUG: none for >20 yrs. Experimented with MJ and "other" drugs
when she was young. Denies any h/o IVDA.
COFFEE: drinks four 32oz glasses of coffee daily. does not want
to cut down.
SOCIAL HX: Raised in [**Location (un) **] and [**Location (un) 686**]. Sexually abused by
father from age [**5-2**]. Went to court for which her father was
sent
to [**Location (un) **] for substance abuse treatment. Then lived with
her
mother, who she reports made her drop out of school in 9th grade
to support the family. She worked in telescope factory. Has 2
sisters and 1 brother, only stays in contact with one sister in
[**Name (NI) 26671**] MA. 1st marriage with 2 children (son and daughter)
who now live in [**Location (un) **] and hullbrook ma. Divorced and
remarried 38 yrs ago to current husband. [**Name (NI) **] children with
current
husband. [**Name (NI) **] now on SSDI for many years due to psych
illness.
Husband works. [**Name2 (NI) **] legal issues in past. Reports DV by husband in
past, hit patient once in [**2167**]'s and pushed patient once. She
does not feel unsafe. He currently calls her names at times, but
she reports they are in couples counseling for this and working
through their issues. Reports she has one friend (with mild
mental retardation) who she is close to and sees almost every
day.
Family History:
FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and SA
when he was 9 years old. Denies any other known psychiatric
family history.
Physical Exam:
Physical Exam:
VS: BP: 180/66 HR: 56 temp: 98.6 resp: O2 sat: 98%
height:
5'3" weight: 203.8 lbs
Gen: obese Caucasian female, alert and interactive, looking
stated age, dressed in hospital [**Doctor First Name **], grooming fair
HEENT: normocephalic, oropharnyx clear. PERRL, EOMI.
CV: RRR, no M/R/G
Pulm: CTAB
Abd: +BS, NDNT, soft
Ext: mild 1+ pitting edema of right foot
Skin: extensive erythematous scarring of shins bilaterally "pt
attributes to her ehlers-danlos syndrome)
Neurological:
CN:
II: PERRLA
III, IV, VI: EOM intact
V: facial sensation intact bilat
VII: facial mvts symmetric bilat
VIII: finger rub audible bilat
IX, X: palate raise symmetric bilat
[**Doctor First Name 81**]: SCM and trapezii [**5-24**] bilat
XII: tongue midline
Motor: Normal bulk and tone, strength 4/5 in R leg
(longstanding), [**5-24**] in left leg and right arm; also appears full
strength in left arm but cannot fully test due to pain in left
shoulder
Sensory: grossly intact to light touch bilaterally
Reflexes: 1+ biceps, triceps, brachioradialis and patellar
reflexes. hyporeflexic
Cerebellar: Intact finger to nose.
Gait: intact
Abnormal movements: none noted.
Mental Status:
Appearance: obese Caucasian female, alert and interactive,
looking stated age, dressed in hospital [**Doctor First Name **], grooming fair,
good eye contact
Behavior: cooperative with interview, friendly, pleasant,
frequently laughing and joking
Mood: "great"
Affect: hyperthymic, pleasant, energetic
Thought process: tangential, rambling, but logical and
redirectable
Thought Content: regarding her medical issues (shoulder, rash
on
buttocks); no delusions or bizarre content
Judgment: fair
Insight: fair
SI/HI: denies SI/HI
Perception: no AVH, delusions, or paranoia
Cognitive Exam:
Attention: able to recite DOWB
Orientation: oriented to person, place, and date
Memory: [**3-22**] registration and recall
Fund of knowledge: knows president
Calculations: quarters in $2.25 = 9
Abstraction: "don't throw stones if you live in a glass house"
=
'how dare you shit on someone else when you're shitting on
yourself'
Speech: pressured rate, high volume, normal prosody
Language: used appropriately
Pertinent Results:
LAB DATA: From OSH ([**Hospital3 **]) dated [**2198-5-15**]:
CBC WNL; BMP WNL except GLU 112; LFTS WNL; TSH/T4 WNL; B12 WNL
Serum tox negative
VPA 22.0
U/A: tr bld
UTOX: negative
Head CT: no intracranial abnl
MRI brain/neck & MRA with gad on [**5-12**]: small vessel disease and
mld atrophy.
EKG [**5-15**]: sinus brady at 58, qt/qtc 464/456
LAB DATA: From [**Hospital1 18**]
[**2198-5-15**] 08:10PM GLUCOSE-93 UREA N-22* CREAT-0.9 SODIUM-140
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2198-5-15**] 08:10PM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-99 TOT
BILI-0.3
[**2198-5-15**] 08:10PM CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-2.2
[**2198-5-15**] 08:10PM VIT B12-928*
[**2198-5-15**] 08:10PM TSH-0.86
[**2198-5-15**] 08:10PM VALPROATE-18*
[**2198-5-15**] 08:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2198-5-15**] 08:10PM WBC-7.3 RBC-4.12* HGB-13.3 HCT-38.3 MCV-93
MCH-32.2* MCHC-34.6 RDW-13.5
[**2198-5-15**] 08:10PM NEUTS-59.2 LYMPHS-27.8 MONOS-7.9 EOS-3.8
BASOS-1.3
[**2198-5-15**] 08:10PM PLT COUNT-257
Brief Hospital Course:
Admitted to [**Hospital1 **] 4 for further work-up and management of
?bipolar illness. On day 1 of hospitalization, pt was continued
on her medication regimen as described in discharge records from
[**Hospital3 417**] Hospital. She was interactive in the milieu and
was able to participate in conversation with her treatment team.
She was ambulatory, ate meals, showered, engaged in
conversations, had a visit from her husband. She did endorse
pain from a recent car accident and received prn doses of
percocet q8h prn. Her citalopram and bupropion were
discontinued on day 1 of hospital stay due to concern for pt
having bipolar illness and antidepressants worsening risk for
mania. Her gabapentin was decreased from 600mg [**Hospital1 **] to 300mg
[**Hospital1 **].
During the night after, pt reported rolling out of bed and
hitting her head. She was evaluated right away by the intern
on-call (see her note in OMR) and did not have any exam findings
or mental status changes after this fall. Then around 8am on
day 2 of hospitalization she was found in bed to be
hypersomnolent with slowed respirations ([**6-27**]/min). Her O2sats
were stable around 95%. Her HR was in the 40s, BP elevated at
190s/160s (some concern as to whether or not this was an
accurate [**Location (un) 1131**] based on machine used and cuff size used).
Medicine was called urgently to see the patient and evaluate.
She received IV access urgently. She then responded to a very
brisk sternal rub and became more aroused. Moved all 4
extremities spontaneously in thrashing/writing movements that
were non-rhythmic, non-stereotyped movements. Her level of
arousal continued to improve such that after several minutes she
could respond to orientation questions, knew she was at [**Hospital1 **] in
[**Apartment Address(1) 105362**], knew month/date/year. Stat head CT ordered to to
concern for intracranial event s/p fall with altered mental
status. Meds given for hypertension. Over the course of the
next half hour or so, pt remained agitated, thrashing all limbs,
writhing in bed, intermittently more responsive to persons at
bedside. She was unable to participate in a neuro exam due to
not being cooperative. Medicine consult resident was in to see
pt and agreed with stat head CT and BP management. Pt had head
CT done and during that again became unarousable with slowed
respirations. Decision was made due to limited medical support
on psych unit that pt would be transferred to medicine for
ongoing care.
[In [**Location (un) 1131**] through notes from [**Hospital3 417**] Hospital, she was
admitted there prior to transfer to [**Hospital1 **] 4 with what sounds like
nearly identical symptoms to what we're seeing here this morning
(altered mental status, abnormal body movements). She is listed
in their discharge diagnosis as having seizures as primary
diagnosis. She received a work-up there including head CT,
brain MRI/MRA and routine EEG which did not demonstrate acute
intracranial abnormality nor active seizure activity on EEG.
She was transferred to [**Hospital1 **] 4 for further psych management, and
now seems to have recurrent symptoms similar to what she
presented with there.]
Medications on Admission:
1. Wellbutrin SR 150mg daily ([**Month (only) **] from 150mg [**Hospital1 **] on [**2198-5-13**])
2. Celexa 20mg daily ([**Month (only) **] from 30mg daily on [**2198-5-13**])
3. Depakote 500mg [**Hospital1 **] (has not been taking accuratly, VPA 22.0
on
[**2198-5-15**])
4. Baclofen 20 TID
5. ASA 81 daily
6. Gabapentin 600 [**Hospital1 **]
7. Metoprolol tartrate 25mg qhs
8. Singulair 10mg qhs
9. Omeprazole 20mg qhs
10. oxybutynin 1mg daily
11. KCL 20mg [**Hospital1 **]
12. Simvastatin 40mg daily
13. Amlodipine 10mg daily
14. Lisinopril 5mg daily
Discharge Medications:
1. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for pain.
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for candidal rash.
6. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day).
7. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
13. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO Q4H (every 4 hours) as needed for stomach
upset.
16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed for stomach upset,
constipation.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain,fever.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Bipolar disorder type II with current hypomanic episode;
reported PTSD, not active; Reported multiple personality
disorder, not active.
Discharge Condition:
Level of Consciousness: Lethargic and not arousable.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - Independent.
MSE:
General: somnolent, unarousable except to sternal rub;
previously pleasant, talkative
Speech: none, snoring; previously rambling, easily redirectable
Mood/Affect: unable to assess; previously hypomanic
T. Form: unable to assess. Previously no LOA/TT/TB. Severe FOI
T. Content: unable to assess; previously no
hallucinations/delusions/paranoid ideation. No grandiosity
Cognition : somnolent, previously oriented
J/I: fair
Discharge Instructions:
You were admitted because you were experiencing symptoms of
hypomania, including decreased sleep, pressured speech, and
expansive affect. There was also a concern for seizures and you
had a workup at [**Hospital3 417**] Hospital that was negative. While
on the inpatient psychiatric unit at [**Hospital3 **], you had
another episode of altered mental status, moving your limbs and
were sleepy afterwards. Due to concern for another seizure or
other medical cause for this episode, you were transferred to
medicine for a further workup.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
*It was a pleasure to have worked with you, and we wish you the
best of health.*
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 14200**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2199-4-25**] 10:30
Completed by:[**2198-5-17**] Admission Date: [**2198-5-17**] Discharge Date: [**2198-6-20**]
Date of Birth: [**2134-6-28**] Sex: F
Service: MEDICINE
Allergies:
Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Unresponsive episode
Major Surgical or Invasive Procedure:
Intubation
Initiation of Hemodialysis
EGD [**2198-5-31**], repeat EGD [**2198-6-6**]
Exploratory laparotomy, oversewing of bleeding duodenal ulcer,
four point ligation [**2198-5-31**]
History of Present Illness:
63 yo F with [**Month/Day/Year 72564**] Danlos syndrome, bipolar disorder, multiple
personalities, PTSD, depression, initally admitted [**2198-5-17**] with
mental status changes, with long subsequent hospital course
including acute renal failure from aortic clot, bleeding
duodenal ulcer requiring surgery, RP bleed, now transferred to
MICU for altered mental status.
.
The patient was initially admitted to [**Hospital1 **] 4 on [**2198-5-15**]. On
[**2198-5-17**], she became somnolent and was transferred to the MICU.
She developed acute renal failure, for which MRA was done on
[**2198-5-22**], showing near total occlusive thrombus at the level of
the suprarenal abdominal
aorta. The patient was started on heparin, and her Hct began to
fall. CT abd/pelvis [**2198-5-25**] showed large right retroperitoneal
hemorrhage involving the right iliopsoas muscles, with
dissection throughout the abdomen and pelvis, and large
loculated collection along the right paracolic gutter. The
patient subsequently developed GI bleeding. EGD [**2198-5-31**] showed
diffusely ulcerated duodenal bulb, with active arterial bleeding
from the lateral wall of the apex. For this, the patient
underwent exploratory laparotomy on [**2198-5-31**], with oversewing of
bleeding duodenal ulcer and 4 point ligation. Repeat EGD [**2198-6-6**]
showed multiple oozing ulcers in the duodenal bulb. This was
treated non-operatively. The patient hematocrit remiained
stable.
.
Until [**2198-6-10**], the patient was on the surgical floor, conversing
normally. Then, on the afternoon of [**2198-6-10**], she became
somnolent. CT head [**2198-6-10**] showed no acute intracranial process.
Neurology was called to reassess the patient and found her to be
arousable with prompting and conversant with the examiner,
although she was tangential and has some problems with following
focused examinations, similar to prior assessments. Neurology
concluded that the patient's symtoms were related to renal
failure, medications, and psychiatric problems. Of note, she had
received oxycodone, valproate, and haldol. She received Narcan
with little response.
.
The patient was transferred to the SICU on [**2198-6-10**]. MICU was
requested for altered mental status.
Past Medical History:
- [**Date Range 72564**] Danlos syndrome
- HTN
- Angina
- Sleep apnea (refuses CPAP)
- h/o seizure [**2-21**] to intracranial hematoma (unclear details)
- h/o TIA or stroke (unclear details)
- Cataracts
- bipolar
- multiple personality disorder
- PTSD
- Obesity
.
PAST SURGICAL HISTORY:
L5-S1 fusion and laminectomy
.
Psych history:
PSYCH HX: (per patient, verified with husband)
DX: Multiple personality disorder since teens diagnosed by
counselor at [**Doctor First Name **], due to trauma history. Reports this has not
been active for many years. Reports h/o depressive episodes that
required hospitalization. History of PTSD, not currently active.
Denies Bipolar disorder, however recent psych eval at [**Hospital3 **]
reports diagnosis of Bipolar disorder (hypomanic episodes)
HOSP: multiple (up to 10) at [**Doctor First Name **]. 1st at age 15. Most recent
was [**2188**]. Mostly for depressive episodes.
MED TRIALS: unknown (reports Seroquel once, but caused
significanat inc appetite).
SA/SIB: twice: first age 15 (ASA overdose 85 tablets). Admitted
to hospital. Second (unknown age, but not recent) was by psych
med ingestion.
TREATERS: previously was seen at [**Doctor First Name **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80749**]
(psychopharm) and Dr. [**First Name8 (NamePattern2) 1258**] [**Last Name (NamePattern1) **] (therapist) for many years
until [**2197-11-20**] (at which time they suggested patient get
treaters at Southbay MHC, closer to her home, bc the patient had
a bad MVA due to her driving and didn't want to put the patient
further at risk by making her drive to [**Location (un) 10059**] from [**Location (un) 701**]).
Currently, the patient is in the intake process at Southbay, but
does not have an actual therapist or psychiatrist.
Social History:
< Per OMR >
SUBSTANCE ABUSE HX:
ETOH: h/o etoh abuse drinking 1 bottle wine daily up until 6
months ago, at which time she self tapered with help of her
outpt
psychiatrist. Has not used since. No h/o blackouts or inpt
detoxes.
TOB: smoked 2ppd for 40 yrs, quit in [**2195**]
DRUG: none for >20 yrs. Experimented with MJ and "other" drugs
when she was young. Denies any h/o IVDA.
COFFEE: drinks four 32oz glasses of coffee daily. does not want
to cut down.
SOCIAL HX: Raised in [**Location (un) **] and [**Location (un) 686**]. Sexually abused by
father from age [**5-2**]. Went to court for which her father was
sent
to [**Location (un) **] for substance abuse treatment. Then lived with
her
mother, who she reports made her drop out of school in 9th grade
to support the family. She worked in telescope factory. Has 2
sisters and 1 brother, only stays in contact with one sister in
[**Name (NI) 26671**] MA. 1st marriage with 2 children (son and daughter)
who now live in [**Location (un) **] and hullbrook ma. Divorced and
remarried 38 yrs ago to current husband. [**Name (NI) **] children with
current
husband. [**Name (NI) **] now on SSDI for many years due to psych
illness.
Husband works. [**Name2 (NI) **] legal issues in past. Reports DV by husband in
past, hit patient once in [**2167**]'s and pushed patient once. She
does not feel unsafe. He currently calls her names at times, but
she reports they are in couples counseling for this and working
through their issues. Reports she has one friend (with mild
mental retardation) who she is close to and sees almost every
day.
Family History:
FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and
suicide attempt when he was 9 years old. Denies any other known
psychiatric
family history.
Physical Exam:
On arrival to MICU:
General: Initially somnolent, but subsequently woke up and was
alert, with normal speech but not answering question
appropriately.
HEENT: Anicteric sclerae. Moist mucous membranes.
Neck: Supple.
CV: RRR. Normal s1 and s2. I/VI midsystolic murmur RUSB.
Resp: Normal respiratory effort. CTAB.
Abdomen: Healing surgical scar in midline with staples in place.
Wound C/D/I. +BS. Soft. NT/ND.
Ext: Warm and well-perfused.
Neuro: Mental status as above. Said she was "[**First Name5 (NamePattern1) **] [**Known lastname 105363**]".
Right pupil round and reactive. Left pupil post-surgical. Left
esotropia. Did not cooperate with extraocular movement testing.
Face move symmetrically. Moves all extremities with apparent
full strength but does not cooperate with formal strength
testing. Toes downgoing bilaterally.
Pertinent Results:
ADMISSION LABS
--------------
[**2198-5-17**] 11:57PM GLUCOSE-88 UREA N-46* CREAT-3.4* SODIUM-143
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
[**2198-5-17**] 11:57PM CK(CPK)-57
[**2198-5-17**] 11:57PM CALCIUM-8.0* PHOSPHATE-5.6* MAGNESIUM-2.3
[**2198-5-17**] 11:57PM VALPROATE-71
[**2198-5-17**] 11:57PM WBC-6.4 RBC-4.13* HGB-12.7 HCT-38.8 MCV-94
MCH-30.8 MCHC-32.8 RDW-13.6
[**2198-5-17**] 11:57PM PLT COUNT-203
[**2198-5-17**] 01:59PM CK-MB-3 cTropnT-<0.01
.
DISCHARGE LABS
--------------
White Blood Cells 4.0
Red Blood Cells 2.80
Hemoglobin 9.0
Hematocrit 26.9
MCV 96
MCH 32.3
MCHC 33.5
RDW 18.4
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 269
.
Glucose 88
Urea Nitrogen 26
Creatinine 3.1
Sodium 132
Potassium 3.9
Chloride 95
Bicarbonate 29
Calcium, Total 7.7
Phosphate 4.5
Magnesium 1.9
.
MICROBIOLOGY
------------
[**2198-6-15**] 4:52 pm STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT [**2198-6-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2198-6-16**]):
Reported to and read back by D. [**Doctor Last Name **] ON [**2198-6-16**] AT
0810.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
.
[**2198-6-14**] 5:29 am SEROLOGY/BLOOD HELI ADDED TO CHEM#[**Serial Number 105364**]P.
**FINAL REPORT [**2198-6-15**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2198-6-15**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
.
[**2198-5-22**] 7:50 am BLOOD CULTURE RIJ 2 OF 2.
**FINAL REPORT [**2198-5-28**]**
Blood Culture, Routine (Final [**2198-5-28**]):
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.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2198-5-23**]):
Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**] PAGER# [**Serial Number **]
@ 0620 ON
[**2198-5-23**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2198-6-10**] 8:33 pm URINE Source: Catheter.
**FINAL REPORT [**2198-6-13**]**
URINE CULTURE (Final [**2198-6-13**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGING
-------
CT head w/o contrast [**2197-6-10**]:
1. No CT evidence of acute intracranial process such as
hemorrhage.
2. If clinical suspicion for ischemic infarct remains high, MRI
or CTA could be performed for further assessment.
3. Stable mild age-related involution.
.
CT abdomen/pelvis [**2197-6-6**]:
1. New or enlarged 8.2 x 4.7 x 10.2 cm right psoas hematoma,
since the [**2198-5-25**] study. An older right psoas hematoma is
also seen, with decreased fluid along the right paracolic
gutter.
2. Unchanged body wall edema.
.
Bilateral lower extremity venous ultrasound [**2198-6-5**]: No DVT in
the left or right lower extremity.
.
CT abdomen/pelvis [**2198-5-25**]:
1. Large right retroperitoneal hemorrhage involving the right
iliopsoas muscles, with dissection throughout the abdomen and
pelvis, and large loculated collection along the right paracolic
gutter.
2. Severe calcific aortic plaque, with near-complete suprarenal
and moderate infrarenal stenosis.
3. Renal atrophy, right greater than left.
4. Lumbar spine degenerative changes, with lytic L5-S1
anterolisthesis.
5. Body wall edema and small bilateral pleural effusions.
.
Echo (TTE) [**2198-5-23**]: The left atrium is normal in size. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). 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. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined. The
main pulmonary artery is dilated. There is no pericardial
effusion.
.
IMPRESSION: No cardiac source of embolism seen. Hyperdynamic
biventricular systolic function. No significant valvular
abnormality seen. Dilated main pulmonary artery.
.
MRA Kidney w/o contrast [**2198-5-22**]:
1. Near total occlusive thrombus at the level of the suprarenal
abdominal aorta, most probably the cause of acute kidney injury.
2. High-grade stenosis at the origin of right renal artery and
at the origin of the left renal artery. Normal renal veins.
.
MR [**Name13 (STitle) 430**] w/o constrast [**2198-5-20**]:
1. Periventricular and deep white matter FLAIR hyperintensities
likely to suggest small vessel ischemic change.
2. No evidence of an acute intracranial process or a large
pituitary lesion in this unenhanced study. Pituitary
microadenoma cannot be ruled out in this unenhanced study.
3. MRA brain demonstrates no evidence of aneurysms or vascular
malformation.
4. 14mm x 6mm T2 hyperintense lesion in the left parietal skull
may represent epidermoid cyst as the lesion is mildly bright on
diffusion or possibly a hemangioma.
Brief Hospital Course:
63 y/o female with multiple personality disorder, depression,
PTSD, bipolar disorder, sleep apnea, [**Month/Day/Year **]-danlos, and previous
seizure due to intracranial hematoma, who initially presented to
[**Hospital3 417**] Hospital for questionable seizures (negative
work-up), with subsequent admission to [**Hospital1 18**] for bipolar
disorder treatment, now transferred to MICU for altered mental
status and concern for ? seizures and episodes of apnea.
.
ACTIVE ISSUES
-------------
# Altered mental status: previous work-up at [**Hospital3 417**]
hospital notable for negative non-contrast head CT, MRI, MRA and
neck MRA for stroke. Her head MRA did show some atrophy and
small vessel disease. Patient had a portable EEG on [**5-12**] which
showed moderately abnormal, generalized encephalopathic proces
without lateralizing or epileptogenic abnormalities. Potential
etiologies included post-ictal confusion from unwitnessed
seizure (possible given subtherapeutic depakote level) versus
hypoxemia during night-time from her sleep apnea given her
desaturations. Interestingly, she also appears to have numerous
episodes of apnea and periodic limb movements during the day,
remniscent of restless leg syndrome and narcolepsy, questioning
a sleep disordered breathing pattern. Of note, she had an
unrevealing head CT on [**5-17**]. With regard to toxic metabolic
etiologies, her blood glucose was normal, her CBC and chemistry
10 were normal, her serum toxicology was negative, her liver
enzymes and synthetic function were normal, and her B12 and TSH
were normal. Also, there did not appear to be a withdrawal
syndrome present. There were no fevers or signs/symptoms of
infection. There was no evidence for benzodiazepine or narcotic
overuse. Mental status was improved upon discharge, and patient
had returned to baseline.
.
# Oliguric acute renal failure: Likely ischemic acute tubular
necrosis from thrombus in aorta. Patient's urine output <100cc
daily initially and gradually improved. Renal was consulted and
the patient started on hemodialysis, which she will continue
upon discharge. She will follow up with nephrology upon
discharge. There are pending wound cultures upon discharge from
the site of her hemodialysis line.
.
# Bacteremia: MSSA in one blood culture was isolated during
[**Hospital 228**] hospital course, drawn off a newly placed right-sided
hemodialysis line. Patient was without fever or white count and
subsequent cultures were without growth. Infectious disease was
consulted. All lines were removed at the time and her HD line
was replaced. As all surveillance cultures are negative to
date, plan was to treat through the infection using nafcillin
(MSSA also in sputum), after she was initially on vancomycin.
TTE was without evidence of vegetation. Patient remained
afebrile and without leukocytosis throughout remainder of
hospital stay. During her stay in the SICU, nafcillin was
temporarily discontinued. During this interim, she was
mom[**Name (NI) 11711**] on ceftriaxone for urinary tract infection. IV
nafcillin was restarted upon arrival to the medical floor. Per
ID, she should complete a course of nafcillin to end on [**2198-7-12**].
She will follow up with infectious disease on [**2198-7-5**].
.
# Atrial fibrillation with rapid ventricular response: Patient
developed atrial fibrillation with rapid ventricular response on
[**6-11**]. She was treated with metoprolol 5 mg IV, then labetalol 20
mg IV, with return of sinus rhythm. With improvement in her
mental status, she was resumed on PO Metoprolol 12.5 twice
daily, which was eventually transitioned to PO labetalol for
added blood pressure control. She was not anticoagulated given
her gastrointestinal bleeding and retroperitoneal bleed
experienced during hospitalization.
.
# Gastrointestinal bleeding from duodenal ulcer: On [**5-25**], serial
hematocrits were decreasing and patient had a CTA abdomen
demonstrating a retroperitoneal bleed/psoas bleed/duodenal ulcer
bleed. On [**5-30**] the patient developed melena and a rapid upper
gastrointestinal bleed. She received 8 units of pRBC initially
and her hct dropped despite the blood. On [**5-31**], she had an EGD
demonstrating a large duodenal ulcer with evidence of active
bleeding. The patient was taken to the OR for an urgent
exploratory laparotomy and oversew of the duodenal ulcer. The
anticoagulation was stopped and she was monitored closely for
signs of bleeding and serial hematocrits were followed, which
remained stable from then on. The patient was continued on an IV
PPI, and eventually transitioned to PO high dose PPI therapy
upon discharge. She will follow up with General Surgery upon
discharge.
.
# Retroperitoneal hemorrhage: On [**5-25**], serial hematocrits were
decreasing and patient had a CTA abdomen demonstrating a
retroperitoneal bleed/psoas bleed/duodenal ulcer bleed. Patient
was transfused as necessary and serial hematocrits were trended.
The patient remained hemodynamically stable, with stable
hematocrit when she eventually reached the medical floor.
Surgery and Vascular followed the patient during the duration of
the bleed.
.
# Aortic clot: Etiology unclear but the patient has known [**Name (NI) 72564**]
Danlos, ? stasis vs. intimal weakening. An MRA abdomen was done
to look at renal arteries, which demonstrated an aortic clot
that was straddling the origin of the renal arteries. Renal
arteries still had flow, but this was somewhat diminished.
Vascular was consulted for clot and they recommended a heparin
gtt, which was eventually discontinued due to bleeding episodes.
Echocardiogram was unremarkable for source of the clot.
Differential diagnosis included an anatomic abnormality of
aorta, hypercoagulability, or intravascular tumor. The patient
could not be continued on anticoagulation given severe bleeding
this hospitalization. Patient will follow up with Vascular
Surgery upon discharge on [**2198-7-26**].
.
# Clostridium difficile colitis: During hospital course, pt
complained of frequent loose stools. C.diff toxin returned
positive. Abdominal exam showed slight tenderness during her
hospital stay with no peritoneal signs. WBC remained within
normal range. Patient was initially on IV metronidazole, then
transitioned to both IV metronidazole and PO vancomycin when she
developed transient abdominal pain and increased bowel
movements. She was eventually placed on PO vancomycin upon
discharge, with plan to continue this therapy for two weeks
after she finishes her IV nafcillin therapy on [**2198-7-12**]. This
would mean she would be set to cease PO vancomycin therapy on
[**2198-7-26**].
.
# Hyponatremia: patient was noted to be hyponatremic to the low
130s during her hospitalization. She was placed on a 1500 ml
fluid restriction. Etiology was thought to be related to her
kidney failure and need for hemodialysis.
.
# Psychiatric issues: patient was taken off her home dose of
valproic acid, bupropion and citalopram during her
hospitalization due to acute medical issues. She was eventually
placed back on valproic acid. She is being discharged on this
medication, but will not resume citalopram or bupropion at this
time. Psychiatry will see the patient as an outpatient for a
time to be determined.
.
# Hypertension: patient was admitted on metoprolol tartrate and
amlodipine. During her hospital course, it was determined that
this was not adequate therapy for her elevated blood pressure,
and she was switched from metoprolol to labetalol therapy, which
she will continue as an outpatient.
.
TRANSITION OF CARE
------------------
# Follow-up: patient is scheduled for follow-up appointments
with Vascular Surgery, Infectious Disease, Acute Care Surgery,
Nephrology and her primary care provider upon discharge. A
psychiatry appointment has not yet been scheduled, but this will
happen after discharge. There are pending blood cultures and
wound cultures which will need to be followed up after
discharge. She should have daily complete blood counts and
chemistry panels (Chem7) for at least the first week after
discharge to assure stability. She should also get weekly
BUN/Creatinine, LFTs, and CBC/differential going forward, with
results to be faxed to the Infectious Disease [**Hospital 4898**] clinic at
[**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
.
# Communication: HCP is husband [**Name (NI) 15954**] [**Name (NI) 105363**] [**Telephone/Fax (1) 105365**]
.
# Code status: FULL CODE, confirmed with husband (healthcare
proxy)
Medications on Admission:
Aspirin 81mg qd
Depakote 500mg [**Hospital1 **]
Neurontin 600mg [**Hospital1 **]
Lopressor 25mg qHS
Singulair 10mg qHS
Simvastatin 40mg qd
Omeprazole 20mg qd
Ditropan-XL daily
KCl 20mEq [**Hospital1 **]
Norvasc 10mg qd
Critic-aid clear AF [**Hospital1 **] coccygeal area
Wellbutrin SR 150mg qd
Celexa 20mg qd
Lisinopril 5mg qd
Discharge Medications:
1. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
4. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Nafcillin 2 g IV Q4H
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-21**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for dyspepsia.
13. Outpatient Lab Work
Please perform weekly BUN/Creatinine, LFTs, and CBC/differential
going forward, with results to be faxed to the Infectious
Disease [**Hospital 4898**] clinic at [**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
14. Outpatient Lab Work
Please perform daily CBC and Chem10 for one week until [**2198-6-26**],
or until lab values have stabilized
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
16. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1)
Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Hypomania/bipolar disorder
Aortic thrombus
MSSA bacteremia
Duodenal ulcer bleed
Retroperitoneal hemorrhage
Hyponatremia
End-stage renal disease on hemodialysis
Clostridium difficile colitis
Hypertension
Secondary diagnosis:
[**Location (un) 72564**]-Danlos syndrome
Obstructive sleep apnea
History of seizures
Bipolar disorder
Multiple personality disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 105363**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You came for
further evaluation of your bipolar disorder. While here, there
were many medical issues which occurred, including aortic
thrombus, gastrointestinal bleeding, bleeding into your
retroperitoneal space, blood stream infection, and Clostridium
difficile gastrointestinal infection. You are now being
discharged to a long term assisted care facility. It is
important that you continue to take your medications as
prescribed.
The following changes have been made to your medications:
We have STARTED labetalol for control of your blood pressure.
We have STARTED vancomycin for treatment of your C. diff
infection/
We have STARTED naficillin for treatment of your Staph aureus
blood infection.
We have STARTED trazodone to help you sleep.
We have STARTED artificial tears to prevent eye dryness.
We have STARTED simethicone to help with stomach upset.
We have STARTED acetaminophen to help with pain.
We have STARTED calcium carbonate for nutritional
supplementation.
We have STARTED pantoprazole for your reflux and to protect
against gastrointestinal bleeding.
We STOPPED omeprazole in favor of pantoprazole.
We have STOPPED your wellbutrin and Celexa until you are seen by
Psychiatry and they determine what psychiatric medications you
should be on going forward.
We have STOPPED your Baclofen and gabapentin until you follow up
with your primary care doctor and it is determined if you should
resume this therapy.
We have STOPPED your aspirin, since you had numerous bleeding
episodes while hospitalized.
We have STOPPED your metoprolol in favor of labetalol to further
control your blood pressure.
We have STOPPED your lisinopril due to decreased kidney
function.
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2199-4-25**] at 10:30 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 14200**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2198-7-26**] at 2:35 PM
With: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2198-7-5**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2198-7-26**] at 2:00 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
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2198-7-5**] at 1:45 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2198-7-11**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Admission Date: [**2198-6-23**] Discharge Date: [**2198-7-3**]
Date of Birth: [**2134-6-28**] Sex: F
Service: MEDICINE
Allergies:
Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose
Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
Frequent dark stools, falling hematocrit
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Ms. [**Known lastname 105363**] is a 36 year old female with a history of an aortic
clot, retroperitoneal bleed, and duodenal ulcer bleed, who
presents with melena and anemia.
.
She presented to [**Hospital3 417**] Hospital today with greater than
20 liquid black bm in 16 hrs. She had hgb 6, hct 18.1, vitals
99.2, hr 93, rr 16, 122/64, 98% RA. Guaiac positive times two.
.
Prior to admission to [**Last Name (LF) **], [**First Name3 (LF) **] [**Hospital1 **] nursing
notes, [**2198-6-22**] at 0700 pt she was incontinent of liquid stool and
urine, hypertensive 190/90, labetalol and nitropaste prior to
dialysis. At 5pm, 3 large loose black BMs, stat hct 22.5 hgb 7,
2 units of blood given. [**6-22**] at 2300 pt continued to have black
liquid stool about 8 per shift. [**6-23**] 0800, 6 liquid black tarry
stools, given 1 unit prbcs and transferred to [**Hospital3 **].
.
She had a recent admission in [**4-30**] for the workup of altered
mental status, which was unrevealing with negative MRI/MRA head,
CT head, MRA neck, EEG. Ultimately unclear what caused her MS
changes. She also developed renal failure, MSSA bacteremia,
A-fib with RVR, GI bleed from duodenal ulcer, RP bleed, C. diff,
hyponatremia and aortic clot. Briefly her previous
hospitalization was significant for the development of an aortic
occlusion for which she was started on heparin. She then
developed RP hematoma and heparin was stopped. She then had a
GI bleed. Endoscopy showed ulcer with stigmata of recent bleed.
Treated with injectible epi and BICAP. Unfortuantely she
re-bled and as she has a potential allergy to dye and given her
aortic occlusion she was felt to be a poor candidate for IR
procedure; thus she was taken to the OR for an ex-lap and
oversewing of bleeding duodenal ulcer and 4 point ligation (on
[**5-31**]). Her hct then improved to her baseline on 38-40. On [**6-5**]
it dropped again to 31 from 39. A repeat EGD on [**6-6**] showed
multiple erosions and ulcers in the duodenal bulb with bright
red blood consistent with active recent bleeding. No
intervention was done at that time. Her hct then trended down
slowly to 26.
.
In the ED, she was found to have a hematocrit of 20.4 (from
26.9 on [**2198-6-20**]). She remained hemodynamically stable and without
tachycardia. Initial vitals there were 99.1, BP 186/94, HR 98,
RR 16, Sat 98% RA.
.
On the floor, she had no new complaints. She mentioned some
non-specific abdominal cramping during her bowel movements.
.
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, vomitingconstipation. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
h/o alcohol abuse
HTN
Sleep apnea
COPD
s/p ankle fracture repair
h/o TIA
s/p spinal fusion L5-S1 laminectomy [**2170**]
s/p bilateral cataract surgery
?[**Year (4 digits) 72564**] Danlos Syndrome
Aortic thrombus
Mssa bacteremia
Afib
Duodenal cap bleed
PTSD, multiple personalities, bipolar, substance abuse
Social History:
Raised in [**Location (un) **]. History of sexual abuse. History of 1 bottle
of wine daily until 6 months ago. She smoked 2ppd for 40 yrs,
quit in [**2195**]. Denies h/o IVDA.
Family History:
FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and
suicide attempt when he was 9 years old. Denies any other known
psychiatric
family history.
Physical Exam:
On admission:
Tmax: 36.9 ??????C (98.4 ??????F)
Tcurrent: 36.9 ??????C (98.4 ??????F)
HR: 84 (84 - 84) bpm
BP: 159/87(98) {159/87(98) - 159/87(98)} mmHg
RR: 15 (15 - 15) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No acute distress
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: 1+ to thready dp bilaterally but lower
extremities warm
Abdominal: Obese Soft, Non-tender, Bowel sounds present, no
organomegaly
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): times three, Movement: Not assessed,
Tone: Not assessed, moving all extremities
Pertinent Results:
ADMISSION LABS
--------------
[**2198-6-23**] 06:00PM GLUCOSE-90 UREA N-47* CREAT-2.6* SODIUM-133
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-24 ANION GAP-17
[**2198-6-23**] 06:00PM estGFR-Using this
[**2198-6-23**] 06:00PM ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-60 TOT
BILI-0.2
[**2198-6-23**] 06:00PM LIPASE-65*
[**2198-6-23**] 06:00PM ALBUMIN-2.8* CALCIUM-8.3*
[**2198-6-23**] 06:00PM WBC-8.8# RBC-2.08*# HGB-6.8* HCT-20.4* MCV-98
MCH-32.7* MCHC-33.3 RDW-18.9*
[**2198-6-23**] 06:00PM NEUTS-76.5* LYMPHS-14.7* MONOS-5.4 EOS-2.9
BASOS-0.5
[**2198-6-23**] 06:00PM PLT COUNT-302
[**2198-6-23**] 06:00PM PT-12.7 PTT-22.8 INR(PT)-1.1
.
DISCHARGE LABS
--------------
[**2198-7-2**] 05:08AM BLOOD WBC-5.7 RBC-3.05* Hgb-9.7* Hct-29.1*
MCV-96 MCH-31.9 MCHC-33.4 RDW-17.0* Plt Ct-306
[**2198-7-2**] 05:08AM BLOOD Neuts-62.5 Lymphs-11.5* Monos-9.5
Eos-16.0* Baso-0.5
[**2198-7-2**] 05:08AM BLOOD Glucose-84 UreaN-29* Creat-3.7* Na-131*
K-4.3 Cl-97 HCO3-20* AnGap-18
[**2198-7-2**] 05:08AM BLOOD Calcium-8.0* Phos-5.8* Mg-2.3
.
MICROBIOLOGY
------------
MRSA screen: negative
.
IMAGING
-------
CT Abd/Pelvis on admission:
IMPRESSION:
1. Mild decrease in size of two right retroperitoneal/pelvic
hematomas. No
evidence of new bleed.
2. New small amount of simple appearing ascites.
3. Severe suprarenal aortic stenosis, with resulting renal
atrophy.
4. Stable L5-S1 spondylolisthesis.
.
EGD [**2198-6-25**]:
Erythema in the duodenal bulb compatible with mild duodenitis
Ulcer in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
63 yo female with [**Month/Day/Year 72564**] Danlos syndrome, bipolar disorder,
multiple personality disorder, PTSD, and seizure due to
intracranial hematoma and recent hospital course complicated by
suprarenal aortic clot, retroperitoneal bleed, and duodenal
ulcer bleed presents with melena and falling hematocrit.
.
ACTIVE ISSUES
-------------
# Acute on chronic anemia: differential diagnosis included acute
blood loss due to gastrointestinal bleed (with guaiac positive
stools and recent history of duodenal ulcer bleed) versus
retroperitoneal hematomas versus kidney dysfuction. Patient
received 4 units PRBCs with inappropriate hematocrit response
early in admission. Gastroenterology was consulted and
performed repeat EGD on [**2198-6-25**] which showed a healing duodenal
ulcer and no direct source of bleed was identified. Patient
also had CT of the back/abdomen that did not show evidence of an
expanding hematoma, although old hematoma continued to show
signs of resolution. She was initially on a proton pump
inhibitor drip, then transitioned to intravenous route, and
eventually to oral PPI. Hematocrit remained stable after EGD,
with numerous guaiac negative stools noted. Complete blood
counts should be checked daily after the patient leaves the
hospital to trend hematocrit levels, which have remained stable
at 27-30 for days prior to discharge.
.
# Chronic kidney disease: patient was initiated on hemodialysis
during her last admission to [**Hospital1 18**]. Her renal disease was
thought to be due to the large aortic thrombus. It was noted
over the course of her admission that she was producing more
urine, and 24 hour creatinine measurement was initiated.
However, patient's creatinine uptrended while off hemodialysis,
and it was determined that patient will possibly need to
continue dialysis sessions as need at the outside facility, per
the neprologist's discretion. Her hemodialysis line will remain
in and Chem10 should be checked [**Hospital1 **]. Patient is scheduled for
follow-up with nephrology, where further determination will be
made of dialysis need. Patient's dialysis line should be
flushed with heparin at the time of dialysis, if required.
.
# Hypertension: patient was continued on labetalol 200 mg tid
and amlodipine 10 mg daily during her admission for blood
pressure control, which was deemed to be inadequate. Her
labetalol was increased to 600 mg TID for added control before
discharge, and furosemide was also added, due to concern for
fluid overload. Twice daily Chem10 should be performed upon
discharge to trend electrolyte levels. If patient requires
further blood pressure management, further uptitration of
labetalol is recommended. Recommended systolic blood pressure
range should be 130s-160s due to patient's likely impaired
kidney perfusion from her aortic thrombus.
.
# Eosinophilia: patient was noted to have an eosinophilia of 16%
on labs checked before discharge. This problem should be
followed up at the discharge facility going forward.
.
INACTIVE ISSUES
---------------
# Retroperitoneal hematoma: per CT abdomen/pelvis, this was
decreasing in size and no new retroperitoneal hematomas were
noted compared to prior.
.
# Aortic thrombus: patient had been on heparin when the clot was
discovered during her admission in [**5-30**]. She was taken off the
heparin after developing retroperitoneal and GI bleeds. She is
not anticoagulated at this time, because anticoagulation is
contraindicated in the setting of a possible GI bleed. This
should be reevaluated in the future.
.
# Clostridium difficile colitis: patient was toxin positive on
[**2198-6-15**]. She is currently receiving vancomycin 125 mg PO q6hrs
through [**2198-7-26**], two weeks after cessation of nafcillin therapy.
There was noted increased bowel movements prior to admission,
which had slowed considerably on admission. Patient will remain
on oral vancomycin therapy upon discharge until the date noted
above. Patient was experiencing loose stools during her
admission, likely due to osmotic mechanism from diet changes,
and possible GI bleed on admission. There was no noted fever,
leukocytosis or abdominal pain during her hospital course. At
the time of discharge, she ranged from [**5-27**] soft, loose bowel
movements daily.
.
# MSSA Bacteremia: patient will be continuing nafcillin through
[**2198-7-12**], per Infectious Disease recommendations, which should
continue upon discharge. She should also get weekly
BUN/Creatinine, LFTs, and CBC/differential going forward, with
results to be faxed to the Infectious Disease [**Hospital 4898**] clinic at
[**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
.
# Atrial fibrillation: patient was continued on labetalol 600 mg
TID during admission for rate control, which she will continue
upon discharge. She is currently not on anticoagulation given
her recent history of gastrointestinal and retroperitoneal
bleed.
.
# Chronic hyponatremia: During her last admission, this was
thought to be secondary to intrinsic renal disease. During most
of this admission, patient had a normal sodium level. Level was
trended daily, and should continue to be trended regularly as
noted elsewhere.
.
# Dyslipidemia: patient was continued on simvastatin 40 mg daily
during her admission.
.
# Psychiatric conditions: patient was continued on divalproex
500 mg [**Hospital1 **] during her admission. Patient will require
Psychiatry follow-up at [**Hospital 14221**] [**Hospital 4189**] Health Center or [**Hospital1 1535**], which has not yet been
scheduled, and should be initiated upon discharge from the LTAC
facility. The patient's family has been instructed to call and
try to schedule an appointment at one of these two locations.
.
TRANSITION OF CARE
------------------
# Follow-up: patient is scheduled for follow-up appointments
with Vascular Surgery, Infectious Disease, Acute Care Surgery,
Nephrology and her primary care provider upon discharge. A
psychiatry appointment has not yet been scheduled, but this will
occur after discharge. There are pending blood cultures and
wound cultures which will need to be followed up after
discharge. She should have daily complete blood counts and
twice daily chemistry panels (Chem10) for at least the first
week after discharge to assure stability. She should also get
weekly BUN/Creatinine, LFTs, and CBC/differential going forward,
with results to be faxed to the Infectious Disease [**Hospital 4898**] clinic
at [**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
.
# Code status: patient is confirmed full code.
.
Medications on Admission:
acetaminophen 325 mg Tablet q6 prn pain
amlodipine 10 mg Tablet daily
calcium carbonate 200 mg calcium (500 mg) Tablet, TID
divalproex 500 mg [**Hospital1 **]
heparin 5,000 unit/mL SC TID
labetalol 300 mg Tablet TID
montelukast 10 mg Tablet qHS
Nafcillin 2 g IV Q4H
pantoprazole 40 mg [**Hospital1 **]
simethicone 80 mg QID
simvastatin 40 mg daily
trazodone 100 mg qHS prn
vancomycin 125 mg Capsule q6
carboxymethylcellulose sodium 1.4-0.6% 1-2 Drops PRN dry eyes.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
4. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Nafcillin 2 g IV Q4H
end date [**2198-7-12**]
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
11. Outpatient Lab Work
Please perform CBC daily until [**2198-7-6**], then every other day
after that until hematocrit level stabilizes
12. Outpatient Lab Work
Please perform Chem10 twice a day, until electrolytes stabilize,
specifically potassium and magnesium
13. Outpatient Lab Work
Please perform weekly BUN/Creatinine, LFTs, and CBC/differential
going forward, with results to be faxed to the Infectious
Disease [**Hospital 4898**] clinic at [**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. labetalol 300 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
16. Furosemide 40 mg IV BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**]
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic anemia
Hypertension
Chronic kidney disease
Secondary diagnosis:
Retroperitoneal hematoma
Aortic thrombus
Clostridium difficile colitis
MSSA bacteremia
Atrial fibrillation
Chronic hyponatremia
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 105363**],
It was a pleasure taking care of you at [**Hospital1 827**]. You came for further evaluation of anemia and
increased bowel movements. Tests showed that there was no
evident source of bleeding in your stomach and the first part of
your intestine. You are now being dischrged to a long-term
acute care facility. You will also continue dialysis as needed
at the outside facility. Whether or not you need this in the
future will continue to be determined. It is important that you
continue to take your medications and follow up with the
appointments that have been arranged for you.
The following changes have been made to your medications:
We INCREASED your labetalol dose for added blood pressure
control
We ADDED furosemide to take extra fluid off of your legs
Followup Instructions:
Please call [**Hospital 14221**] [**Hospital 4189**] Health Center at [**Telephone/Fax (1) **] to
schedule a Psychiatry appointment.
Department: VASCULAR SURGERY
When: THURSDAY [**2198-7-26**] at 2:00 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
Department: [**Hospital3 249**]
When: THURSDAY [**2198-7-26**] at 2:35 PM
With: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2198-7-5**] at 1:45 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2198-7-12**] at 8:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2198-7-10**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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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Discharge summary
|
report
|
Admission Date: [**2168-6-30**] Discharge Date: [**2168-7-12**]
Date of Birth: [**2105-6-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Fever, Shortness of Breath, Sepsis
Major Surgical or Invasive Procedure:
Left PICC line placement
History of Present Illness:
63 year old woman with a history of [**Doctor First Name 39850**] status post
neck surgery 1 yr ago, trach collar dependent, who presents with
one day of fever to 103.8, increased SOB and increased
secretions. Patient's daughter states that the patient vomited
once earlier, but it may have been respiratory secretions. She
denies known sick contacts. [**Name (NI) **] associated diarrhea, abd pain or
rash. Of note, patient has had recurrent UTIs and a MRSA
pneumonia in past. Also, is on coumadin for history of left
upper extremity DVT.
.
In the ED, initial VS were: T 101.8 HR 119 BP 104/38 RR 22 O2
sat 100% 15L. Patient's temperature peaked at 103.8 in the ED.
She was placed on nonrebreather to trach for dyspnea and
secretions, and saturated 100%. On exam, patient was noted to
have rhonchi bilat. No abdominal tenderness, normal skin exam.
Patient has chronic Foley and urine was sent for UA, urine cx.
Labs were notable for WBC 25.3, Na 128, lactate 2, Hct 28 (close
to baseline). UA was positive for infection. CXR with no clear
consolidation. Pt was started on Cefepime, Vanc, Levofloxacin
for UTI and possible pneumonia. She was given about 900cc NS.
She was transferred to the MICU for respiratory status. On
transfer, VS were: Temperature 101.2 ??????F (38.4 ??????C). Pulse 117.
Respiratory Rate 21. Blood Pressure 171/70. O2 Saturation 97. O2
Flow humidified 02. Pain Level 0.
.
On arrival to the MICU, the patient was tachypneic, slightly
diaphoretic, but not in any distress. She was on humidified O2
via trach collar, complaining of bilateral arm pain c/w
contracture pain.
Past Medical History:
C5 [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39850**]
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardia Infarction in 03 s/p BMS to LCcx
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO [**2146**]
hypotension, on florinef/MICU and glycopyrrelate
history of pan-sensitive respiratory pseudomonas
Social History:
Drugs: None
Tobacco: prior (30-40 years) 1+ pack/day smoker
Alcohol: None
Other: used to work as [**Hospital1 112**] clerk
Family History:
Hypertension
Physical Exam:
ADMISSION EXAM:
Vitals: T: 100.2 BP: 149/47 P: 104 R: 20 O2: 93% trach collar
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, increased oral secretions, [**Name (NI) 3899**], ptosis
L>R, baseline
Neck: supple, JVP not elevated, no LAD, there is a trach-collar
in place
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops, 2+ pulses throughout
Lungs: Diminished excursion, diffuse wheezes without focal
rhonchi or rales, no accessory muscle use. the patient is
tachypneic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, there is a feeding tube present
GU: foley present
Ext: Arms warm/well-perfused, legs cool, 2+ pulses in all
extremities, no clubbing, cyanosis or edema; there is a 22GA
peripheral IV in the right wrist
Neuro: Answers questions appropriately and clearly, insensate
lower extremities, normal sensation BUE, contractures present
BUE
.
DISCHARGE EXAM:
Vitals: 98.1 122/50 65 20 100% TM
General: Alert, oriented, answers appropriately, comfortable
HEENT: Sclera anicteric, [**Name (NI) 3899**]
Neck: supple, JVP not elevated, no LAD, trach-collar in place;
left PICC line in place - non-erythematous, no drainage,
non-tender to palpation
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, 2+ pulses
throughout
Lungs: Diminished excursion, no accessory muscle use, lungs
clear to auscultation, no crackles or rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, feeding tube in place, no pus draining
GU: suprapubic foley in place, no surrounding erythema
Ext: Warm/well-perfused, 2+ pulses in all extremities, 1+ edema
to ankle; no clubbing, cyanosis or edema
Neuro: Answers questions appropriately and clearly, normal
sensation BUE, decreseased but sensation present in BLE, cannot
move UE or LE
Pertinent Results:
ADMISSION LABS:
[**2168-6-30**] 03:00PM BLOOD WBC-25.3*# RBC-3.40* Hgb-8.7* Hct-28.5*
MCV-84 MCH-25.5* MCHC-30.4* RDW-13.6 Plt Ct-294
[**2168-6-30**] 03:00PM BLOOD Neuts-90.5* Lymphs-4.7* Monos-4.0 Eos-0.5
Baso-0.3
[**2168-6-30**] 03:00PM BLOOD Plt Ct-294
[**2168-6-30**] 03:00PM BLOOD Glucose-140* UreaN-16 Creat-0.4 Na-128*
K-4.5 Cl-93* HCO3-22 AnGap-18
[**2168-6-30**] 03:05PM BLOOD Lactate-2.0
.
DISCHARGE LABS [**2168-7-12**] 07:40AM:
WBC-8.5 RBC-3.16* Hgb-8.0* Hct-26.6* MCV-84 MCH-25.2* MCHC-29.9*
RDW-15.2 Plt Ct-249
PT-16.9* PTT-60.6* INR(PT)-1.6*
Glucose-134* UreaN-13 Creat-0.3* Na-141 K-4.2 Cl-108 HCO3-25
AnGap-12
Calcium-8.9 Phos-2.8 Mg-2.1
Vanco-24.5*
.
MICROBIOLOGY:
Urine culture [**6-30**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
.
Sputum culture [**6-30**]:
GRAM STAIN (Final [**2168-7-1**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2168-7-3**]):
Due to mixed bacterial types ( >= 3 colony types) an abbreviated
workup will be performed appropriate to the isolates recovered
from this site. UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS SPP. Unable to definitively determine the
presence or absence of commensal respiratory flora.
.
Blood culture [**7-3**]: Negative
Urine culture [**7-3**]: Negative
.
Blood culture [**7-7**] x 2: Negative
Urine culture [**7-7**]: Negative
.
CATHETER TIP-IV: (Final [**2168-7-10**]): No significant growth.
.
IMAGING:
[**6-30**] CXR:
SINGLE PORTABLE VIEW OF THE CHEST: Opacification of left
hemidiaphragm, downward displacement of the major fissure is
compatible with patient's known chronic left lower lobe
collapse. No new focal consolidation is seen to suggest
pneumonia. There is no pleural effusion or pneumothorax.
Anterior cervical fusion hardware, a percutaneous gastrostomy
tube and tracheostomy collar are noted. Cardiac and mediastinal
contours are unchanged.
IMPRESSION: No acute cardiopulmonary process.
.
Left UE ultrasound [**2168-7-1**]:
IMPRESSION: No evidence of deep vein thrombosis in the left
arm.
.
CXR [**2168-7-3**]:
FINDINGS: There is a right-sided central venous catheter with
the distal lead tip in the distal SVC appropriately sited.
There are no pneumothoraces. Lungs are grossly clear. There is
some atelectasis at the left lung base. The heart size is within
normal limits.
.
CXR [**2168-7-8**]: PICC placement.
1. Placement of a double-lumen Power PICC line into the distal
superior vena cava via the left cephalic vein.
2. The line is ready to use.
Brief Hospital Course:
63 year old woman with a history of [**Month/Day/Year 39850**] status post
neck surgery 1 year ago, trach collar dependent, admitted with
fever to 103.8F and increased secretions.
.
# Sepsis due to HCAP: Patient admitted to the MICU with fevers
to 103.8 and increased secretions. She was started on cefepime,
vancomycin, and Levaquin to cover for HCAP and possible UTI.
Fever resolved and the patient was transferred to the floor.
She underwent sputum cultures 5/24 that grew gram positive
cocci, but serial chest X-rays negative for pneumonia. Urine
culture also positive for > 3 types of bacteria in the setting
of chronic suprapubic catheter. Once fevers resolved and WBC
count normalized on [**7-2**], the patient was transitioned to PO
ciprofloxacin and linezolid. However, she spiked a fever to 101
and became hypotensive on [**7-3**]. Subclavian line was placed and
she was resumed on vanc/cefepime (Day 1 - [**2168-6-30**]) for urinary
and respiratory sources of infection. Given decompensation with
transition from cefepime to ciprofloxacin, the patient was
thought to have a possible gram negative infection as the
culprit for her decompensation. Vancomycin was discontinued for
36 hours, and the patient again spiked a fever. The patient was
resumed on vancomycin on [**7-7**]. A picc line was placed and the
subclavian was removed. The patient will complete a 14 day
course of vancomycin and cefepime as an outpatient. Cefepime
course will complete [**2168-7-14**]. Vancomycin course will complete
[**2168-7-21**].
.
# Left upper extremity DVT/history of pulmonary embolism:
Patient had DVT/PE in [**9-/2167**] off coumadin. Requires life-long
anticoagulation [**3-10**] immobility from [**Month/Day (2) 39850**]. INR 2.0 on
admission. Warfarin continued. A left-upper extremity ultrasound
was negative for ongoing clot, so her left extremity can be used
for IV lines/draws. Warfarin was briefly held during admission
for central line placement. Despite promptly resuming this
medication, her INR trended down to 1.2. She was started on a
lovenox bridge. The patient should undergo daily INR checks,
and stop lovenox bridge once therapeutic on coumadin (INR >
2.0).
.
# history of CAD s/p NSTEMI with stent: Patient without chest
pain throughout admission. She was continued on home ASA,
statin, lisinopril. On [**2168-7-10**], the patient underwent EKG that
showed inverted T waves in the lateral precordial leads. The
patient was asymptomatic at that time. Cardiac enzymes x 2
negative. Repeat EKG at a slower heart rate (65 rather than 95)
showed normalization of her EKG to baseline. The patient likely
has rate-related change secondary to history of CAD. She will
follow up with Dr. [**Last Name (STitle) **], cardiology, as an outpatient.
.
# HTN: Chronic. Lisinopril briefly held on admission, then
resumed with stabilization on the floor. She remained
normotensive for much of admission.
.
# [**Last Name (STitle) **] with spasticity: Tizanidine initially held, but
then restarted after levofloxacin was stopped. The patient was
continued on home tramadol, morphine, baclofen, gabapentin.
=======================
TRANSITIONAL ISSUES:
-code status: Full Code
-Patient to complete 14-day courses of vancomycin and cefepime.
Cefepime course will complete [**2168-7-14**]. Vancomycin course will
complete [**2168-7-21**].
-Please check vancomycin trough [**2168-7-15**]. Adjust dose
accordingly.
-Patient on lovenox bridge, as INR 1.6 at the time of discharge.
Monitor daily INRs. Stop lovenox when INR > 2.0 on coumadin.
Medications on Admission:
-baclofen 20mg @ 0600 and 1200, 30mg @ [**2156**]
-gabapentin 800mg @ 0800, 400mg @ 1200, 800mg @ [**2156**]
-hydroxyzine 50mg (25cc of 10mg/5cc) q4h prn anxiety
-ipratropium-albuterol [DuoNeb] q4h prn dyspnea/wheezing
-lisinopril 5 mg daily
-morphine 10 mg/5 mL Solution 5-10ml G(s) PO q6h PRN pain
-nitroglycerin 0.4 mg SL q5-10 minutes x 3 PRN chest pain
-omeprazole magnesium [Prilosec] 20mg/5mL oral suspension daily
-simvastatin 20 mg once a day
-tizanidine 4-6 mg tid PRN muscle spasm
-tramadol 50-100 q4-6h PRN pain
-warfarin 2mg MF, 4mg all other days PO@1600
-acetaminophen 650mg qid PRN pain
-aspirin 81 mg once a day
-[Calcium 600 + D(3)] 600 mg-400 unit twice a day
-docusate sodium 60 mg/15 mL Syrup 25 ml G tube twice a day
-docusate sodium [Enemeez] 283 mg Enema daily PRN constipation
-inulin [Metamucil Clear-Natural (inul)] 5 gram/5.8 gram Powder
1 tsp by mouth up to three times daily
-nutritional supplement 6 cans(s) per G-Tube--once a day
Discharge Medications:
1. baclofen 10 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO q6am, q12pm.
2. baclofen 10 mg Tablet [**Year (4 digits) **]: Three (3) Tablet PO q8pm.
3. gabapentin 250 mg/5 mL Solution [**Year (4 digits) **]: Eight Hundred (800) mg
PO q 8am and 8pm.
4. gabapentin 250 mg/5 mL Solution [**Year (4 digits) **]: Four Hundred (400) mg PO
NOON (At Noon).
5. hydroxyzine HCl 10 mg/5 mL Syrup [**Year (4 digits) **]: Fifty (50) mg PO every
four (4) hours as needed for anxiety.
6. ipratropium bromide 0.02 % Solution [**Year (4 digits) **]: One (1) inhalation
Inhalation Q4H (every 4 hours) as needed for dyspnea/wheezing:
please give as duoneb with albuterol .
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Year (4 digits) **]: One (1) inhalation Inhalation Q4H (every 4
hours) as needed for dyspnea/wheezing: please give as duoneb
with ipratropium .
8. lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
9. morphine 10 mg/5 mL Solution [**Year (4 digits) **]: 10-20 mg PO Q6H (every 6
hours) as needed for pain.
10. nitroglycerin 0.4 mg Tablet, Sublingual [**Year (4 digits) **]: One (1) SL
Sublingual q5 minutes x 3 as needed for chest pain: call your
doctor if you take this medication.
11. omeprazole magnesium 10 mg Susp,Delayed Release for Recon
[**Year (4 digits) **]: Twenty (20) mg PO once a day.
12. simvastatin 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO at bedtime.
13. tizanidine 2 mg Tablet [**Year (4 digits) **]: 4-6 mg PO TID (3 times a day) as
needed for muscle spasm.
14. tramadol 50 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. warfarin 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO q mon, fri.
16. warfarin 2 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO q sun, tues,
wed, thurs, sat.
17. acetaminophen 650 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO four
times a day as needed for pain.
18. aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet [**Year (4 digits) **]: One
(1) Tablet PO twice a day.
20. docusate sodium 60 mg/15 mL Syrup [**Year (4 digits) **]: Twenty Five (25) mL
PO twice a day: per G tube.
21. docusate sodium 283 mg Enema [**Year (4 digits) **]: One (1) enema Rectal once
a day as needed for constipation.
22. cefepime 2 gram Recon Soln [**Year (4 digits) **]: Two (2) grams Injection Q8H
(every 8 hours) for 5 days.
23. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Year (4 digits) **]: Three
Hundred (300) mg PO once a day.
24. heparin, porcine (PF) 10 unit/mL Syringe [**Year (4 digits) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN.
25. enoxaparin 80 mg/0.8 mL Syringe [**Year (4 digits) **]: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): discontinue when INR > 2.0.
26. metoprolol tartrate 25 mg Tablet [**Year (4 digits) **]: 0.5 Tablet PO BID (2
times a day).
27. vancomycin 750 mg Recon Soln [**Year (4 digits) **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous twice a day for 9 days: please check vanco trough
after 4th dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Hospital 1263**] Hospital in [**Location (un) 686**]
Discharge Diagnosis:
Primary diagnosis: urinary tract infection, upper respiratory
infection, fever
Secondary diagnosis: history of deep vein thrombosis/pulmonary
embolism; history of coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. [**Known lastname 105209**],
.
You were admitted to the hospital with fevers and increased
secretions. You underwent a thorough infectious evaluation, and
were found to have a likely upper respiratory infection and
urinary tract infection as the source of your fevers. You were
started on two antibiotics, called vancomycin and cefepime. We
attempted to transition you to antibiotics by mouth for your
infection, but you began to experience fevers again. You were
discharged to rehab with a special IV in place to continue
antibiotics for a total 14 day course.
.
During your admission, you were resumed on metoprolol for
optimal management of your heart disease.
.
MEDICATIONS CHANGED THIS ADMISSION
START metoprolol 12.5 mg twice a day
START cefepime 2 grams IV every 8 hours for 2 days (last day
[**2168-7-14**])
START vancomycin 750 mg IV twice a day for 9 days (last day
[**2168-7-21**])
START lovenox 80 mg twice a day until INR > 2.0
Followup Instructions:
Please follow up with your primary care physician on discharge
from rehab. [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 2010**]
.
Department: CARDIAC SERVICES
When: FRIDAY [**2168-7-29**] at 10:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"907.2",
"276.1",
"V12.51",
"564.81",
"599.0",
"412",
"596.54",
"465.9",
"344.00",
"285.9",
"707.03",
"E878.8",
"V58.61",
"518.83",
"414.01",
"V44.1",
"V44.0",
"V45.82",
"401.9",
"707.22",
"995.91",
"038.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15261, 15363
|
7419, 10580
|
340, 367
|
15595, 15595
|
4665, 4665
|
16703, 17150
|
2787, 2801
|
12004, 15238
|
15384, 15384
|
11016, 11981
|
15730, 16680
|
2816, 3745
|
3761, 4646
|
10601, 10990
|
266, 302
|
395, 1997
|
15485, 15574
|
4681, 7396
|
15403, 15463
|
15610, 15706
|
2019, 2630
|
2646, 2771
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,762
| 178,743
|
39929
|
Discharge summary
|
report
|
Admission Date: [**2151-12-6**] Discharge Date: [**2151-12-15**]
Date of Birth: [**2085-10-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Oxycodone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2151-12-6**] Aortic valve replacement with a [**Street Address(2) 6158**]. [**Hospital 923**]
Medical mechanical valve
History of Present Illness:
66 year old female who complains of
shortness of breath with activities. Presented to OSH ED with
allergic reaction and vocal cord spasms. Further work up and
echocardiogram showed aortic stenosis and is now referred for
surgical eval.
Past Medical History:
Hypertension
Hyperlipidemia
Osteoporosis
Angioedema secondary to lisinopril
Loss of vision in right eye 7 years ago with resolution d/t TIA
Anxiety
Arthritis
TIA
Social History:
Last Dental Exam:2 weeks ago
Lives with:Husband
Occupation:retired
Tobacco:quit 10-12 years ago, 60 PYH
ETOH:2-3 beers/day
Family History:
Father had CVA's
Physical Exam:
Pulse:98 Resp:16 O2 sat:96/RA
B/P Right:175/92 Left: 159/90
Height:5'4" Weight:71.7 kgs
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anteriorly
Heart: RRR [x] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: left side facial paralysis, alert and oriented x3 MAE [**6-2**]
Pulses:
Femoral Right: cath site Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: murmur vs bruit Left: no bruit
Pertinent Results:
[**2151-12-15**] 05:13AM BLOOD WBC-5.7 RBC-3.47* Hgb-10.7* Hct-31.9*
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.8 Plt Ct-530*
[**2151-12-15**] 05:13AM BLOOD Plt Ct-530*
[**2151-12-15**] 05:13AM BLOOD PT-31.2* PTT-33.7 INR(PT)-3.1*
[**2151-12-15**] 05:13AM BLOOD Glucose-91 UreaN-13 Creat-0.4 Na-131*
K-4.4 Cl-96 HCO3-30 AnGap-9
[**2151-12-15**] 05:13AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.2
Conclusions
The left atrium is mildly dilated. The left ventricular cavity
size is normal. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. There is a
mild resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. A
mechanical aortic valve prosthesis is present. The transaortic
gradient is normal for this prosthesis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. No
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a very small partially echodense
pericardial effusion. There are no echocardiographic signs of
tamponade.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2151-12-9**] 14:47
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. 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 descending thoracic
aorta. The aortic valve leaflets are moderately thickened. There
is moderate aortic valve stenosis (valve area 1.0-cm2). The non
coronary cusp is immobile. The left and right coronary cusps
however have good excursion. Mild to moderate ([**1-30**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.
POSTBYPASS
Biventricular systolic function is preserved. There is a well
seated, well functioning bileaflet mechanical prosthesis in the
aortic position. There is most likely trace paravalvular
regurgitation. Ascending aortic contours appear intact. The
remaining study is otherwise unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2151-12-6**] 11:04
Brief Hospital Course:
Admitted [**12-6**] and underwent surgery with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
phenylephrine and propofol drips. Extubated later that day.
Transferred to the floor on POD #1 to begin increasing her
activity level. Coumadin started that evening for mechanical
valve. Beta blockade titrated. INR rose rapidly to 12.9 and pt
transferred back to CVICU for monitoring and FFP. Repeat INRs
done with additional FFP given. Gently diuresed toward her preop
weight. PICC placed POD #6 for poor IV access and transferred
back to the floor. Coumadin titrated and INR at discharge 3.1.
Cleared for discharge to home with VNA on POD # 9. Target INR
2.5-3.0 for mechanical AVR. Coumadin dosing will be followed
initially by cardiac surgery team and then will be transitioned
to her provider when INR is stable. All f/u appts were advised.
Medications on Admission:
ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet -
one Tablet(s) by mouth weekly on Wednesday
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 0.5 (One half) Tablet(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet -
one Tablet(s) by mouth daily
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - one Tablet(s) by mouth daily
CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] - (Prescribed
by Other Provider) - 315 mg-200 unit Tablet - 2 (Two) Tablet(s)
by mouth daily
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - one
Capsule(s) by mouth daily
Tylenol PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
10. warfarin 1 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a
day: dose to be adjusted based on INR results by Cardiac surgery
office [**Telephone/Fax (1) 170**].
Disp:*100 Tablet(s)* Refills:*2*
11. Outpatient [**Name (NI) **] Work
PT/INR for coumadin Dosing - daily PT/INR
Results to Cardiac Surgery [**Telephone/Fax (1) 170**] - please call results to
office thank you
12. coumadin/warfarin
You have been given a prescription for 1 mg tablets of coumadin
to allow the dose to be adjusted - please have INR drawn daily
until directed differently and the Cardiac surgery office will
call you with dosing - if you do not hear from anyone by 4 pm
each day - please call the office - [**Telephone/Fax (1) 170**]
Please have INR drawn in the am
13. Outpatient [**Name (NI) **] Work
PT/INR for coumadin Dosing - daily PT/INR
Results to Cardiac Surgery [**Telephone/Fax (1) 170**] - please call results to
office thank you
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Hypertension
Hyperlipidemia
Osteoporosis
Angioedema secondary to lisinopril
Loss of vision in right eye 7 years ago with resolution d/t TIA
Anxiety
Arthritis
TIA
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram prn
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace bilateral lower extremities
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**] Date/Time:[**2151-12-30**] 3:00
Dr [**Last Name (STitle) **] office will call you with appointment arranged with
your cardiologist Dr [**Last Name (STitle) **]
Please call to schedule appointments with your
Primary Care Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] in [**5-3**] weeks [**Telephone/Fax (1) 87801**]
**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 Mechanical AVR
Goal INR 2.5-3.0
Daily draws for 1 week and then will reevaluate
Cardiac Surgery office will follow and dose coumadin until
stable regimen and then will set up coumadin coverage with
cardiologist/PCP
Results to Cardiac Surgery Office phone [**Telephone/Fax (1) 170**]
Completed by:[**2151-12-21**]
|
[
"458.29",
"424.1",
"V12.54",
"790.92",
"300.00",
"272.4",
"351.0",
"733.00",
"285.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
8014, 8070
|
4473, 5355
|
295, 420
|
8300, 8500
|
1850, 4450
|
9424, 10408
|
1029, 1048
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6059, 7991
|
8091, 8279
|
5381, 6036
|
8524, 9401
|
1063, 1831
|
252, 257
|
448, 686
|
708, 872
|
888, 1013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,054
| 113,079
|
42456
|
Discharge summary
|
report
|
Admission Date: [**2103-11-12**] Discharge Date: [**2103-11-25**]
Date of Birth: [**2059-4-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
Ms. [**Known lastname 65453**] is a 44 y/o female with a hx of UGIB [**1-10**] duodenal
ulcers and EtOH liver disease who was transferred from [**Hospital1 1562**]
hosptial due to altered mental status.
.
As per her sister, she was recently admitted to [**Name (NI) 1562**]
hospital for an upper Gi bleed. She was discharged to [**Location (un) 3244**]
detox facility for a couple of days. When she came home from
detox, she was mildly confused. over the next few [**Last Name (un) 32460**] she
become progressively more confused and had significant decrease
in her functional status. Also having frequent diarrhea. Her
sister took her to her PCP who promptly sent her to the ED. In
the ED at [**Hospital1 1562**] (per report) it was thought her mental status
may be related to her liver disease and she was transferred to
[**Hospital1 18**].
.
In the ED, initial VS: 98.0 90 113/50 18 98%. She had a head CT
which was negative for an acute process. There was no ascitic
fluid that was visulized therefore could not perform a
diagnostic tap. She was given lactulose and ceftriaxone. ? given
narcan with improvement of mental status.
.
Overnight, Cr was found to be 5.1 with BUN of 15. WBC 22. U/A
suggestive of UTI. She was given 100g albumin for HRS and
ceftriaxone for UTI, ? SBP. This morning on rounds, she was
thought to be acutely confused, and transfer to the MICU
transfer was requested for altered mental status and possible
endoscopy. On evaluation this morning, she was confused and
unable to give a history. She denied having any discomfort. She
oriented to self but not to place and time.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Alcohol abuse
Social History:
Lives with his eldest of 2 sons. [**Name (NI) **] lots of family support
(mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not
currently employed, on SSI.
- Smoking: quit > 16 yrs ago, 25 pack year history
- EtOH: history of abuse, last drink > 22 yrs ago
- Drugs: history of polysubstance abuse including cocaine,
crack, barbiturates, amphetamines, and marijuana. None for 20
years.
Family History:
No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 132/74 96 20 99/ra
GENERAL - NAD, drowsy, confused
HEENT - scleral icterus
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, mild
expiratory wheezing, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, distended but soft/NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - several punctures in volar arms with surround
erythmea, ? injection drug sites vs. prior IVs. bilateral LE 3+
edema
NEURO - AAOx1, mild left facial droop, speech fluent, no
pronator drift
.
Discharge Exam:
Afebrile, HD stable, on RA
GENERAL: Well appearing 51yo M. Comfortable, appropriate and in
good humor. Mildly Jaundiced.
HEENT: Sclera icteric though improved. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, III/VI systolic murmur with best heard at LUSB.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normoactive BS. Distended but Soft, non-tender to
palpation, Tympanic to percussion, No HSM or tenderness.
EXTREMITIES: WWP, trace LLE (reduced from baseline).
NEURO: A and O x 3; approrpiately mentating; motor and sensory
grossly intact
Pertinent Results:
ADMISSION LABS:
[**2103-11-12**] 05:40PM BLOOD WBC-22.4* RBC-3.18* Hgb-10.4* Hct-33.0*
MCV-104* MCH-32.9* MCHC-31.7 RDW-19.2* Plt Ct-387
[**2103-11-12**] 05:40PM BLOOD Neuts-74* Bands-0 Lymphs-16* Monos-5
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-1*
[**2103-11-12**] 05:40PM BLOOD PT-19.3* PTT-44.8* INR(PT)-1.8*
[**2103-11-12**] 05:40PM BLOOD Glucose-81 UreaN-15 Creat-5.2* Na-131*
K-3.2* Cl-97 HCO3-16* AnGap-21*
[**2103-11-12**] 05:40PM BLOOD ALT-52* AST-150* AlkPhos-265*
TotBili-4.8* DirBili-4.0* IndBili-0.8
[**2103-11-12**] 05:40PM BLOOD Lipase-23
[**2103-11-12**] 05:40PM BLOOD Albumin-2.3* Calcium-8.5 Phos-3.6 Mg-2.2
[**2103-11-14**] 02:37PM BLOOD Ammonia-147*
[**2103-11-13**] 06:20AM BLOOD Osmolal-288
[**2103-11-13**] 06:20AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2103-11-12**] 05:40PM BLOOD HCG-<5
[**2103-11-12**] 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-11-13**] 06:20AM BLOOD HCV Ab-NEGATIVE
[**2103-11-13**] 03:06AM BLOOD Type-ART pO2-90 pCO2-26* pH-7.42
calTCO2-17* Base XS--5 Intubat-NOT INTUBA
[**2103-11-12**] 05:51PM BLOOD Glucose-77 Lactate-1.7 Na-132*
K-3.2*[**2103-11-13**] 03:06AM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-96
COHgb-1 MetHgb-0
[**2103-11-13**] 03:06AM BLOOD freeCa-1.14
.
Discharge Labs:
[**2103-11-24**] 07:15AM BLOOD WBC-26.7* RBC-2.46* Hgb-7.8* Hct-25.5*
MCV-104* MCH-31.6 MCHC-30.6* RDW-18.4* Plt Ct-490*
[**2103-11-24**] 07:15AM BLOOD PT-22.1* INR(PT)-2.1*
[**2103-11-24**] 07:15AM BLOOD Glucose-92 UreaN-36* Creat-1.3* Na-136
K-4.3 Cl-105 HCO3-17* AnGap-18
[**2103-11-24**] 07:15AM BLOOD ALT-25 AST-88* AlkPhos-151* TotBili-3.5*
[**2103-11-24**] 07:15AM BLOOD Albumin-2.7* Calcium-8.1* Phos-5.5*
Mg-1.7
.
MICRO:
BCx negative x4
UCx negative x2
C.DIFF NEGATIVE
.
IMAGING:
[**11-12**] CT HEAD TECHNIQUE: Axial MDCT images were acquired of the
head without contrast and reformatted into coronal and sagittal
planes.
FINDINGS:
The exam is somewhat limited by patient motion, although repeat
scans were
performed. There is no intracranial hemorrhage, extra-axial
collection, or
mass effect. The ventricles and sulci are normal in size and
configuration. [**Doctor Last Name **] matter/white matter differentiation is
preserved. The orbits are normal appearing. The soft tissues are
unremarkable. There is an air-fluid level within the left
maxillary sinus, and mucosal thickening of ethmoid air cells.
The frontal sinuses are clear. An air-fluid level is seen in the
sphenoid sinus with aerosolized debris. The mastoid air cells
and middle ear cavities are clear. There is no osseous
abnormality.
IMPRESSION:
1. No acute intracranial process.
2. Air-fluid levels in multiple paranasal sinuses.
.
[**11-12**] LIVER ULTRASOUND: FINDINGS: The liver is diffusely coarse
and echogenic consistent with history of liver disease. No focal
lesions are seen. The gallbladder appears normal. The common
bile duct is mildly dilated measuring up to 8 mm. No definite
stone is seen within the common bile duct. To and fro flow is
seen within the main portal vein. There is no ascites. The right
kidney measures 13.9 cm in the long axis and is normal in
appearance without hydronephrosis or stones.
IMPRESSION:
1. Diffusely echogenic liver consistent with history of
alcoholic hepatitis.
2. To and fro flow within the main portal vein without portal
vein
thrombosis.
3. Common bile duct measures up to 8 mm and is thus dilated.
MRCP/ERCP could better evaluate for an obstructing cause.
.
[**11-13**] RENAL ULTRASOUND: The right kidney measures 12.1 cm. The
left kidney measures 12.5 cm. There is no hydronephrosis, stones
or masses. The bladder is only minimally distended and cannot be
assessed. Small portion of a urinary catheter is seen.
IMPRESSION: Normal renal son[**Name (NI) **]
.
[**11-16**] HIDA SCAN: RADIOPHARMACEUTICAL DATA: 4.2 mCi Tc-[**Age over 90 **]m DISIDA
([**2103-11-16**]); HISTORY: Common duct dilation, leukocytosis, and
right upper quadrant pain. Evaluate for biliary pathology.
METHODS: Following the intravenous injection of tracer, serial
one-minute images of tracer uptake into the hepatobiliary system
were obtained for 75 minutes. A delayed static image was
obtained at 5.5 hours. Images of the injection site were also
acquired.
INTERPRETATION: Serial images over the abdomen show poor uptake
of tracer into the hepatic parenchyma in a homogeneous pattern.
At 15 minutes, the small bowel is visualized, although no tracer
uptake is seen within the gallbladder throughout the first 75
minutes. The patient returned to the nuclear medicine suite
after 5.5 hours for additional imaging, which revealed tracer
activity within the gallbladder.
IMPRESSION:
1. Diffusely poor tracer uptake throughout the liver is
consistent with poor hepatocellular function.
2. Tracer activity within the gallbladder on delayed images
excludes the
diagnosis of acute cholecystitis.
2. Excretion of tracer into the small bowel excludes the
diagnosis of complete biliary obstruction.
.
[**11-17**] CXR HISTORY: Alcoholic hepatitis. Aspiration event.
IMPRESSION: AP chest compared to [**11-13**]:
Consolidation in the perihilar left lung and in the right upper
lung extending to the apex is readily explained by massive
aspiration. A smaller region of consolidation may be present in
the right lung projecting behind the lower pole of the right
hilus. Mild cardiomegaly and mediastinal vascular engorgement
have increased suggesting cardiac decompensation. Dr. [**Last Name (STitle) **]
was paged.
.
CXR [**2103-11-18**] Bilateral upper lobe consolidation is slightly more
pronounced today than yesterday. Whether this is due to
progression of pneumonia or deposition of early edema in a
region of pre-existing pneumonia is difficult to say since the
mediastinal veins are dilated in the supine position. Heart size
is top normal, and there may be mild pulmonary vascular
engorgement, but no clear edema elsewhere. There is no
appreciable pleural effusion. Nasogastric tube passes into the
stomach and out of view
.
Sigmoidoscopy [**2103-11-23**]
- Polyp at 8cm in the rectum
- Polyps at the ranging distance from 18 cm to 28 cm in the
distal sigmoid colon
- Grade 2 internal hemorrhoids
- Otherwise normal sigmoidoscopy to splenic flexure
- Recommendations: Patient will need colonoscopy for removal of
polyps when her alcoholic hepatitis improves and her INR is less
than 1.5.
Brief Hospital Course:
Ms. [**Known lastname 65453**] is a 44 year old female with a history of upper GI
bleed (UGIB) secondary to duodenal ulcers and alcoholic liver
disease who was transferred from [**Hospital 1562**] hospital due to
altered mental status.
.
ACTIVE PROBLEMS BY ISSUES:
.
# Alcoholic Hepatitis: Hepatic encephalopathy, jaundice, LFTs
with alcoholic picture, viral studies were negative. She has
signficant synthetic dysfunction as well with a discriminant
function of 51 on admission. Steroids were deferred initially
for possible acute hepatitis since her LFTs and bilirubin were
improving in the MICU with fluids. Hepatitis B and C virus
serologies negative. On floor tube feeds were started to augment
nutrition and improve hepatitis. NGT was accidentally self
removed. Nutrition reconsulted and felt she could take adequate
caloric intake to treat alcoholic hepatitis and so NGT was not
replaced. Discriminant function 36 on discharge but patient
clinically much improved, walking around floor, jaundice
improving, POing well with downtrending T.Bili <4 on discharge.
Patient discharged in improved condition agreement with plan to
abstain from alcohol completely. She was discharged home with
outpatient alcohol rehabilitation.
.
# Encephalopathy: The patient was transferred to the MICU for
altered mental status (AMS); likely due to hepatic
encephalopathy. A lumbar puncture was attempted, but
unsuccessful. She received Narcan in the ED to which there was
a questionable improvement in her mental status. She was given
lactulose and rifaxamin, aiming for 4 bowel movements/day and
was also started on empiric antibiotic coverage since she had a
leukocytosis with the AMS including acyclovir, vancomycin,
ampillicin, and ceftriaxone. The patient then had a right upper
quadrant ultrasound that showed dilated common bile duct, so she
underwent a HIDA scan which ruled out cholangitis as a cause of
her AMS and leukocytosis. At that point, ampicillin was
discontinued and the patient was continued on vanc/acyclovir,
flagyl/ceftriaxone was added for intra abdominal pathology.
Antibiotics were changed to Vanc/Zosyn after she developed PNA.
The patient also has a drinking history and was started on
thiamine. As the patient's mental status slowly improved, the
acyclovir was stopped, as the concern for encephalitis lessened.
On arrival to the floor her mental status continued to improve
with lactulose and Rifaximin. He encephalopathy was attributed
to alcoholic hepatitis and continued to improve throughot
duration of stay.
.
# Acute Renal Failure: The patient was found to be in ARF
(baseline creatinine is around 0.9) and presented with creat
5.2. FeNa of 0.22 consistent with prerenal etiology and muddy
brown casts were found in the urine sediment suggesting acute
tubular necrosis (ATN). With significant liver dysfunction
hepatorenal syndrome (HRS) was of concern. Renal consulted but
thought that the etiology was pure ATN. She underwent a renal
ultrasound which was normal and an albumin challenge which ruled
out hepatorenal syndrome. Creatinine continued to improve after
albumin was given and with improvement in hepatitis.
.
# Aspiration pneumonia: She developed aspiration pneumonia on
[**11-17**] with a rising leukocytosis. She was fed with a
[**Last Name (un) **]-gastric tube and continued on vanc/zosyn. She completed an
HCAP course with Vanc/Zosyn and she remained on RA throughout
duration of floor stay.
.
# Leukoctosis: Patient with profound leukocytosis which
uptrended initially and remained elevated. Initial concern was
for HCAP which was adequately treated. C.Diff returned negative
multiple times. Leukocytosis remained elevated despite HCAP
treatment and so WBCs thought most likely related to alcoholic
hepatitis rather than infectious etiology. Cultures negative
otherwise in work up.
.
# Upper GI bleed (UGIB): Presented with bright red blood per
rectum (BRBPR), and a Hematocrit trending down 33 -> 30. Upon
further questioning, she reported that she was having her
menses. Her hematocrit remained stable and she did not recieve
any blood transfusions. This was initially stable until 2 days
prior to discharged when on the floor she began having GIB.
Patient again felt this was menses though rectal exam with
internal hemorrhoids. Flex Sig was completed given concern for
rectal bleed which showed grade 2 hemorrhoids and multiple
recto-sigmoid polyps. Polyps were not removed because of
elevated INR and tenuous Alc Hep. Repeat colonoscopy deferred to
outpatient after improvement in hepatitis and coagulopathy.
.
# Anion Gap Acidosis: She is noted to have a gap of 18 upon
admission labs. Her lactate was within normal limits, no osmolar
gap. Given BUN unlikely to be uremia, but possible contribution
of acute renal failure. Also possible alcoholic/starvation
ketosis. Gap closed and remained stable after transfer to floor
from MICU.
.
# Sodium imbalance: She likely had hypervolemic hyponatremia due
to liver dysfunction. She was maintained on a fluid restricted
diet. She later developed hypernatremia while she was on tube
feeds only for aspiration. This was treated with free water
flushes through the NG tube. After hepatitis and HCAP
improved/resolved her Na remained stable requiring no further
intervention.
.
# Macrocytic Anemia: With significant alcohol use she is likely
either folate or B12 deficient.
.
# Peptic ulcer disease (PUD): she has a history of duodenal
ulcers and was continued on pantoprazole.
.
TRANSITIONAL ISSUES:
- Colonoscopy needs to be completed as an outpatient with
removal of colonic polyps after INR improves
- Patient counseled extensively on the importance of alcohol
abstainence and she is agreeable with plan. Should continue
reinforcing abstinence
- Consider Baclofen for alcohol abuse prophylaxis
Medications on Admission:
Oxycodone 5mg
Vitamin B12
Ondansetron 4mg
Pantoprazole 40mg daily
Discharge Medications:
1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed) as needed for rectal irritation.
Disp:*1 tube* Refills:*0*
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a
day.
Disp:*1800 ML(s)* Refills:*1*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every twelve (12) hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
hepatic encephalopathy
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 65453**],
.
You were admitted to the hospital because you were more confused
than your baseline and there was concern that you had bleeding
from your intestines. We did not find that there was any
significant bleeding in your intestines and the levels of your
blood stayed steady. You do have a hemorrhoid which bleeds a
little bit when you have bowel movements. Flex Sigmoidoscopy
performed showed polyps in your sigmoid colon which should be
followed up after you are discharged.
.
For your confusion, we think that it relates to your liver
disease. When your liver disease progresses, a condition called
cirrhosis, your body builds up toxic substances. You were
treated with lactulose to make you have bowel movements which
will remove these toxic substances.
.
Finally, you developed a pneumonia because when you swallow the
food sometimes goes into your lungs. This is called aspiration.
You have to eat very slowly to help the food go into your
stomach not your lungs.
.
The following changes were made to your medications:
- START Folic Acid 1mg Daily
- START Thiamine 100 mg DAILY
- START Vitamin D 400 UNIT DAILY
- START Hydrocortisone cream: apply rectally as needed for
irritation
- CONTINUE Pantoprazole
- START Lactulose 30 mL Twice daily
- START Rifaximin 550 mg twice daily
.
It is also very important that you keep all of the follow-up
appointments listed below.
.
It is also very important that you have a colonoscopy to
evaluate polyps in your colon.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: Wednesday [**2103-12-5**] 10:45am
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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"276.8",
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"533.90",
"507.0",
"275.3",
"585.9",
"266.2",
"578.1",
"276.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
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|
328, 344
|
17575, 17575
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3514, 4151
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2000, 2247
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267, 290
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372, 1981
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4186, 5423
|
17509, 17554
|
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|
2269, 2284
|
2300, 2711
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,602
| 149,786
|
51358
|
Discharge summary
|
report
|
Admission Date: [**2193-4-25**] Discharge Date: [**2193-5-22**]
Date of Birth: [**2108-2-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
cystoscopy
History of Present Illness:
Pt is a 85 y/o F PMH anemia, afib on coumadin, valve
replacement, CAD, HLD, stroke, dementia who presents with
hematuria. Pt woke up at 3AM [**2193-4-24**] noting gross hematuria and
clots. No dysuria or frequency, nover/abd pain. Very weak and
dizzy today. Pt has afib on coumadin - last INR was 4.1 on [**4-6**].
Was seen by PCP [**2193-4-25**] with vs 90/40, 114, 16, pt noted to be
pale with benign abdomen. Endorses black tarry stools x [**2-22**]
days. Last BM this morning. No diarrhea/vomiting. Was referred
by PCP for GI consult and possible cystoscopy.
.
Of note, last colonoscopy 10 years ago; never with abnormal
colonoscopy. Pt is on PPI which she states is for her
abdominally located pacer. Reports never having experienced
hematuria before.
.
On arrival to the ED vs - 97.7 114 89/39 16 100%.
1pm ED labs showed: Hct of 25 down from 33.4 on [**4-8**], and INR of
2.3 along with the following:
Na135 K 5.1 Cl 100 CO2 38 glu 125 BUNcr 38/1.4 (b/l 0.9)
Ca: 8.9 Mg: 3.1 P: 5.9 ∆
ALT: 25 AP: 61 Tbili: 0.3 Alb: 3.9
AST: 38 LDH:
CBC 7.1 >25.4< 242
N:85.6 L:10.9 M:2.7 E:0.2 Bas:0.6
PT: 24.0 PTT: 38.4 INR: 2.3
Lactate:3.2
Pt was noted to have guiaic positive dark brown stool. No blood
seen in vaginal vault. NG lavage showed no blood. Pt received
bolus 80 protonix and started on protonix gtt at 8. 2PIVs
placed. Received 750ccs NS.
EKG showed Afib, na/ni, c/w prior (downgoing T in II,II,aVF)
.
.
On arrival to the ICU, pt is in no distress. Fully oriented,
husband is at bedside. Notably foley has grossly bloody urine
.
Review of systems:
(+) Per HPI
(-) Denies fever, 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.. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
CAD s/p CABG
s/p mechanical MVR
s/p mechanical AVR and TVRs [**2189-10-15**]
right hemothorax s/p VATS [**10-28**]
CVA
atrial fibrillation
anemia
pacer for heart block
h/o R hip replacement
s/p appendectomy
osteoporosis
Social History:
Retired mill worker. Lives with husband in [**Name (NI) **]. Tobacco 50
pack year history quit in [**2151**]. Denies any current etoh use.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: T:95.6 BP:108/44 P:92 R: 21 O2: 100% rA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, conjunctiva pale. dry MM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: irregular rhythm,loud S2
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly pacer
generator palpable over left lower ribcage
GU: foley full of gross frank blood
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL EXAM:
afebrile, BP 90s-110s/40s-60s, HR 70s, saturation 100% RA
exam unchanged except:
no foley
Pertinent Results:
ADMISSION LABS:
[**2193-4-25**] 12:45PM BLOOD WBC-7.1 RBC-2.83* Hgb-7.8* Hct-25.4*
MCV-90 MCH-27.6 MCHC-30.7* RDW-15.7* Plt Ct-242
[**2193-4-25**] 05:57PM BLOOD WBC-5.4 RBC-1.95*# Hgb-5.6*# Hct-17.2*#
MCV-89 MCH-28.7 MCHC-32.5 RDW-16.3* Plt Ct-168
[**2193-4-25**] 12:45PM BLOOD PT-24.0* PTT-38.4* INR(PT)-2.3*
[**2193-4-25**] 12:45PM BLOOD Glucose-125* UreaN-38* Creat-1.4* Na-135
K-5.1 Cl-100 HCO3-23 AnGap-17
[**2193-4-25**] 12:45PM BLOOD ALT-25 AST-38 AlkPhos-61 TotBili-0.3
[**2193-4-25**] 12:45PM BLOOD Albumin-3.9 Calcium-8.9 Phos-5.9*#
Mg-3.1*
[**2193-4-25**] 12:47PM BLOOD Lactate-3.2*
[**2193-4-25**] 02:20PM URINE Color-RED Appear-Cloudy Sp [**Last Name (un) **]-1.026
[**2193-4-25**] 02:20PM URINE Blood-LG Nitrite-POS Protein-300
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-2* pH-8.0 Leuks-TR
[**2193-4-25**] 02:20PM URINE RBC->182* WBC->182* Bacteri-NONE
Yeast-NONE Epi-0
.
DISCHARGE LABS:
[**2193-5-22**] 02:21AM BLOOD PT-30.3* PTT-58.1* INR(PT)-2.9*
.
MICRO:
URINE
**FINAL REPORT [**2193-5-20**]**
URINE CULTURE (Final [**2193-5-20**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
.
**FINAL REPORT [**2193-4-27**]**
MRSA SCREEN (Final [**2193-4-27**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
.
[**2193-4-25**] 2:20 pm URINE Site: NOT SPECIFIED
CHM S# [**Serial Number 106506**]G UCU ADDED [**4-25**].
**FINAL REPORT [**2193-4-28**]**
URINE CULTURE (Final [**2193-4-28**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
sensitivity testing performed by Microscan.
SENSITIVE TO MEROPENEM (MIC: <= 1MCG/ML).
SENSITIVE TO CEFEPIME (MIC: <= 2MCG/ML).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ <=1 S
.
IMAGING:
CHEST (PORTABLE AP) Study Date of [**2193-4-25**] 6:37 PM
FINDINGS: In comparison with the study of [**2189-11-19**], there is
again
enlargement of the cardiac silhouette in a patient with valve
replacement and intact midline sternal wires. Pacemaker device
remains in place. No evidence of vascular congestion or pleural
effusion or acute focal pneumonia. The electronic pacer device
overlying the left chest has been removed, though the abandoned
leads persist.
.
CT ABD & PELVIS W & W/O CONTRAST, [**2193-4-26**] 12:46 PM
IMPRESSION:
1. No focal renal lesion to explain gross hematuria. No proximal
ureteral
lesion to explain hematuria. The distal ureters are not
opacified with
contrast.
2. Small bilateral pleural effusions.
.
CHEST PORT. LINE PLACEMENT Study Date of [**2193-4-27**] 10:37 AM
FINDINGS: Tip of right PICC is either at or just below the
cavoatrial
junction, as communicated by telephone by Dr. [**Last Name (STitle) **] to nurse, [**Doctor First Name **]
at 11:30 a.m. on [**2193-4-27**] at the time of discovery of this
finding.
.
UNILAT UP EXT VEINS US RIGHt [**2193-5-5**] 1:56 PM
IMPRESSION: No right upper extremity DVT.
.
UNILAT LOWER EXT VEINS [**2193-5-8**] 1:36 PM
No evidence of deep vein thrombosis in the right leg. Note is
made that
visualization of the right calf veins is limited.
.
PATHOLOGY:
[**2193-4-26**] URINE CYTOLOGY: Urine, catheter:
NEGATIVE FOR MALIGNANT CELLS.
Rare urothelial cells, numerous neutrophils, and few red
blood cells.
Brief Hospital Course:
Ms. [**Known lastname **] is an 85 year old female with history of Afib on
coumadin, prosthetic mitral, aortic and tricuspid valves
(rheumatic fever), who presented with 18 hours of hematuria and
black stools, found to have an acute 8pt drop in hematocrit
within the first day of admission. She was found to have
pseudomonal urine infection and ulcerations of bladder on
cystoscopy which were cauterized. She had recurrent bleeding of
the bladder and overall required 15 units of pRBC as well as
other products. This required two stays in the intensive care
unit and almost 2 weeks of continuous bladder irrigation (CBI).
Eventually, she was restarted on a heparin gtt with lower target
PTT while bridging to warfarin for her mechanical heart valves.
By the time of discharge, she had been free of hematuria for
days and had a therapeutic INR (2.5-3.5). She did however have
residual bladder atony from the prolonged foley cath and was
intermittently straight cathing herself for high post-void
residuals.
.
# Hematuria complicated by hypovolemic shock requiring 15 units
pRBCs but no pressors. CT urogram was unremarkable. Cytoscopy on
[**2193-4-30**] showed ulcers and excoriations in bladder that were
cauterized; urine cytology showed no malignant cells, then
atypical specimen following. After the cystoscopy, she
continued to have large volume bleeding and her systolic blood
pressure dropped to the 70s with altered mental status due to
hypovolemic shock. Received a total of 15units PRBCs during
hospital stay over two ICU admissions. Hct now stable in 20s
and blood pressure stable 90s-110s. She was off heparin gtt,
aspirin, and coumadin for 3 days starting [**2193-5-3**] given
bleeding. Eventually restarted on heparin gtt [**5-6**] bridging to
coumadin. She had some clots and then bright red blood in urine
early on [**2193-5-8**] and CBI was restarted. Trial of clamping on
[**2193-5-9**] failed because clot developed and CBI restarted.
Finally, on [**2193-5-14**] she tolerated clamping of the CBI and
continued to make lightly tea-colored urine without clots. On
[**2193-5-15**] the foley was discontinued and she continued to have
urine output (no clots) which was not grossly bloody. Even
after her INR became therapeutic she maintained non- bloody
urine without clots.
.
# Bladder atony: After the foley catheter was removed, she was
having high post-void residuals. She was able to urinate
150-300 cc at a time but retained up to 700 cc in the bladder.
After discussion with urology, this was felt most likely bladder
atony due to prolonged foley. The patient and her husband were
taught how to perform straight catheterizations if she does not
void more than 300 cc of urine every 8 hours. (She will measure
each time.) They were offered a [**Hospital1 1501**] for a time period until her
atony improves and they become comfortable with cathing her.
.
# Melena - patient reported black tarry stools for several days
prior to admission. Last colonoscopy was normal 10 years ago.
She denied associated pain. Her stool guiac was positive in ED.
GI consulted and recommended outpatient colonoscopy. She had
several non-melanotic stools during the hospitalization.
.
# Bioprosthetic/mechanical valves: Patient has 3 non-native
heart valves due to history of rheumatic heart disease--2
metallic and one bioprosthetic valve, was on coumadin at home.
The risk of stroke is a concern with her metallic valves, but
patient has also experienced 2 episodes of life-threatening
bleeding during this admission. Balancing risks and benefits,
heparin was held from [**5-3**] to [**5-6**] in the setting of bladder
bleeding which allowed time for clot organization in the
bladder. Heparin gtt was restarted on [**5-6**] and bridged to
warfarin with INR goal 2.5-3.5. Her discharge warfarin regimen
was 7.5 mg daily everyday except 10mg on Tuesdays/Thursdays and
she was therapeutic.
.
# Urinary tract infection (UTI) - She had a positive urinalysis
(leuks, nitrites) on admission and culture grew Pseudomonas sp.
intermediate sensitivities to cipro but sensitive to cefepime.
She was treated with a total of 19 days of cefepime due to
ongoing instrumentation for CBI. This may have been the
original precipitant of her hematuria. Because she had high
post-void residuals after foley was removed (see above), urology
recommended checking another urinalysis which looked improved
from prior. The cultures grew vancomycin-resistant enterococcus
(VRE) and she was started on 10 days of linezolid 600 mg PO BID
(was intermittently instrumented). She should continue the
linezolid until [**2193-5-30**].
.
#Atrial fibrillation (Afib)- For anticoagulation changes, see
above. For rate control, she takes metoprolol at home. Had
episode of afib with rapid ventricular response in ICU with HR
160s so patient was placed on diltiazem gtt for rate control.
Metoprolol was restarted once hematuria was stable and she did
not have any rapid rates. Discharge regimen was metoprolol
succinate 25 mg daily.
.
# Thrombocytopenia: Thrombocytopenia likely from receiving 16
units PRBCs with only 1 bag of platelets. Her platelet count was
monitored closely (especially since she was on heparin gtt for
anticoagulation) but it returned to [**Location 213**].
.
# Osteoporosis: continued alendronate 70 mg weekly, calcium and
vitamin D supplements.
.
# Hyperlipidemia: continued simvastatin 40 mg daily
.
TRANSITIONAL ISSUES:
- Please complete her course of PO linezolid 600 mg [**Hospital1 **] for VRE
urine culture
- Please monitor INR very closely because elevated levels will
likely predispose to recurrent hematuria. Goal is 2.5 -3.5.
Adjust her dose of warfarin as needed to maintain therapeutic
levels.
- Re: bladder atony. The patient and her husband were taught
how to perform straight catheterizations if she does not void
more than 300 cc of urine every 8 hours. (She will measure each
time.) They need ongoing teaching to become more comfortable
with this at home.
Medications on Admission:
ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet - 1
Tablet(s) by mouth q week on fridays
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day for
chol
WARFARIN - 7mg on tuesdays and thursdays all other days takes
5mg
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 400 unit Tablet - 1 Tablet(s) by mouth Twice daily
FERROUS SULFATE [IRON] - (Prescribed by Other Provider) - 325
mg
(65 mg) Tablet - 1 Tablet(s) by mouth qam
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
Disp:*30 Tablet(s)* Refills:*0*
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
Disp:*qs ML(s)* Refills:*0*
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
12. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 5X/WK
(MO,WE,FR,SAT,SUN).
13. warfarin 5 mg Tablet Sig: Two (2) Tablet PO 2X/WEEK (TU,TH).
14. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) **] [**Hospital **] Nursing Home
Discharge Diagnosis:
PRIMARY:
Hematuria
Urinary Tract Infection
hypovolemia from blood loss
SECONDARY:
Rheumatic Heart Disease with mechanical valve replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking part in your care. You presented to the
hospital because you were experiencing blood in the urine.
While in the hospital we found that you had a urinary tract
infection that was likely the initial precipitant of the
bleeding. The urologists (urinary tract specialists) looked
inside your bladder and found excoriations which they
cauterized.
We gave you blood and had to irrigate the bladder, but
eventually it did stop bleeding. You were restarted on your
coumadin very slowly for the mechanical heart valves that you
have.
Please make the following changes to your medications:
- START senna and colace daily
- START milk of magnesia 30 mL daily as needed for constipation
- STOP aspirin
- START linezolid 600 mg twice a day until [**2193-5-30**]
- CHANGE your warfarin (coumadin) to 7.5 mg 5x per week (Mo,
Wed, Fri, Sat, Sun) and 10 mg 2x per week (Tues, Thurs). Your
level will be checked frequently and the doses might be adjusted
Please keep all follow-up appointments listed below. You should
bring your medications to each appointment so your doctors [**Name5 (PTitle) **]
update their records and adjust the doses as needed.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: THURSDAY [**2193-5-30**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
***Please note this appt is in [**Location (un) 2352**]
Please discuss with the staff at the facility a follow up
appointment with your PCP below when you are ready for
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**],MD
[**Hospital1 **] HEALTH CARE [**Location (un) 2352**] - ADULT MEDICINE
1000 [**Last Name (LF) **], [**First Name3 (LF) 2352**],[**Numeric Identifier 13951**]
[**Telephone/Fax (1) 1144**]
Department: CARDIAC SERVICES
When: THURSDAY [**2193-5-23**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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|
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3531, 4401
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2595, 2737
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,041
| 175,730
|
1473
|
Discharge summary
|
report
|
Admission Date: [**2178-3-21**] Discharge Date: [**2178-3-29**]
Service: MEDICINE
Allergies:
Codeine / Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p Coronary cath [**3-23**] with POBA to SVG-PDA
History of Present Illness:
[**Age over 90 **] yo M with PMH CAD s/p CABG [**2153**] with SVG to RPDA, SVG to LAD,
SVG to diagonal, s/p PCI to SVG-Diag 100% occluded, DES to
SVG-LAD graft in [**4-29**], DESx2 to SVG-RPDA in [**9-30**], BMS to SVG-RCA
in [**10-1**], DES to SVG to LAD [**2175**] and DES x2 to proximal and mid
SVG to LAD in [**1-4**], and DESx2 to proximal and ostial [**Date Range **] in
[**2-5**]; right renal artery stenosis s/p stenting [**3-31**], [**Month/Year (2) 2091**], DMII,
HLD, HTN, ???GI bleed, small AAA presenting to OSH with chest
pain. Pt described the quality of the same as the same as that
which occurred prior to his previous stent placements - it was a
pressure, located in the center of his chest, nonradiating,
accompanied by intermittent SOB, "feeling hot," and
palpitations. It was also accompanied by dizziness and weakness
which was new for him. It was also more severe than any other
pain he has ever had, nearly bringing him to tears. No nausea,
vomiting, or diaphoresis. It lasted 30 minutes and was relieved
after taking 5 tabs of nitro. He was watching television when
the pain began. He states that he has had the pain 6 times over
the past week; all episodes occurred in the evening when he was
either lying in bed or just getting into bed. The pain has not
occurred during the day or with exertion. He denies h/o reflux
symptoms. States he eats dinner around 6pm. No fevers, chills,
abdominal pain, muscle aches, joint pains. Admits to SOB when
lying down and has become SOB at night before. Admits to cough
productive of white phlegm for about 1 week now. Also has a
runny nose. Sister has been sick but otherwise no sick contacts.
[**Name (NI) **] been constipated the past few days. Has been undergoing
treatment for diverticulitis with flagyl since hospitalization
at [**Hospital3 **] on [**2178-3-14**]. Does not like flagyl and says it
gives him an acid taste in his mouth. Last dose [**2178-3-24**]. Has
been taking of his medications as prescribed daily.
.
At OSH, initial VS were 98.1, 181/103, 68, 18, 98% O2. He
reportedly had initial improvement and then recurrence of the
chest pain during which he became pink, appeared uncomfortable,
and was warm to the touch. He was lying down when the pain
occurred. He was given ativan, a GI cocktail, morphine, imdur,
and nitro gtt at various points in the ED there and it is
unclear which of these helped his pain. He was started on
heparin gtt at 1000 units/hr and nitro gtt at 10 mcgs. He was
also given bicarb 100/hr and mucomyst 600 mg po for possibility
of cath with his CRI. EKG's taken at the onset and peak of the
pain were unchanged. Labs there were significant for trop 0.02
and Hct 32.7. An echo showed moderately dilated LA, LVEF 55-60%,
and "distolic dysfunction." EKG showed stable biphasic t-waves
in V2-V4 and stable RBBB. There was borderline [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8730**]. He
was transferred to [**Hospital1 18**] for possible cardiac cath but with
question as to cardiac nature of pain.
.
In the ED, initial vitals were 98.2, 66, 141/70, 18, 100%. Labs
significant for Hct 29.5, WBC 3.3, INR 1.1, lipase 32, LFTs WNL,
Cr 2.6, BUN 37, trop 0.01. Pt was continued on nitro gtt and
heparin gtt and transferred to [**Hospital1 **] service.
.
On arrival to the floor, VS 98.3, 160/83, 75, 20, 98% RA. He
currently denies CP or SOB.
.
REVIEW OF SYSTEMS
per HPI
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: CABG [**2153**], with SVG to RPDA, SVG to LAD, SVG to diagonal.
-PERCUTANEOUS CORONARY INTERVENTIONS:
SVG-Diag 100% occluded, DES to SVG-LAD graft in [**4-29**], DESx2 to
SVG-RPDA in [**9-30**], BMS to SVG-RCA in [**10-1**], DES to SVG to LAD [**2175**]
and DES x2 to proximal and mid SVG to LAD in [**1-4**], DESx2 to
proximal and ostial [**Date Range **] in [**2-5**]
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- right renal artery stenosis s/p stenting [**3-31**]
- CRI: baseline creat according to our records was 2.0 in [**2176**]
- Type 2 DM
- Hyperlipidemia
- Hypertension
- PTSD
- GI bleed [**2175**] s/p cath on integrilin and heparin (thought to
be [**2-26**] internal hemorrhoids vs bleeding diverticula)
- small AAA
- chronic dizziness
- spondylosis
- deviated septum
- hiatal hernia
- pneumonia
Social History:
Tobacco: 150+ pack years of tobacco use. Quit at the age of 64
at time of first MI. Smoked 3-4ppd when young.
EtOH: He uses alcohol occasionally.
Illicits: He has no history of recreational drug use.
- He lives with his wife. [**Name (NI) 2760**] gambling weekly. Two children,
both live in area. 4 grandchildren
Family History:
Father had a myocardial infarction at age 70. Mother had cancer
and myocardial infarction. Brothers have diabetes.
Physical Exam:
ADMISSION EXAM:
VS: 98.3, 160/83, 75, 20, 98% RA
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 with JVP of 3cm above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. faint heart sounds
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. mild left base
crackles, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. papery LE skin; trace edema in
LE bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM:
VS: 97.9, 135/65, 76, 20, 100% RA
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 with JVP of 3cm above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. faint heart sounds
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. mild left base
crackles, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. papery LE skin; trace edema in
LE bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
ADMISSION LABS:
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] WBC-3.3* RBC-3.65* Hgb-10.1* Hct-29.5*
MCV-81* MCH-27.7 MCHC-34.3 RDW-14.5 Plt Ct-115*
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Neuts-66.7 Lymphs-23.1 Monos-4.2 Eos-5.6*
Baso-0.3
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] PT-12.2 PTT-35.9 INR(PT)-1.1
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Glucose-96 UreaN-37* Creat-2.6* Na-141
K-4.2 Cl-108 HCO3-25 AnGap-12
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] ALT-39 AST-18 AlkPhos-99 TotBili-0.3
[**2178-3-22**] 06:55AM [**Month/Day/Year 3143**] Calcium-8.8 Phos-2.7 Mg-1.9
Cardiac labs
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] cTropnT-<0.01
[**2178-3-21**] 04:55PM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-0.02*
[**2178-3-22**] 06:55AM [**Month/Day/Year 3143**] cTropnT-0.08*
[**2178-3-22**] 06:29PM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-0.10*
[**2178-3-23**] 07:10PM [**Month/Day/Year 3143**] CK-MB-7 cTropnT-0.16*
[**2178-3-24**] 05:26AM [**Month/Day/Year 3143**] CK-MB-50* MB Indx-8.8* cTropnT-2.28*
[**2178-3-24**] 02:25PM [**Month/Day/Year 3143**] CK-MB-84* MB Indx-10.6* cTropnT-2.85*
[**2178-3-24**] 11:16PM [**Month/Day/Year 3143**] CK-MB-65* MB Indx-9.0* cTropnT-2.81*
[**2178-3-25**] 06:02AM [**Month/Day/Year 3143**] cTropnT-2.84*
[**2178-3-26**] 07:12AM [**Year/Month/Day 3143**] CK-MB-13* MB Indx-5.5 cTropnT-3.20*
[**2178-3-26**] 07:12AM [**Year/Month/Day 3143**] CK-MB-13* MB Indx-5.5 cTropnT-3.20*
[**2178-3-27**] 07:10AM [**Year/Month/Day 3143**] CK-MB-7 cTropnT-3.78*
Discharge labs
[**2178-3-29**] 07:34AM [**Year/Month/Day 3143**] WBC-3.1* RBC-3.34* Hgb-9.2* Hct-26.3*
MCV-79* MCH-27.5 MCHC-35.0 RDW-15.2 Plt Ct-191
[**2178-3-29**] 07:34AM [**Year/Month/Day 3143**] Glucose-101* UreaN-54* Creat-2.8* Na-141
K-3.8 Cl-109* HCO3-23 AnGap-13
[**2178-3-29**] 07:34AM [**Year/Month/Day 3143**] Calcium-8.2* Phos-3.1 Mg-2.1
OTHER LABS:
[**2178-3-21**] 04:55PM [**Month/Day/Year 3143**] Ret Aut-2.4
[**2178-3-21**] 04:55PM [**Month/Day/Year 3143**] LD(LDH)-247 CK(CPK)-37* TotBili-0.3
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Lipase-32
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] Albumin-3.5 Iron-54
[**2178-3-21**] 10:40AM [**Month/Day/Year 3143**] calTIBC-267 Hapto-169 Ferritn-71 TRF-205
IMAGING:
CXR [**2178-3-21**]: Frontal and lateral views of the chest were
obtained. Lung volumes are lower than on the prior study. There
is mild bibasilar atelectasis. No focal consolidation, pleural
effusion or pneumothorax. The cardiac silhouette is top normal
in size. Mediastinal silhouette and hilar contours are stable
allowing for lower lung volumes. Calcifications are seen along
the course of the thoracic aorta. Mediastinal post-surgical
changes including coronary stents and intact median sternotomy
wires are unchanged. IMPRESSION: No pneumonia, edema or
effusion. Mild bibasilar atelectasis.
TTE [**2178-3-24**]: The left atrium is dilated. The estimated right
atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Right
ventricular chamber size and free wall motion are normal. Right
ventricular chamber size is normal. Tricuspid annular plane
systolic excursion is depressed consistent with right
ventricular systolic dysfunction. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. Compared
with the prior study (images reviewed) of [**2174-1-22**], prior
views are suboptimal for comparison.
Cardiac cath [**2178-3-23**]: full report pending. POBA ISRS SVG-PDA.
RFA Perclose.
No issues
Brief Hospital Course:
[**Age over 90 **] yo M with PMH CAD s/p CABG [**2153**] with SVG to RPDA, SVG to LAD,
SVG to diagonal, s/p PCI to SVG-Diag 100% occluded, DES to
SVG-LAD graft in [**4-29**], DESx2 to SVG-RPDA in [**9-30**], BMS to SVG-RCA
in [**10-1**], DES to SVG to LAD [**2175**] and DES x2 to proximal and mid
SVG to LAD in [**1-4**], and DESx2 to proximal and ostial [**Date Range **] in
[**2-5**]; right renal artery stenosis s/p stenting [**3-31**], [**Month/Year (2) 2091**], DMII,
HLD, HTN, GI bleed, small AAA presenting to OSH with chest pain.
# chest pain: Pt was transferred to the CCU from the cardiology
service on both heparin gtt and nitro gtt. While on the
cardiology service the patient had troponins were neg x 3 the
day of admission (1 day prior) but bumped to 0.08 the morning
after. EKG stable. no tele events. Attempted to wean nitro gtt
the evening of admission and CP began to recur at level of [**2-3**]
when nitro drip stopped and resolved when it was restarted.
Given his initial chest pain and given the patient's extensive
cardiac history, plan was to go for cath on [**2178-3-23**], which
showed stenosis of the RCA graft. The RCA was balooned and
stented and during the procedure the patient complainted of
[**11-4**] chest pain. It is likely that a clot had embolized and
went downstream during the stenting procedured. Subsequently,
the patient cardiac enzymes started to rise and peaked at
CK-796, CK-MB->84 and trop at 2.85. EKG showed ST elevations in
inferior leads. The next day nitro drip was stopped and the
patient was started on his home dose ranolazine and stared on
imdur 60mg, and remained chest pain free. Back on the floor, he
was uptitrated to imdur 180 daily, and had no more chest pain or
discomfort.
.
# anemia: Hct stable near 29 on admission. No overt s/s
bleeding. iron studies normal. hemolysis labs neg, retic index
1.2. Review of prior records indicated pt has long history of
anemia that predates worsened [**Last Name (LF) 2091**], [**First Name3 (LF) **] it was thought that this
may be [**2-26**] thalassemia. [**Month/Day (2) 2091**] may also be contributor.
.
# [**Month/Day (2) 2091**]: baseline creat according to our records was 2.0 in [**2176**]
and it was 2.7 after discharge from [**Hospital1 18**] in [**2178-1-25**] for
stenting. unsure if this is new baseline or [**Last Name (un) **]. His Cr was 2.6
on admission and remained between 2.3 and 2.8 during his CCU
course. On the floor he, did develop [**Last Name (un) **] with Cr to 3.3, likely
[**2-26**] CIN, which was down to 2.8 on discharge.
.
# Rhythm: after coming out of CCU, found to have sinus
bradycardia, 2:1 block. Rate had been controlled with metop
succ. 100 daily, which was held. Rate improved during the rest
of his stay, though was still in 50's upon discharge, and he was
discharged off BB. When exercised on EKG, he did have a good
response and HR came up, indicating a higher AV block. No need
for pacemaker.
.
# Type 2 DM: continued lantus and humalog SS; diabetic diet
# Hyperlipidemia: had been on simvastatin 10mg daily. Discharged
on atorvastatin 80mg daily.
.
# Hypertension: Initially controlled with home doses of
amlodipine, metoprolol. Once bradycardia (above) developed,
those were stopped. Imdur 180mg daily was started. He went out
on amlodipine 10mg daily as well.
.
Medications on Admission:
aspirin 325 mg Delayed Release DAILY
clopidogrel 75 mg Tablet DAILY
amlodipine 10 mg Tablet once a day
insulin glargine Thirty Eight (38) units Subcutaneous once a day
metoprolol succinate 100 mg Tablet DAILY
simvastatin 10 mg Tablet once a day
Not sure of isosorbide mononitrate ER 60mg TID
metronidazole 500 mg Tab Oral Three times daily until [**3-24**] for
diverticolitis
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. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. insulin glargine Subcutaneous
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day: please avoid
drinking grapejuice while on this medication.
7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Secondary Diagnoses:
chronic kidney disease
anemia
coronary artery disease
hypertension
2nd degree heart block
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital because you had chest pain. Your EKG
was unchanged but you had elevated [**Hospital **] markers that indicated
you could be having a heart attack. You were started on
medications to treat a heart attack and taken for a cardiac
catheterization which showed aqan obstruction in one of your
venous graphs which was stented. You were also monitored for low
heart rate which was stable and low kidney functions which seem
to have improved. You are now discharged home.
.
The following medications were stopped:
Please STOP Metoprolol
Please STOP Simvastatin
.
The following medications were started:
.
Please START Atorvastatin 80mg tablet, once daily.
please START Furosamide, 20mg tablet once daily.
.
Please weigh yourself everyday and call your PCP if you gain
more than 3 lb in 24 hour.
Followup Instructions:
Please call the number below to make an appointment with your
PCP and cardiologist within 1 week of your discharge. You will
also need to have your [**Hospital **] tests drawm within 1 week to test
electrolytes and renal functions.
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 8724**]
Phone: [**Telephone/Fax (1) 8725**]
Fax: [**Telephone/Fax (1) 8719**]
Email: [**University/College 8731**]
.
|
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icd9cm
|
[
[
[]
]
] |
[
"37.22",
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] |
icd9pcs
|
[
[
[]
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] |
15281, 15344
|
10796, 14118
|
274, 326
|
15526, 15526
|
6766, 6766
|
16545, 17147
|
5020, 5136
|
14544, 15258
|
15365, 15365
|
14144, 14521
|
15709, 16522
|
5151, 5949
|
15413, 15505
|
3854, 4246
|
5965, 6747
|
224, 236
|
354, 3741
|
6782, 8664
|
15384, 15392
|
15541, 15685
|
4277, 4673
|
3763, 3834
|
4689, 5004
|
8676, 10773
|
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